Summary

The addition of lateral extra-articular augmentation procedures to quadriceps or patellar tendon ACL reconstruction is non-inferior to isolated ACL reconstruction in terms of return-to-sport testing outcomes and psychological readiness for sport at 6 and 9 months postoperatively.

Abstract

Background

The addition of lateral extra-articular augmentation procedures (LEAP), including anterolateral ligament reconstruction (ALLR) and lateral extra-articular tenodesis (LET), to anterior cruciate ligament reconstruction (ACLR) are known to reduce graft failure rates. However, their effects on return to sport (RTS) testing and timing are not well understood. Existing literature on the topic has focused only on the combination of hamstring autograft with LEAP.

Objective

The objective was to evaluate the effects of adding LEAP to quadriceps (Quad) or patellar tendon bone-tendon-bone (BTB) autograft ACLR in young athletes, with respect to typical RTS testing outcomes and psychological readiness for RTS. We hypothesized that the addition of LEAP to Quad or BTB ACLR would result in non-inferior outcomes as compared to isolated ACLR.

Methods

A retrospective case-control analysis was performed of prospectively-collected data from patients under the age of 25 undergoing Quad or BTB ACLR, with or without LEAP, between 2021 and 2023. Isolated ACLR without LEAP made up the control group and those with ACLR and LEAP (either ALLR or LET) made up the study group (ACL/LEAP). All patients underwent standardized RTS testing at 6- and 9-months post-surgery. The 6-month outcomes included the modified landing error scoring system (iLESS), Horizontal Single Hop, Single Leg Squats on a BOSU ball, and calculated 1-repetition maximal loads with Single Leg Press. The 9-month outcomes included Horizontal Triple Crossover Hop, T-drill Hop, Vertical Hop and ACL-RSI scores. The thresholds for “passing” these tests were defined as 0 faults on iLESS, > 90% limb symmetry index (LSI) for all hop testing and strength testing, and an ACL-RSI score > 65%. The study was adequately powered based on a priori power analysis to assess non-inferiority of the ACL/LEAP group.

Results

There were 93 patients eligible for this study, with 51 (54.8%) in the isolated ACLR group and 42 (45.2%) in the ACLR/LEAP group. The only significant differences between groups were age, with ACL/LEAP being significantly younger (14.8 years versus 16.8 years, p<.001), and increased use of BTB graft in the isolated ACLR group (88.2% versus 35.7%, respectively, p<.001).

There were no significant differences in LSI or passing rates for any of the 6-month tests. The only significant difference for 9-month tests was the Horizontal Triple Crossover Hop pass rate in favor of the ACL/LEAP group (p=.044). There were no differences in LSI at 9 months for any test. There was no significant difference in overall pass rate between the control group and ACL/LEAP group (33% versus 45.2%, respectively, p=.273) at 9 months. Subgroup analysis showed no differences in any of the outcome variables between ACL/ALL and ACL/LET.

Conclusion

This study confirmed our hypothesis that the addition of LEAP to Quad or BTB ACLR is non-inferior to isolated ACLR in terms of RTS testing outcomes and psychological readiness for sport at 6 and 9 months postoperatively. Patients can be counseled that even with the addition of a LEAP procedure to an ACL, they can expect a similar ability to pass formal RTS testing.