ANTEROLATERAL LIGAMENT / LATERAL EXTRAARTICULAR TENODESIS
ALL reconstruction / LET could be considered when performing hamstring autograft reconstruction in select patients to reduce graft failure and improve short-term function, although long-term outcomes are yet unclear.

Rationale

The ALL/ LET recommendation was downgraded one level due to potential added incisions, implants, and time under anesthesia. Two high quality (Hamido 2020, Chen 2021) studies report a lower rate of graft rupture/failure when ALL reconstruction is performed at the time of ACL reconstruction with a hamstring autograft. Two high quality studies (Hamido 2020, Ibrahim 2017) report that post-operative function favors combined ACL and ALL reconstruction over isolated ACL reconstruction with a hamstring autograft. One high quality study (Getgood 2020) and two low quality studies (King 2020, Rowan 2019) report a lower rate of graft rupture/failure, ACL reinjury, or revision ACL surgery when LET is performed with hamstring ACL reconstruction. One high quality study (Vadala 2013) and two low quality studies (King 2020, Rowan 2019) report better post-operative function when LET is performed. The long-term impact of ALL reconstruction and LET are unclear. One moderate quality study (Castoldi 2020) reports a higher rate of lateral compartment osteoarthritis in patients that underwent LET, but these patients also had a higher rate of partial lateral meniscectomy during or after the time of ACL reconstruction. 

Benefits/Harms of Implementation

ALL reconstruction and LET are additional procedures that may require additional time under anesthesia, incisions, and implants. These may increase the peri-operative risks. One recent study (Castoldi 2020) demonstrated early signs of lateral compartment osteoarthritis in the ACL/LET cohort compared to the ACL only cohort. The key benefits of these procedures may be improved function and lower risk of revision surgery.

Outcome Importance

Given the increasing incidence of ACL injury and the potential medical, financial, and psychosocial impact of revision surgery, evaluation of factors affecting the risk of re-operation is important.

Cost Effectiveness/Resource Utilization

ALL reconstruction and LET are additional procedures that may require additional time under anesthesia and implants, both of which increase the overall cost. However, this may be balanced against the cost of revision surgery and subsequent rehabilitation.

Acceptability

Much debate persists about anterolateral augmentation procedures, although they continue to rise in popularity. Selected use of this technique is appropriate based on surgeon and patient specific factors.

Feasibility

Implementation of the recommendation is feasible, but a learning curve may exist for surgeons that have not performed these procedures previously.

Future Research

Future research should focus on medium and long-term outcomes after ALL reconstruction or LET (including graft failure, osteoarthritis, and patient reported outcomes). Furthermore, the impact of ALL or LET with patellar tendon or quadriceps tendon grafts should be investigated, as the majority of current data pertains to hamstring ACL reconstruction. Additional research can also investigate the impact of these procedures on adolescents, especially females, who are at highest risk of graft failure.