AJSM - 2026-08-19 - Journal Article
Increased Posterior Tibial Slope and Lateral Extra-articular Tenodesis Are Independently Associated With Revision ACLR in a Young High-Risk Population.
van der Wal WA, de Groot TM, Tamana L, Tsoulgkounidis N, Veraart JT, Hoogeslag RAG, van der Hoeven H, Engelsma Y, Custers RJH, Saris DBF
Topics
Key Takeaway
In patients ≤25 years with PTSmax ≥12°, adding LET to primary ACLR reduced revision rate from 21.0% to 9.2% (ARR 11.8%, NNT 9).
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Summary
This multicenter cohort study examined whether LET mitigates revision risk conferred by elevated PTS (≥12°) in patients ≤25 years undergoing primary ACLR. Four prespecified multivariable logistic regression models showed LET independently reduced revision odds (OR 0.37; 95% CI 0.22–0.62) and lateral PTS independently increased revision odds (OR 1.09 per 1°). Elevated PTSmax ≥12° was present in 28.2% of the cohort and was more prevalent in revision cases (38.6% vs. 27.0%, P=.03), yet LET reduced revision rates in both high- and normal-slope subgroups.
Key Limitation
Non-randomized LET allocation means unmeasured confounders (e.g., pivot-shift grade, sport level, contralateral ACL history) likely influenced the decision to add LET, limiting causal inference.
Original Abstract
BACKGROUND
Increased posterior tibial slope (PTS) has been associated with higher revision rates after anterior cruciate ligament reconstruction (ACLR). Whether the addition of lateral extra-articular tenodesis (LET) mitigates the risk associated with increased PTS is unclear.
PURPOSE
To determine the prevalence of increased PTS (≥12°) in a young high-risk primary ACLR population and evaluate whether LET is associated with lower revision rates in patients with increased PTS.
STUDY DESIGN
Cohort study; Level of evidence, 3.
METHODS
This study included patients aged ≤25 years undergoing primary ACLR across 3 high-volume centers with ≥2 years between surgery and data collection. PTS was measured on lateral radiographs for medial and lateral plateaus. Primary analyses consisted of 4 prespecified multivariable logistic regression models with different PTS operationalizations as continuous predictors per 1° increase (medial PTS, lateral PTS, the maximum [PTSmax], and the lateral-medial difference), adjusted for patient and surgical covariates including graft type, with surgical center as a fixed effect. Secondary analyses used PTS dichotomized at 12°; revision rates were compared between isolated ACLR and ACLR with LET, with the treatment effect quantified as absolute risk reduction and number needed to treat.
RESULTS
A total of 780 patients were included; 84 (10.8%) underwent revision ACLR. Increased PTS (≥12°) was present in 28.2% of patients and more common in those requiring revision (38.6% vs 27.0%; P = .03). In patients with PTSmax ≥12°, revision occurred in 21.0% without LET and 9.2% with LET (absolute risk reduction, 11.8% [95% CI, 2.3%-21.3%]; number needed to treat, 9); in patients with PTSmax <12°, revision occurred in 13.2% without LET and 5.4% with LET (absolute risk reduction, 7.8% [95% CI, 3.0%-12.6%]; number needed to treat, 13). In the 4 prespecified multivariable models with PTS as a continuous predictor, LET was independently associated with substantially lower odds of revision ACLR (odds ratio [OR], 0.37; 95% CI, 0.22-0.62; P < .001). Lateral PTS (OR, 1.09 per 1° increase; 95% CI, 1.00-1.18; P = .04) and PTSmax (OR, 1.09; 95% CI, 1.00-1.19; P = .04) were independently associated with revision ACLR. The lateral-medial PTS difference was not associated with revision ACLR.
CONCLUSION
In a young high-risk primary ACLR population, increased PTS was present in nearly 30% of patients. LET was associated with a lower risk of revision irrespective of PTS, while increased PTS was independently associated with revision ACLR.