Low graft failure and favourable outcomes after anterior cruciate ligament reconstruction and lateral extra-articular tenodesis in young athletes

Abstract

Purpose: Young athletes undergoing anterior cruciate ligament reconstruction (ACLR) are at high risk of graft failure and contralateral anterior cruciate ligament (CACL) injury, despite advances in surgical technique. Lateral extra-articular tenodesis (LET) has emerged as a potential adjunct to improve graft survivability in high-risk young populations. The study aimed to describe graft survival, CACL rates, patient-reported outcome measures (PROMs) and return-to-sport (RTS) outcomes in high-risk under-20 athletes undergoing ACLR and LET. Methods: This retrospective cohort study analysed U20 athletes who underwent primary ACLR with hamstring tendon autografts and concurrent LET between 2017 and 2023. All surgeries were performed by a single surgeon using a standardized technique. Outcomes included graft survivability, CACL injury incidence, and RTS level, with functional recovery assessed via the Marx Activity Scale and Tegner–Lysholm Score. Kaplan–Meier survival analysis, independent t-tests, χ2 tests, and multivariate logistic regression were used to evaluate outcomes and identify predictors, with significance set at p < 0.05. Results: One hundred fifty-nine patients (mean age 17.6 ± 1.9 years) were included, with a mean follow-up of 49.7 ± 18.8 months. Graft rerupture occurred in 2.5% of patients, all within 40 months postoperatively. CACL injury was observed in 12.6% of patients. Over 60% of athletes returned to their pre-injury level of sport, with higher PROMs in those achieving same-level RTS. A smaller graft diameter was significantly associated with increased risk of CACL injury (p < 0.05). LET was not associated with adverse effects on functional recovery. Conclusions: This cohort showed low graft rerupture rates, favourable functional outcomes and encouraging RTS levels following ACLR and LET. However, CACL injury remained a substantial concern. LET may be considered in adolescent athletes participating in pivoting sports to potentially reduce graft failure, although further comparative studies are needed. Level of Evidence: Level IV.