Read the full published article in Annals of Joint – https://aoj.amegroups.org/article/view/9891/html
Reducing graft failure and optimising outcomes in elite athletes
For an elite athlete, ACL reconstruction is about more than restoring knee stability. A graft failure can mean another operation, another lengthy rehabilitation and potentially a significant impact on their sporting career.
This has driven renewed interest in lateral extra-articular tenodesis (LET) as an adjunct to ACL reconstruction, particularly in athletes at higher risk of reinjury.
What is LET?
LET uses a strip of the iliotibial band on the outside of the knee to provide additional restraint against rotational movement.
The aim is to improve rotational stability and reduce the forces placed on the reconstructed ACL graft. Biomechanical studies suggest LET can reduce ACL graft stress by approximately 43%.
Does LET reduce graft failure?
Increasing evidence suggests it can, particularly in high-risk athletes.
Studies of professional athletes have reported significantly lower graft failure rates when ACL reconstruction is combined with a lateral extra-articular procedure. Reported examples include:
- 3.4% vs 9.5% graft failure with ACLR + LET versus isolated ACLR in professional athletes
- 6.5% vs 34% in professional skiers
- 6.0% vs 15.5% in a large cohort of professional athletes at a mean 8.3-year follow-up.
For an elite athlete, even a modest reduction in graft failure can have significant consequences.
What about return to sport?
The available evidence is encouraging. Across studies of high-level athletes, 85.7-100% returned to their pre-injury level of sport following ACL reconstruction with a lateral extra-articular procedure. This includes professional soccer, rugby and skiing athletes. Importantly, these studies are predominantly retrospective, so these results should be interpreted with appropriate caution.
Could LET increase career longevity?
One particularly interesting finding is the potential effect on sporting career length. In professional rugby players, 88% of athletes who underwent ACL reconstruction with a lateral extra-articular procedure were still playing five years later, compared with 70% following isolated ACL reconstruction.
For elite athletes, the goal is not simply to return to sport – it is to stay there.
Who should be considered for LET?
I don’t believe LET should be routinely performed with every ACL reconstruction. Instead, the decision should be individualised according to the athlete’s sport, knee morphology and risk of reinjury.
Factors that may favour LET include:
- Age under 25
- Pivoting or contact sports
- Generalised ligamentous laxity
- Knee hyperextension >10°
- Increased posterior tibial slope
- High-grade pivot shift
- Revision ACL reconstruction.
For these athletes, the potential benefit of additional rotational protection may outweigh the additional complexity of the procedure.
Is LET safe?
Modern LET techniques have a favourable safety profile. Lateral knee pain, stiffness and hardware irritation can occur, but are generally uncommon and manageable.
Importantly, contemporary evidence does not demonstrate an increased risk of lateral compartment osteoarthritis when modern techniques and appropriate graft tensioning are used.
The bottom line
LET is an increasingly valuable tool in ACL reconstruction, particularly for young, high-demand and elite athletes at increased risk of graft failure. The evidence suggests it can improve rotational stability, reduce graft failure and support high rates of return to pre-injury sport, with emerging evidence that it may also help prolong sporting careers.
However, LET is not for every ACL reconstruction. The key is identifying the athlete in whom the potential benefits of additional rotational protection outweigh the risks and added complexity.
For elite athletes, ACL reconstruction should be about more than getting back on the field – it should be about giving them the best possible chance of staying there.