Knee Surgery, Sports Traumatology, Arthroscopy

, Volume 25, Issue 4, pp 1149–1160 | Cite as

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

  • Brian M. DevittEmail author
  • Nicolas Bouguennec
  • Kristoffer W. Barfod
  • Tabitha Porter
  • Kate E. Webster
  • Julian A. Feller



The role of lateral extra-articular tenodesis (LEAT) as an augment to primary anterior cruciate ligament reconstruction (ACLR) remains controversial. However, concerns exist regarding the risk of development of osteoarthritis due to over constraint of the knee. To systematically review the literature to analyse the long-term incidence of osteoarthritis in patients who had an LEAT performed in isolation or in combination with intra-articular ACLR for the treatment of ACL deficiency.


Two reviewers independently searched five databases for randomized controlled trials (RCTs), non-randomized comparative, and retrospective cohort studies (CS) with long-term radiological follow-up of patients with ACL deficiency treated with ACLR combined with LEAT or LEAT in isolation. Risk of bias was performed using a modified Downs & Black’s checklist. The primary outcome was the development of osteoarthritis. The studies were divided into those with moderate/severe osteoarthritis at between 5 to 10 years and >10-year follow-up. The rate of meniscal pathology at the time of the index surgery was recorded. A best evidence synthesis was performed.


Eight studies reported on 421 patients in which an LEAT procedure was carried out. There were two high-quality RCTs and six low-quality CS. The follow-up was between 5- and 10-years in 5 studies and >10-years in 3. The presence of moderate/severe osteoarthritis was not detected in three studies and was found in 4/44 (9%) and 13/70 (18.6%) patients in the other two. At 11 year follow-up, one study demonstrated no osteoarthritis, while the other two studies reported rates of 54/100 (54%) and 17/24 (71%) respectively at >24 years. In the latter two cases, the rate of meniscal pathology was >50%. A best evidence synthesis revealed that there was insufficient evidence that the addition of a LEAT to an ACLR resulted in an increased rate of osteoarthritis.


The best available evidence would suggest that the addition of a LEAT to ACLR does not result in an increase rate of osteoarthritis of the knee. In knees that have undergone a combined ACLR and LEAT, the incidence of osteoarthritis was low up to 11 years but increased thereafter. The presence of meniscal injury at the index surgery was reported to be greater predictor of the development of osteoarthritis.

Level of evidence



Osteoarthritis Anterior Cruciate Ligament Anterior Cruciate Ligament Reconstruction Anterior Cruciate Ligament Injury Lateral Compartment 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Compliance with ethical standards

Conflict of interest

None of the authors declare that they have any conflict of interest related to this work.

Ethical approval

This article is a systematic review and does not contain any studies with human participants or animals performed by any of the authors.

Informed consent

For this type of study formal consent is not required.


  1. 1.
    Acquitter Y, Hulet C, Locker B, Delbarre JC, Jambou S, Vielpeau C (2003) Patellar tendon-bone autograft reconstruction of the anterior cruciate ligament for advanced-stage chronic anterior laxity: Is an extra-articular plasty necessary? A prospective randomized study of 100 patients with five year follow-up. Rev Chir Orthop Reparatrice Appar Mot 89:413–422PubMedGoogle Scholar
  2. 2.
    Aglietti P, Buzzi R, D’Andria S, Zaccherotti G (1992) Long-term study of anterior cruciate ligament reconstruction for chronic instability using the central one-third patellar tendon and a lateral extraarticular tenodesis. Am J Sports Med 20:38–45CrossRefPubMedGoogle Scholar
  3. 3.
    Ahn JH, Kim JG, Wang JH, Jung CH, Lim HC (2012) Long-term results of anterior cruciate ligament reconstruction using bone-patellar tendon-bone: an analysis of the factors affecting the development of osteoarthritis. Arthroscopy 28:1114–1123CrossRefPubMedGoogle Scholar
  4. 4.
    Ait Si Selmi T, Fithian D, Neyret P (2006) The evolution of osteoarthritis in 103 patients with ACL reconstruction at 17 years follow-up. Knee 13:353–358CrossRefPubMedGoogle Scholar
  5. 5.
    Ajuied A, Wong F, Smith C, Norris M, Earnshaw P, Back D, Davies A (2014) Anterior cruciate ligament injury and radiologic progression of knee osteoarthritis: a systematic review and meta-analysis. Am J Sports Med 42:2242–2252CrossRefPubMedGoogle Scholar
  6. 6.
    Anderson AF, Snyder RB, Lipscomb AB Sr (1994) Anterior cruciate ligament reconstruction using the semitendinosus and gracilis tendons augmented by the losee iliotibial band tenodesis. A long-term study. Am J Sports Med 22:620–626CrossRefPubMedGoogle Scholar
  7. 7.
    Barenius B, Ponzer S, Shalabi A, Bujak R, Norlen L, Eriksson K (2014) Increased risk of osteoarthritis after anterior cruciate ligament reconstruction: a 14-year follow-up study of a randomized controlled trial. Am J Sports Med 42:1049–1057CrossRefPubMedGoogle Scholar
  8. 8.
    Borchers JR, Kaeding CC, Pedroza AD, Huston LJ, Spindler KP, Wright RW, Consortium M, the MG (2011) Intra-articular findings in primary and revision anterior cruciate ligament reconstruction surgery: a comparison of the MOON and MARS study groups. Am J Sports Med 39:1889–1893.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Caterine S, Litchfield R, Johnson M, Chronik B, Getgood A (2015) A cadaveric study of the anterolateral ligament: re-introducing the lateral capsular ligament. Knee Surg Sports Traumatol Arthrosc 23:3186–3195CrossRefPubMedGoogle Scholar
  10. 10.
    Chol C, Ait Si Selmi T, Chambat P, Dejour H, Neyret P (2002) Seventeen year outcome after anterior cruciate ligament reconstruction with a intact or repaired medial meniscus. Rev Chir Orthop Reparatrice Appar Mot 88:157–162PubMedGoogle Scholar
  11. 11.
    Christodoulou NA, Sdrenias CV, Tsaknis RN, Mavrogenis AF, Tsigginou AM (2005) Reinforced iliotibial tenodesis for chronic anterolateral instability of the knee: a 6-year follow-up. Orthopedics 28:472–478PubMedGoogle Scholar
  12. 12.
    Claes S, Hermie L, Verdonk R, Bellemans J, Verdonk P (2013) Is osteoarthritis an inevitable consequence of anterior cruciate ligament reconstruction? A meta-analysis. Knee Surg Sports Traumatol Arthrosc 21:1967–1976CrossRefPubMedGoogle Scholar
  13. 13.
    Claes S, Vereecke E, Maes M, Victor J, Verdonk P, Bellemans J (2013) Anatomy of the anterolateral ligament of the knee. J Anat 223:321–328CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Clancy WG Jr, Nelson DA, Reider B, Narechania RG (1982) Anterior cruciate ligament reconstruction using one-third of the patellar ligament, augmented by extra-articular tendon transfers. J Bone Joint Surg Am 64:352–359CrossRefPubMedGoogle Scholar
  15. 15.
    Cox CL, Huston LJ, Dunn WR, Reinke EK, Nwosu SK, Parker RD, Wright RW, Kaeding CC, Marx RG, Amendola A, McCarty EC, Spindler KP (2014) Are articular cartilage lesions and meniscus tears predictive of IKDC, KOOS, and Marx activity level outcomes after anterior cruciate ligament reconstruction? A 6-year multicenter cohort study. Am J Sports Med 42:1058–1067CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Dejour D, Vanconcelos W, Bonin N, Saggin PR (2013) Comparative study between mono-bundle bone-patellar tendon-bone, double-bundle hamstring and mono-bundle bone-patellar tendon-bone combined with a modified Lemaire extra-articular procedure in anterior cruciate ligament reconstruction. Int Orthop 37:193–199CrossRefPubMedGoogle Scholar
  17. 17.
    Dejour H, Dejour D, Selmi TAS (1999) Chronic anterior laxity of the knee treated by free patellar graft and extra-articular lateral plasty: long term results on 148 cases. Rev Chir Orthop Reparatrice Appar Mot 85:777–789PubMedGoogle Scholar
  18. 18.
    Deledda D, Rosso F, Cottino U, Bonasia DE, Rossi R (2015) Results of meniscectomy and meniscal repair in anterior cruciate ligament reconstruction. Joints 3:151–157PubMedGoogle Scholar
  19. 19.
    Dodds AL, Bauze AJ, Keene GC (2014) Revision surgery for failed anterior cruciate ligament reconstruction in the knee. Orthop Trauma 28:116–122CrossRefGoogle Scholar
  20. 20.
    Dodds AL, Halewood C, Gupte CM, Williams A, Amis AA (2014) The anterolateral ligament: anatomy, length changes and association with the Segond fracture. Bone Joint J 96-B:325–331CrossRefPubMedGoogle Scholar
  21. 21.
    Draganich LF, Reider B, Miller PR (1989) An in vitro study of the Muller anterolateral femorotibial ligament tenodesis in the anterior cruciate ligament deficient knee. Am J Sports Med 17:357–362CrossRefPubMedGoogle Scholar
  22. 22.
    Ellison AE (1979) Distal iliotibial-band transfer for anterolateral rotatory instability of the knee. J Bone Joint Surg Ser A 61:330–337CrossRefGoogle Scholar
  23. 23.
    Engebretsen L, Lew WD, Lewis JL, Hunter RE (1990) The effect of an iliotibial tenodesis on intraarticular graft forces and knee joint motion. Am J Sports Med 18:169–176CrossRefPubMedGoogle Scholar
  24. 24.
    Fairbank TJ (1948) Knee joint changes after meniscectomy. J Bone Joint Surg Br 30B:664–670PubMedGoogle Scholar
  25. 25.
    Felson DT, Nevitt MC, Zhang Y, Aliabadi P, Baumer B, Gale D, Li W, Yu W, Xu L (2002) High prevalence of lateral knee osteoarthritis in Beijing Chinese compared with Framingham Caucasian subjects. Arthritis Rheum 46:1217–1222CrossRefPubMedGoogle Scholar
  26. 26.
    Felson DT, Niu J, Gross KD, Englund M, Sharma L, Cooke TD, Guermazi A, Roemer FW, Segal N, Goggins JM, Lewis CE, Eaton C, Nevitt MC (2013) Valgus malalignment is a risk factor for lateral knee osteoarthritis incidence and progression: findings from the Multicenter Osteoarthritis Study and the Osteoarthritis Initiative. Arthritis Rheum 65:355–362CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Foroughi N, Smith R, Vanwanseele B (2009) The association of external knee adduction moment with biomechanical variables in osteoarthritis: a systematic review. Knee 16:303–309CrossRefPubMedGoogle Scholar
  28. 28.
    Fox JM, Blazina ME, Del Pizzo W, Ivey FM, Broukhim B (1980) Extra-articular stabilization of the knee joint for anterior instability. Clin Orthop Relat Res 147:56–61Google Scholar
  29. 29.
    Frobell RB, Roos HP, Roos EM, Roemer FW, Ranstam J, Lohmander LS (2013) Treatment for acute anterior cruciate ligament tear: five year outcome of randomised trial.[Reprint in Br J Sports Med. 2015 May;49(10):700; PMID: 25926596]. BMJ 346:f232CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Keene GCR, Bickerstaff D, Rae PJ, Paterson RS (1993) The natural history of meniscal tears in anterior cruciate ligament insufficiency. Am J Sports Med 21:672–679CrossRefGoogle Scholar
  31. 31.
    Kennedy JC, Stewart R, Walker DM (1978) Anterolateral rotatory instability of the knee joint. An early analysis of the Ellison procedure. J Bone Joint Surg Am 60:1031–1039CrossRefPubMedGoogle Scholar
  32. 32.
    Kennedy MI, Claes S, Fuso FA, Williams BT, Goldsmith MT, Turnbull TL, Wijdicks CA, LaPrade RF (2015) The anterolateral ligament: an anatomic, radiographic, and biomechanical analysis. Am J Sports Med 43:1606–1615CrossRefPubMedGoogle Scholar
  33. 33.
    Lohmander LS, Englund PM, Dahl LL, Roos EM (2007) The long-term consequence of anterior cruciate ligament and meniscus injuries: osteoarthritis. Am J Sports Med 35:1756–1769CrossRefPubMedGoogle Scholar
  34. 34.
    Marcacci M, Zaffagnini S, Giordano G, Iacono F, Presti ML (2009) Anterior cruciate ligament reconstruction associated with extra-articular tenodesis: A prospective clinical and radiographic evaluation with 10- to 13-year follow-up. Am J Sports Med 37:707–714CrossRefPubMedGoogle Scholar
  35. 35.
    Moher D, Liberati A, Tetzlaff J, Altman DG, Group P (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. J Clin Epidemiol 62:1006–1012CrossRefPubMedGoogle Scholar
  36. 36.
    O’Brien SJ, Warren RF, Wickiewicz TL, Rawlins BA, Allen AA, Panariello R, Kelly AM (1991) The iliotibial band lateral sling procedure and its effect on the results of anterior cruciate ligament reconstruction. Am J Sports Med 19:21–24 (discussion 24–25)CrossRefPubMedGoogle Scholar
  37. 37.
    Oiestad BE, Engebretsen L, Storheim K, Risberg MA (2009) Knee osteoarthritis after anterior cruciate ligament injury: a systematic review. Am J Sports Med 37:1434–1443CrossRefPubMedGoogle Scholar
  38. 38.
    Pernin J, Verdonk P, Si Selmi TA, Massin P, Neyret P (2010) Long-term follow-up of 24.5 years after intra-articular anterior cruciate ligament reconstruction with lateral extra-articular augmentation. Am J Sports Med 38:1094–1102CrossRefPubMedGoogle Scholar
  39. 39.
    Schindler OS (2012) Surgery for anterior cruciate ligament deficiency: a historical perspective. Knee Surg Sports Traumatol Arthrosc 20:5–47CrossRefPubMedGoogle Scholar
  40. 40.
    Schon JM, Moatshe G, Brady AW, Serra Cruz R, Chahla J, Dornan GJ, Turnbull TL, Engebretsen L, LaPrade RF (2016) Anatomic anterolateral ligament reconstruction of the knee leads to overconstraint at any fixation angle. Am J Sports Med 44:2546–2556CrossRefPubMedGoogle Scholar
  41. 41.
    Seon JK, Song EK, Park SJ (2006) Osteoarthritis after anterior cruciate ligament reconstruction using a patellar tendon autograft. Int Orthop 30:94–98CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    Simic M, Hinman RS, Wrigley TV, Bennell KL, Hunt MA (2011) Gait modification strategies for altering medial knee joint load: a systematic review. Arthritis Care Res (Hoboken) 63:405–426Google Scholar
  43. 43.
    Steultjens EM, Dekker J, Bouter LM, van de Nes JC, Cup EH, van den Ende CH (2003) Occupational therapy for stroke patients: a systematic review. Stroke 34:676–687CrossRefPubMedGoogle Scholar
  44. 44.
    Strickler FP (1937) A satisfactory method of repairing crucial ligaments. Ann Surg 105:912–916CrossRefPubMedPubMedCentralGoogle Scholar
  45. 45.
    Trichine F, Alsaati M, Chouteau J, Moyen B, Bouzitouna M, Maza R (2014) Patellar tendon autograft reconstruction of the anterior cruciate ligament with and without lateral plasty in advanced-stage chronic laxity. A clinical, prospective, randomized, single-blind study using passive dynamic X-rays. Knee 21:58–65CrossRefPubMedGoogle Scholar
  46. 46.
    van Tulder MW, Assendelft WJ, Koes BW, Bouter LM (1997) Method guidelines for systematic reviews in the Cochrane Collaboration Back Review Group for Spinal Disorders. Spine (Phila Pa 1976) 22:2323–2330.CrossRefGoogle Scholar
  47. 47.
    Warren RF, Marshall JL (1978) A retrospective analysis of clinical records–part I. Clin Orthop Relat Res 136:191–197Google Scholar
  48. 48.
    Yamaguchi S, Sasho T, Tsuchiya A, Wada Y, Moriya H (2006) Long term results of anterior cruciate ligament reconstruction with iliotibial tract: 6-, 13-, and 24-year longitudinal follow-up. Knee Surg Sports Traumatol Arthrosc 14:1094–1100CrossRefPubMedGoogle Scholar
  49. 49.
    Zaffagnini S, Marcacci M, Lo Presti M, Giordano G, Iacono F, Neri MP (2006) Prospective and randomized evaluation of ACL reconstruction with three techniques: a clinical and radiographic evaluation at 5 years follow-up. Knee Surg Sports Traumatol Arthrosc 14:1060–1069CrossRefPubMedGoogle Scholar
  50. 50.
    Zarins B, Rowe CR (1986) Combined anterior cruciate-ligament reconstruction using semitendinosus tendon and iliotibial tract. J Bone Joint Surg Ser A 68:160–177CrossRefGoogle Scholar

Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2017

Authors and Affiliations

  • Brian M. Devitt
    • 1
    Email author
  • Nicolas Bouguennec
    • 1
  • Kristoffer W. Barfod
    • 1
  • Tabitha Porter
    • 1
  • Kate E. Webster
    • 2
  • Julian A. Feller
    • 1
  1. 1.OrthoSport Victoria Research UnitEpworth HealthcareMelbourneAustralia
  2. 2.School of Allied HealthLa Trobe UniversityMelbourneAustralia

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