Arthroscopy - 2026-07-21 - Journal Article; Review
Lateral Extra-articular Procedures Decrease Rates of Graft Failure and Positive Pivot Shift in Primary Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis.
Macciacchera M, Nucci N, Hayes E, Zhang T, Pickell M, Matache BA
Topics
Key Takeaway
Adding a lateral extra-articular procedure to primary ACLR with hamstring autograft significantly reduces graft failure (OR CI 0.235–0.580, p<0.001) and positive pivot-shift rates (OR CI 0.324–0.703, p<0.001) across 1,327 patients in 12 RCTs.
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Summary
This systematic review and meta-analysis of 12 Level I–II RCTs asked whether adding a lateral extra-articular procedure (LEAP—7 ALL reconstructions, 5 LET) to primary hamstring autograft ACLR improves outcomes versus ACLR alone. LEAP significantly reduced graft failure and positive pivot-shift rates, and improved Lysholm scores (mean difference 0.779–3.093, p=0.001). IKDC and Tegner scores showed no significant between-group difference, though ceiling effects were identified in ≥75% of studies reporting those measures.
Key Limitation
Pooling ALL reconstruction and LET as a single 'LEAP' category obscures whether one lateral procedure is superior, limiting procedure-specific surgical decision-making.
Original Abstract
PURPOSE
To synthesize the existing literature on clinical outcomes and patient-reported outcome measures following primary anterior cruciate ligament reconstruction (ACLR) and lateral extra-articular procedures (LEAP) in randomized controlled trials, whereas also determining ceiling effects for the patient-reported outcome measures utilized.
METHODS
A systematic review and meta-analysis were performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. PubMed, MEDLINE, and Embase databases were used for an electronic search of Level I-II randomized controlled trials. Publications which followed skeletally mature patients randomized to undergo primary ACLR with or without the addition of LEAP were considered. Studies with <9-month follow-up were excluded to ensure clinical relevance.
RESULTS
Twelve publications met eligibility criteria for this review, including a total of 1327 patients with outcomes available for data extraction. Anterolateral ligament reconstruction was performed in 7 studies, and lateral extra-articular tenodesis was performed in 5 studies. A significant reduction in graft failure was found in patients who underwent ACLR plus LEAP ([0.235, 0.580], P < .001). A significantly lower rate of positive postoperative pivot shift was also found in this group ([0.324, 0.703], P < .001). Regarding patient-reported outcome measures, Lysholm scores favored the addition of LEAP to ACLR ([0.779, 3.093], P = .001), whereas International Knee Documentation Committee scores ([-0.521, 3.757], P = .138) and Tegner scores ([-0.304, 0.222], P = .760) showed no significant difference between groups. Using a 15% threshold of study subjects, significant ceiling effects were found in 3 of 4 studies reporting International Knee Documentation Committee scores and all studies reporting Lysholm scores.
CONCLUSIONS
Clinical outcomes, including graft failure and persistent positive pivot shift following ACLR with hamstring autograft, are improved by the addition of LEAP. Lysholm scores also improved, favoring the addition of LEAP to ACLR. The nonsignificant finding for International Knee Documentation Committee scores should be interpreted with caution, as there is a ceiling effect observed in a majority of included trials.
LEVEL OF EVIDENCE
Level II, meta-analysis of Level I and II studies.