Differences in Clinical Outcomes and Rotational Stability Between Anterolateral Ligament Reconstruction and Lemaire Lateral Tenodesis Following Primary Anterior Cruciate Ligament Reconstruction

Document Type : RESEARCH PAPER

Authors

1 Department of Orthopedic, School of Medicine, Iran University of Medical Sciences, Tehran, Iran

2 versity of Medical Sciences, Tehran, Iran 2 Bone and Joint Reconstruction Research Center, Department of Orthopedics, School of Medicine, Iran University of Medical Sciences, Tehran, Iran

3 University of California, Davis School of Medicine, Sacramento, CA, USA

4 Orthopedic & Rehabilitation Research Center, Shiraz University of Medical Sciences, Shiraz, Iran

5 Trauma Research Center, Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran

6 Bone and Joint Reconstruction Research Center, Department of Orthopedics, School of Medicine, Iran University of Medical Sciences, Tehran, Iran

10.22038/abjs.2025.84170.3826

Abstract

Objectives: Residual instability following anterior cruciate ligament reconstruction (ACLR) is a common 
concern among young, active patients. Currently, two primary methods are used to address this matter: 
anterolateral ligament reconstruction (ALLR) using a graft and lateral extra-articular tenodesis (LET). 
This study aims to compare the Lemaire method for LET with ALLR in minimizing rotational instability 
after ACLR.
Methods: This retrospective cohort study included patients with ACL ruptures who underwent simultaneous 
arthroscopic ACLR and either Lemaire lateral tenodesis or ALL reconstruction between April 2013 and March 2021. 
Patients were re-examined approximately 24 months post-operatively. We evaluated rotational instability using the 
pivot shift test, and anterior stability with the KT-1000 test. Outcomes were measured using the Lysholm and 
International Knee Documentation Committee (IKDC) questionnaires.
Results: This study evaluated 53 patients who underwent ACLR using either the Lemaire method for LET (n=24) 
or ALLR technique (n=29). No substantial differences were observed in terms of age, sex, body mass index (BMI), 
number of physiotherapy sessions, time from injury to surgery, or the diameter of the ACL graft. Rotational stability 
was significantly better in the Lemaire group (16.7% vs. 82.8%, P < 0.001). Although functional outcomes were 
higher in the Lemaire group, these differences were not statistically significant. Multivariate logistic regression 
analysis revealed that the surgical technique was the only significant predictor of rotational instability, with patients 
undergoing ALLR being 18.8 times more likely to experience a positive pivot shift (OR: 18.78, 95% CI: 4.34–81.18, 
P < 0.001).
Conclusion: This retrospective cohort study suggests that Lemaire LET may be more effective than ALLR in 
minimizing rotational instability following arthroscopic ACLR. However, there was no superiority in functional scores 
between the groups.
 Level of evidence: III

Keywords

Main Subjects

References

  1. Astur DC, Margato GF, Zobiole A, et al. The incidence of anterior cruciate ligament injury in youth and male soccer athletes: an evaluation of 17,108 players over two consecutive seasons with an age-based sub-analysis. Knee Surg Sports Traumatol Arthrosc. 2023; 31(7):2556-2562. doi: 10.1007/s00167-023-07331-0.
  2. Diermeier T, Rothrauff BB, Engebretsen L, et al. Treatment after anterior cruciate ligament injury: Panther Symposium ACL Treatment Consensus Group. J ISAKOS. 2021; 6(3):129-137. doi:10.1136/jisakos-2020-000493.
  3. Panni AS, Milano G, Tartarone M, Demontis A, Fabbriciani C. Clinical and radiographic results of ACL reconstruction: a 5- to 7-year follow-up study of outside-in versus inside-out reconstruction techniques. Knee Surg Sports Traumatol Arthrosc. 2001; 9(2):77-85. doi:10.1007/s001670000171.
  4. Shafizadeh S, Huber HJ, Grote S, et al. Principles of fluoroscopic-based navigation in anterior cruciate ligament reconstruction. Oper Tech Orthop. 2005; 15(1):70-5. doi: 10.1053/j.oto.2004.11.004.
  5. Hong L, Li X, Zhang H, et al. Anterior cruciate ligament reconstruction with remnant preservation: a prospective, randomized controlled study. Am J Sports Med. 2012; 40(12):2747-2755. doi:10.1177/0363546512461481.
  6. Chambat P, Guier C, Sonnery-Cottet B, Fayard J-M, Thaunat M. The evolution of ACL reconstruction over the last fifty years. Int Orthop. 2013; 37(2):181-186. doi:10.1007/s00264-012-1759-3.
  7. Webster KE, Feller JA. Exploring the High Reinjury Rate in Younger Patients Undergoing Anterior Cruciate Ligament Reconstruction. Am J Sports Med. 2016; 44(11):2827-32.
  8. Delaloye JR, Hartog C, Blatter S, et al. Anterolateral Ligament Reconstruction and Modified Lemaire Lateral Extra-Articular Tenodesis Similarly Improve Knee Stability After Anterior Cruciate Ligament Reconstruction: A Biomechanical Study. Arthroscopy. 2020; 36(7):1942-1950. doi:10.1016/j.arthro.2020.03.027.
  9. Rothrauff BB, Kondo E, Siebold R, Wang JH, Yoon KH, Fu FH. Anterior cruciate ligament reconstruction with remnant preservation: current concepts. Journal of ISAKOS. 2020; 5(3):128-33.
  10. Musahl V, Herbst E, Burnham JM, Fu FH. The Anterolateral Complex and Anterolateral Ligament of the Knee. J Am Acad Orthop Surg. 2018; 26(8):261-267. doi:10.5435/JAAOS-D-16-00758.
  11. Willinger L, Athwal KK, Holthof S, Imhoff AB, Williams A, Amis AA. Role of the Anterior Cruciate Ligament, Anterolateral Complex, and Lateral Meniscus Posterior Root in Anterolateral Rotatory Knee Instability: A Biomechanical Study. Am J Sports Med. 2023; 51(5):1136-1145. doi:10.1177/03635465231161071.
  12. Farinelli L, Meena A, Sonnery-Cottet B, et al. Distal Kaplan fibers and anterolateral ligament injuries are associated with greater intra-articular internal tibial rotation in ACL-deficient knees based on magnetic resonance imaging. J Exp Orthop. 2023; 10(1):113. doi:10.1186/s40634-023-00682-0.
  13. Sonnery-Cottet B, Vieira TD, Ouanezar H. Anterolateral Ligament of the Knee: Diagnosis, Indications, Technique, Outcomes. Arthroscopy. 2019; 35(2):302-303. doi:10.1016/j.arthro.2018.08.019.
  14. Peng WL, Chen YJ, Hung YC, et al. Single-bundle ACL combined with ALL reconstruction yields comparable outcomes in patients with varied anatomical risk factors for ACL graft failure. BMC Musculoskelet Disord. 2024; 25(1):625. doi:10.1186/s12891-024-07725-2.
  15. Monaco E, Fabbri M, Mazza D, et al. The Effect of Sequential Tearing of the Anterior Cruciate and Anterolateral Ligament on Anterior Translation and the Pivot-Shift Phenomenon: A Cadaveric Study Using Navigation. Arthroscopy. 2018; 34(4):1009-1014. doi:10.1016/j.arthro.2017.09.042.
  16. van der Wal WA, Meijer DT, Hoogeslag RAG, LaPrade RF. The Iliotibial Band is the Main Secondary Stabilizer for Anterolateral Rotatory Instability and both a Lemaire Tenodesis and Anterolateral Ligament Reconstruction Can Restore Native Knee Kinematics in the Anterior Cruciate Ligament Reconstructed Knee: A Systematic Review of Biomechanical Cadaveric Studies. Arthroscopy. 2024; 40(2):632-647.e1. doi:10.1016/j.arthro.2023.05.005.
  17. Jesani S, Getgood A. Modified Lemaire Lateral Extra-Articular Tenodesis Augmentation of Anterior Cruciate Ligament Reconstruction. JBJS Essent Surg Tech. 2019; 9(4):e41.1-7. doi:10.2106/JBJS.ST.19.00017.
  18. Trinchese GF, Oliva F, Maffulli N. Minimally invasive anatomic reconstruction of the anterolateral ligament with ipsilateral gracilis tendon. Muscles Ligaments Tendons J. 2017; 7(2):240-246. doi:10.11138/mltj/2017.7.2.240.
  19. Perelli S, Costa GG, Terron VM, et al. Combined Anterior Cruciate Ligament Reconstruction and Modified Lemaire Lateral Extra-articular Tenodesis Better Restores Knee Stability and Reduces Failure Rates Than Isolated Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients. Am J Sports Med. 2022; 50(14):3778-3785. doi:10.1177/03635465221128926.
  20. Delaloye JR, Murar J, Gonzalez M, Amaral T, Kakatkar V, Sonnery-Cottet B. Clinical Outcomes After Combined Anterior Cruciate Ligament and Anterolateral Ligament Reconstruction. Tech Orthop. 2018; 33(4):225-231. doi:10.1097/BTO.0000000000000326.
  21. Park JG, Han SB, Lee CS, Jeon OH, Jang KM. Anatomy, Biomechanics, and Reconstruction of the Anterolateral Ligament of the Knee Joint. Medicina (Kaunas). 2022; 58(6):786. doi:10.3390/medicina58060786.
  22. Arneja S, Leith J. Review article: Validity of the KT-1000 knee ligament arthrometer. J Orthop Surg (Hong Kong). 2009; 17(1):77-79. doi:10.1177/230949900901700117.
  23. Lane CG, Warren R, Pearle AD. The pivot shift. J Am Acad Orthop Surg. 2008; 16(12):679-688. doi:10.5435/00124635-200812000-00001.
  24. Vaudreuil NJ, Rothrauff BB, de Sa D, Musahl V. The Pivot Shift: Current Experimental Methodology and Clinical Utility for Anterior Cruciate Ligament Rupture and Associated Injury. Curr Rev Musculoskelet Med. 2019; 12(1):41-49. doi:10.1007/s12178-019-09529-7.
  25. Briggs KK, Lysholm J, Tegner Y, Rodkey WG, Kocher MS, Steadman JR. The reliability, validity, and responsiveness of the Lysholm score and Tegner activity scale for anterior cruciate ligament injuries of the knee: 25 years later. Am J Sports Med. 2009; 37(5):890-897. doi:10.1177/0363546508330143.
  26. Higgins LD, Taylor MK, Park D, et al. Reliability and validity of the International Knee Documentation Committee (IKDC) Subjective Knee Form. Joint Bone Spine. 2007; 74(6):594-599. doi:10.1016/j.jbspin.2007.01.036.
  27. Ebrahimzadeh MH, Makhmalbaf H, Golhasani-Keshtan F, Rabani S, Birjandinejad A. The International Knee Documentation Committee (IKDC) Subjective Short Form: a validity and reliability study. Knee Surg Sports Traumatol Arthrosc. 2015; 23(11):3163-3167. doi:10.1007/s00167-014-3107-1.
  28. Fakoor M, Sadoni H, Mohammad Hosseini P, Bastan S. Statistical Relationship Between Clinical and Functional Findings Based on the Lysholm Standard Score on the Success Rate of ACL Arthroscopic Reconstruction Surgery. Iranian Journal of Orthopedic Surgery. 2020; 18(3):83-8. doi:10.22034/ijos.2020.121419.
  29. von Elm E, Altman DG, Egger M, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet. 2007; 370(9596):1453-1457. doi:10.1016/S0140-6736(07)61602-X.
  30. World Medical Association. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA. 2013; 310(20):2191-2194. doi:10.1001/jama.2013.281053.
  31. Geeslin AG, Moatshe G, Chahla J, et al. Anterolateral Knee Extra-articular Stabilizers: A Robotic Study Comparing Anterolateral Ligament Reconstruction and Modified Lemaire Lateral Extra-articular Tenodesis. Am J Sports Med. 2018; 46(3):607-616. doi:10.1177/0363546517745268.
  32. Inderhaug E, Stephen JM, Williams A, Amis AA. Anterolateral Tenodesis or Anterolateral Ligament Complex Reconstruction: Effect of Flexion Angle at Graft Fixation When Combined With ACL Reconstruction. Am J Sports Med. 2017; 45(13):3089-3097. doi:10.1177/0363546517724422.
  33. Laboudie P, Douiri A, Bouguennec N, Biset A, Graveleau N. Combined ACL and ALL reconstruction reduces the rate of reoperation for graft failure or secondary meniscal lesions in young athletes. Knee Surg Sports Traumatol Arthrosc. 2022; 30(10):3488-3498. doi:10.1007/s00167-022-06956-x.
  34. Firth AD, Bryant DM, Litchfield R, et al. Predictors of Graft Failure in Young Active Patients Undergoing Hamstring Autograft Anterior Cruciate Ligament Reconstruction With or Without a Lateral Extra-articular Tenodesis: The Stability Experience. Am J Sports Med. 2022; 50(2):384-395. doi:10.1177/03635465211061150.
  35. Ra HJ, Kim JH, Lee DH. Comparative clinical outcomes of anterolateral ligament reconstruction versus lateral extra-articular tenodesis in combination with anterior cruciate ligament reconstruction: systematic review and meta-analysis. Arch Orthop Trauma Surg. 2020; 140(7):923-931. doi:10.1007/s00402-020-03393-8.
  36. Agarwal N, Monketh J, Volpin A. Clinical and mechanical outcomes in isolated anterior cruciate ligament reconstruction vs additional lateral extra-articular tenodesis or anterolateral ligament reconstruction. World J Orthop. 2022; 13(7):662-675. doi:10.5312/wjo.v13.i7.662.
  37. Bosco F, Giustra F, Masoni V, et al. Combining an Anterolateral Complex Procedure With Anterior Cruciate Ligament Reconstruction Reduces the Graft Reinjury Rate and Improves Clinical Outcomes: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Am J Sports Med. 2024; 52(8):2129-2147. doi:10.1177/03635465231198494.
  38. Agarwal N, Monketh J, Volpin A. Clinical and mechanical outcomes in isolated anterior cruciate ligament reconstruction vs additional lateral extra-articular tenodesis or anterolateral ligament reconstruction. World J Orthop.

 

        2022; 13(7):662-675. doi:10.5312/wjo.v13.i7.662.

  1. Boksh K, Sheikh N, Chong HH, Ghosh A, Aujla R. The Role of Anterolateral Ligament Reconstruction or Lateral Extra-articular Tenodesis for Revision Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis of Comparative Clinical Studies. Am J Sports Med. 2024; 52(1):269-285. doi:10.1177/03635465231157377.
  2. Lutz C, Sonnery-Cottet B, Niglis L, Freychet B, Clavert P, Imbert P. Behavior of the anterolateral structures of the knee during internal rotation. Orthop Traumatol Surg Res. 2015; 101(5):523-528. doi:10.1016/j.otsr.2015.04.007.
  3. Borque K, Ngo D, Laughlin M, et al. Lateral extra-articular tenodesis at primary ACL reconstruction increases career length in professional rugby players. Knee Surg Sports Traumatol Arthrosc. 2025; 33(4):1252-1258. doi:10.1002/ksa.12434.
  4. Shybut TB. Editorial Commentary: This Is the Way: Extra-Articular Augmentation Is an Essential Consideration in Contemporary Anterior Cruciate Ligament Surgery. Arthroscopy. 2021; 37(5):1667-1669. doi:10.1016/j.arthro.2021.01.014.
  5. Neri T, Cadman J, Beach A, et al. Lateral tenodesis procedures increase lateral compartment pressures more than anterolateral ligament reconstruction, when performed in combination with ACL reconstruction: a pilot biomechanical study. J ISAKOS. 2021; 6(2):66-73. doi:10.1136/jisakos-2019-000368.
  6. Neri T, Dabirrahmani D, Beach A, et al. Different anterolateral procedures have variable impact on knee kinematics and stability when performed in combination with anterior cruciate ligament reconstruction. J ISAKOS. 2021; 6(2):74-81. doi:10.1136/jisakos-2019-000360.
  7. Slette EL, Mikula JD, Schon JM, et al. Biomechanical Results of Lateral Extra-articular Tenodesis Procedures of the Knee: A Systematic Review. Arthroscopy. 2016; 32(12):2592-2611. doi:10.1016/j.arthro.2016.04.028.
  8. Devitt BM, Bouguennec N, Barfod KW, Porter T, Webster KE, Feller JA. Combined anterior cruciate ligament reconstruction and lateral extra-articular tenodesis does not result in an increased rate of osteoarthritis: a systematic review and best evidence synthesis. Knee Surg Sports Traumatol Arthrosc. 2017; 25(4):1149-1160. doi:10.1007/s00167-017-4510-1.
  9. Inderhaug E, Stephen JM, El-Daou H, Williams A, Amis AA. The Effects of Anterolateral Tenodesis on Tibiofemoral Contact Pressures and Kinematics. Am J Sports Med. 2017; 45(13):3081-3088. doi:10.1177/0363546517717260.

 

 

 

 

The Archives of Bone and Joint Surgery
Volume 13, Issue 7
July 2025
Pages 426-434

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History

  • Receive Date: 03 December 2024
  • Revise Date: 10 March 2025
  • Accept Date: 22 January 2025

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