Second injuries after ACL reconstruction and lateral tenodesis with hamstrings

Background: Anterior cruciate ligament (ACL) injuries frequently result in rotatory instability, necessitating surgical interventions that restore both translational and rotational knee mechanics. While various reconstruction techniques exist, the integration of lateral extra-articular tenodesis (LET) has emerged as a strategy to address residual laxity and reduce graft failure rates, particularly in high-demand populations.

Objective: This article describes the surgical methodology of the over-the-top single-bundle ACL reconstruction combined with a hamstring-based lateral plasty and evaluates its long-term clinical efficacy, safety, and survivorship.

Key Points: The procedure utilizes harvested gracilis and semitendinosus autografts, preserved at their tibial insertions. A vertical tibial tunnel is created freehand, and the graft is routed through an over-the-top femoral passage, bypassing traditional femoral tunneling. Fixation is achieved using metallic staples at the lateral femoral condyle and below Gerdy’s tubercle for the LET component. Clinical data spanning up to 24 years demonstrate high International Knee Documentation Committee (IKDC) scores, with over 90% of patients achieving normal or nearly normal knee function. Comparative studies indicate superior rotatory control and faster return-to-sport intervals compared to isolated intra-articular reconstructions. The technique is associated with a low 10-year revision rate of 3.7% and a 90-day readmission rate of 2.3%, primarily due to minor perioperative complications such as joint swelling or superficial infection.

Conclusion: The combined over-the-top and lateral extra-articular tenodesis technique provides durable knee stability and favorable functional outcomes. This approach effectively mitigates rotatory laxity with a low incidence of long-term graft failure or significant complications.