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Lateral extra-articular tenodesis by femoral fixation is beneficial to anterior cruciate ligament graft survival: A systematic review and meta-analysis
*Corresponding author: Vishnu Senthil, Department of Orthopaedics, Government Royapettah Hospital, Chennai, Tamil Nadu, India. vishsnake@gmail.com
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Received: ,
Accepted: ,
How to cite this article: Desouza C, Senthil V, Desouza J. Lateral extra-articular tenodesis by femoral fixation is beneficial to anterior cruciate ligament graft survival: A systematic review and meta-analysis. J Arthrosc Surg Sports Med. doi: 10.25259/JASSM_9_2026
Abstract
Background and Aims:
Lateral extra-articular tenodesis (LET) is increasingly used as an adjunct to anterior cruciate ligament reconstruction (ACLR) to reduce graft failure, particularly in high-risk patients. Multiple femoral fixation techniques for LET have been described; however, their relative effectiveness in improving graft survivorship and associated complications remains unclear.
Materials and Methods:
A systematic review and meta-analysis were performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Electronic databases were searched for studies comparing ACLR with and without LET using the modified Lemaire technique. Subgroup analyses were conducted based on femoral fixation method, graft type, reconstruction setting (primary vs. revision), and level of evidence. The primary outcome was anterior cruciate ligament (ACL) graft failure. Pooled odd ratios (ORs) were calculated using a random-effects model.
Results:
Eleven studies encompassing 2208 knees were included. Overall, ACLR augmented with LET significantly reduced graft failure compared with isolated ACLR (OR, 0.45; 95% confidence interval [CI], 0.30–0.68; P = 0.0002). Subgroup analysis demonstrated a significant reduction in failure rates with anchor fixation (OR, 0.31; 95% CI, 0.13–0.75) and staple fixation (OR, 0.43; 95% CI, 0.23–0.79). Screw, button, and suture fixation did not demonstrate statistically significant reductions in graft failure. No significant heterogeneity was observed across analyses.
Conclusion:
LET augmentation significantly improves ACL graft survivorship compared with ACLR alone. Anchor and staple femoral fixation methods demonstrate the greatest clinical benefit; however, overlapping confidence intervals preclude definitive superiority of one technique.
Keywords
Anterior cruciate ligament reconstruction
Femoral fixation
Graft failure
Lateral extra-articular tenodesis
Modified Lemaire technique
INTRODUCTION
Anterior cruciate ligament reconstruction (ACLR) is among the most commonly performed procedures in orthopedic sports medicine.[1,2] Despite continued refinements in surgical techniques and post-operative rehabilitation protocols, graft failure remains a clinically relevant concern, with reported rates reaching up to 15%.[3-9]
Residual rotational instability following ACLR has been increasingly recognized as an important factor contributing to graft failure.[8,10] Consequently, multiple strategies have been explored to improve rotational control and enhance graft survivorship.[11] Intra-articular reconstruction techniques have evolved toward more anatomic graft placement, and modifications such as the shift from single-bundle to double-bundle anterior cruciate ligament (ACL) reconstruction have demonstrated improved biomechanical stability in experimental settings.[12-15] However, the translation of these biomechanical advantages into consistent clinical benefit has been variable.[16,17]
In light of these limitations, interest has grown in the use of lateral extra-articular procedures (LEAPs) as an adjunct to ACLR.[18] These procedures target the anterolateral complex of the knee, a key contributor to anterolateral rotatory stability, comprising the superficial and deep layers of the iliotibial band (ITB), the capsulo-osseous layer, and the anterolateral ligament (ALL).[19-26]
Among the various LEAP techniques, the modified Lemaire procedure has gained widespread acceptance.[27] This technique utilizes a shorter strip of the ITB compared with the original description, leaving it distally attached to Gerdy’s tubercle, passing it deep to the lateral collateral ligament, and securing it proximally on the femur to augment anterolateral stability. Biomechanical investigations have shown that the addition of a lateral extra-articular tenodesis (LET) can significantly reduce internal tibial rotation and decrease strain on the ACL graft, potentially lowering the risk of graft failure.[20,22,28]
Proper femoral fixation of the LET graft is critical to ensure consistent tension throughout knee motion, thereby avoiding overconstraint or residual laxity.[27] Various fixation methods, including screws, staples, and suture anchors, have been described, yet there is limited comparative evidence evaluating their relative effectiveness.
Although the modified Lemaire technique has been associated with improved clinical outcomes,[29,30] direct comparisons of femoral fixation techniques remain scarce. Therefore, the purpose of this systematic review and meta-analysis is to assess graft rupture rates in patients undergoing ACLR with LET compared with ACLR alone, with subgroup analysis based on the femoral fixation method used for LET.
MATERIALS AND METHODS
Study design
This systematic review and meta-analysis were conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) recommendations.[31]
Literature search
A systematic literature search was performed across four electronic databases – PubMed (MEDLINE), Embase (Ovid), Scopus, and the Cochrane Central Register of Controlled Trials. Studies published from database inception through November 2025 were screened. Search terms included combinations of keywords and Medical Subject Headings related to ACLR, LET, and the modified Lemaire technique. In addition, reference lists of eligible articles and relevant systematic reviews were manually reviewed to identify further studies.
Eligibility criteria
Study eligibility was defined using the population, intervention, comparison, and outcomes framework. We included English-language primary studies with level I to III evidence, including randomized controlled trials, prospective or retrospective cohort studies, and case series involving at least 20 patients. Eligible studies evaluated ACL graft failure in patients undergoing ACL reconstruction with a modified Lemaire LET.
Participants were required to be older than 10 years with clinically symptomatic ACL insufficiency. Both primary and revision ACL reconstructions incorporating a modified Lemaire LET were eligible. Studies that did not specify the femoral fixation technique for the LET graft were excluded.
Comparisons included ACLR with LET versus isolated ACLR, as well as comparisons between different LET femoral fixation methods. Studies reporting outcomes following ACLR with LET without a direct ACLR-only control group were also included. Investigations involving alternative extra-articular techniques, such as Arnold–Coker modification of the McIntosh procedure or isolated ALL reconstruction (ALLR), were excluded.
The primary outcome of interest was graft failure, defined as either confirmed graft rupture on magnetic resonance imaging or knee arthroscopy, or the need for revision ACL reconstruction. Subjective failure indicators, including patient-reported instability or positive Lachman or pivot-shift tests without objective graft disruption, were not considered. Secondary outcomes included the requirement for subsequent symptomatic hardware removal.
Study selection
Two reviewers independently screened titles, abstracts, and full-text articles for eligibility. Any discrepancies were resolved through consensus, with arbitration by the senior author when necessary.
Risk of bias (ROB) assessment and data extraction
Methodological quality and ROB were evaluated independently by two reviewers. Randomized controlled trials were assessed using the Cochrane ROB-2 tool, while non-randomized studies were evaluated using the ROB in non-randomized studies of interventions (ROBINS-I) framework. Relevant data were extracted using a standardized data collection form.
Statistical analysis
Meta-analysis was conducted using a random-effects model to account for expected clinical and methodological heterogeneity. Statistical analyses were performed using the Statistical Package for the Social Sciences (Version 29; IBM Corp) and Revman 5.3. Studies with incomplete or missing outcome data were excluded from quantitative synthesis.
Between-study heterogeneity was evaluated using the I2 statistic, the Cochran’s Q test, and visual inspection of forest plots. Publication bias was assessed through funnel plot analysis. A two-tailed P < 0.05 was considered statistically significant.
RESULTS
Study selection and characteristics
The literature search identified 1,345 records through database searching [Figure 1]. After removal of duplicates and screening of titles and abstracts, 144 articles underwent full-text review. Eleven studies satisfied the predefined inclusion criteria and were included in the final analysis. Methodological quality was deemed acceptable across all included studies based on assessment with the RoB-2 and ROBINS-I tools [Figure 2]. Of the included studies, 6 were retrospective cohort studies, 3 were randomized controlled trials, and 2 were prospective cohort studies [Table 1].
- Preferred Reporting Items for Systematic Reviews and Meta-analyses 2020 flow diagram for systematic reviews.
- (a) Methodological quality and assessment of bias, risk of bias-2 for Level 1 studies. (b) Methodological quality and assessment of bias, risk of bias in non-randomized studies of interventions for level 2 and 3 studies.
| Study | Design | Level of evidence | N | Mean age (years) | Male (%) | Primary/revision ACLR | ACLR graft source | LET femoral fixation | Mean follow-up (months) | Minimum follow-up (months) |
|---|---|---|---|---|---|---|---|---|---|---|
| Abou Al Ezz et al.[29] | Cohort | III | LET+ACLR: 106 ACLR: 61 | 28.7±8.9 28.2±7.2 | 114 | Revision | BPTB autograft | Screw | 47.2±22.7 | 24 |
| Borque et al.[34] | Cohort | III | LET+ACLR: 117 ACLR: 338 | 21.5±4.1 22.9±4.9 | 376 | Primary | HT autograft | Anchor | NR | 24 |
| Castoldi et al.[35] | RCT | II | LET+ACLR: 38 ACLR: 42 | 26.2 (15–40) 25.9 (16–40) | 90 | Primary | BPTB autograft | Suture | 232.8 (228–242.4) | 24 |
| El-Azab et al.[36] | RCT | I | LET+ACLR: 47 ACLR: 48 | 28±6 27±5.85 | 80 | Primary | HT autograft | Screw | NR | 24 |
| Getgood et al.[44] | RCT | I | LET+ACLR: 291 ACLR: 298 | 19.1±3.3 18.8±3.2 | 151 | Primary | HT autograft | Staple | NR | 24 |
| Helito et al.[37] | Cohort | III | LET+ACLR: 45 ACLR: 88 | 29.5±7.8 31±5.2 | 110 | Revision | Mixed | Anchor | 34.1±11.2 (24–84) | 24 |
| Jacquet et al.[38] | Cohort | III | LET+ACLR: 134 ACLR: 55 | 30.5±8.6 30.5±7.9 | 137 | Primary | BPTB autograft | Screw | 44.3 | 24 |
| Joseph et al.[39] | Cohort | III | LET+ACLR: 35 ACLR: 52 | 23±6.3 34.2±10.5 | 57 | Primary | HT autograft | Screw | NR | 8 |
| Perelli et al.[40] | Cohort | II | LET+ACLR: 32 ACLR: 34 | 13.8±1.4 13.5±1.2 | 43 | Primary | HT autograft | Screw | 25.9±3.5 | 24 |
| Vivacqua et al.[32] | Cohort | III | LET+ACLR: 35 ACLR: 39 | 24.6±7.4 29.2±12.2 | 31 | Revision | Mixed | Staple | 50.8±23.5 | 24 |
| Rowan et al.[33] | Cohort | III | LET+ACLR: 55 ACLR: 218 | 26 (16–64) 33 (14–56) | 154 | Primary | HT autograft | Staple | 52 (24–96) | 24 |
ACLR: Anterior cruciate ligament reconstruction, LET: Lateral extra-articular tenodesis, BPTB: Bone–patellar tendon–bone, HT: Hamstring tendon, NR: Not reported, RCT: Randomized control trail
Effect of LET fixation on graft failure
Across all included studies, ACL reconstruction augmented with LET demonstrated a significantly lower risk of graft failure compared with isolated ACL reconstruction (odds ratio [OR], 0.45; 95% confidence interval [CI], 0.30–0.68, P = 0.0002) [Figure 3].
- (a) Forrest plot for graft failure. (b) Funnel plot for graft failure. ACLR: Anterior cruciate ligament reconstruction, LET: Lateral extra-articular tenodesis, CI: Confidence interval.
Subgroup analysis of graft failure based on the LET femoral fixation method
Subgroup analysis based on femoral fixation technique demonstrated variability in graft failure outcomes. Anchor fixation was associated with a significant reduction in graft failure compared with isolated ACL reconstruction (OR, 0.31; 95% CI, 0.13–0.75; P = 0.009), as was staple fixation (OR, 0.43; 95% CI, 0.23–0.79; P = 0.007). In contrast, screw fixation did not demonstrate a statistically significant reduction in graft failure (OR, 0.84; 95% CI, 0.34–2.08; P = 0.71). Suture fixation showed a trend toward improved graft survivorship; however, this did not reach statistical significance (OR, 0.38; 95% CI, 0.12–1.20; P = 0.10). No significant heterogeneity was observed within subgroups (I2 = 0%), and the test for subgroup differences was not significant (χ2 = 2.58; P = 0.46) [Figure 4].
- (a) Forrest plot for sub-group analysis of graft failure based on lateral extra-articular tenodesis (LET) femoral fixation method. (b) Funnel plot for sub-group analysis of graft failure based on LET femoral fixation method. ACLR: Anterior cruciate ligament reconstruction, CI: Confidence interval.
Subgroup analysis by ACL graft type
Subgroup analysis stratified by graft type demonstrated differential effects of LET. In hamstring tendon [HT] autograft reconstructions, the addition of LET was associated with a significant reduction in graft failure compared with isolated ACL reconstruction (OR, 0.36; 95% CI, 0.21–0.60; P = 0.0001), with no observed heterogeneity (I2 = 0%). In contrast, no significant reduction in graft failure was observed in reconstructions using bone–patellar tendon– bone [BPTB] autografts (OR, 0.91; 95% CI, 0.26–3.15; P = 0.88), with moderate heterogeneity (I2 = 45%). The test for subgroup differences was not statistically significant (χ2 = 1.84; P = 0.17), suggesting that graft type did not significantly modify the effect of LET augmentation [Figure 5].
- (a) Forrest plot for sub-group analysis by anterior cruciate ligament (ACL) graft type. (b) Funnel plot for sub-group analysis by ACL graft type. ACLR: Anterior cruciate ligament reconstruction, LET: Lateral extra-articular tenodesis, CI: Confidence interval, BPTB: Bone–patellar tendon– bone, HT: Hamstring tendon.
Subgroup analysis on primary versus revision ACL reconstruction
The included studies encompassed predominantly primary ACL reconstructions (n = 8), along with revision cases (n = 3). Subgroup analysis based on the reconstruction setting demonstrated a differential effect of LET. In primary ACL reconstruction, the addition of LET was associated with a significant reduction in graft failure compared with isolated ACL reconstruction (OR, 0.38; 95% CI, 0.24–0.61; P < 0.0001), with no observed heterogeneity (I2 = 0%). In contrast, LET augmentation in revision ACL reconstruction did not result in a statistically significant reduction in graft failure (OR, 0.82; 95% CI, 0.25–2.73; P = 0.75), with moderate heterogeneity (I2 = 48%). The test for subgroup differences was not statistically significant (χ2 = 1.37; P = 0.24) [Figure 6].
- Forrest plot for subgroup analysis on primary versus revision anterior cruciate ligament reconstruction. ACLR: Anterior cruciate ligament reconstruction, LET: Lateral extra-articular tenodesis, CI: Confidence interval.
Subgroup analysis by level of evidence
Subgroup analysis stratified by study design demonstrated a significant reduction in graft failure with LET in Level I studies (OR, 0.37; 95% CI, 0.19–0.74; P = 0.005). Level II studies demonstrated a borderline significant reduction in graft failure (OR, 0.38; 95% CI, 0.15–0.99; P = 0.05). In contrast, Level III studies did not demonstrate a statistically significant benefit of LET augmentation (OR, 0.58; 95% CI, 0.29–1.14; P = 0.11). Heterogeneity within subgroups was low (I2 ≤ 13%), and the test for subgroup differences was not significant (χ2 = 0.89; P = 0.64) [Figure 7].
- Forrest plot for subgroup analysis by level of evidence. ACLR: Anterior cruciate ligament reconstruction, LET: Lateral extra-articular tenodesis, CI: Confidence interval.
DISCUSSION
The principal finding of this systematic review and meta-analysis is that ACLR augmented with LET significantly reduces graft failure rates compared with with isolated ACLR.[29,32-40] This protective effect was consistent across most subgroup analyses, with the magnitude of benefit influenced by the method of femoral fixation, graft type, reconstruction setting (primary vs. revision), and study quality level. Among fixation techniques, anchor- and staple-based femoral fixation demonstrated the most robust association with reduced graft failure, although staple fixation was also associated with a higher incidence of symptomatic hardware irritation requiring secondary surgery.
The overall reduction in graft failure observed with ACLR + LET in this study aligns closely with prior high-quality investigations and meta-analyses.[41-43] Large, randomized trials such as the STABILITY study by Getgood et al.[44] and subsequent pooled analyses have demonstrated a meaningful reduction in graft rupture in high-risk populations undergoing ACLR augmented with LET. Our findings corroborate these reports and further extend the literature by focusing specifically on femoral fixation methods used in the modified Lemaire LET, an area that has been incompletely addressed in previous reviews.
Previous studies have often grouped LET techniques together or combined LET with ALLR, introducing heterogeneity in surgical technique and biomechanical intent.[45-48] By isolating studies using modified Lemaire-type LET and stratifying outcomes by femoral fixation method, the present analysis provides clinically actionable insights for surgeons selecting fixation strategies.
Subgroup analysis demonstrated that anchor-based femoral fixation was associated with the lowest odds of graft failure, followed closely by staples. Screw-based fixation did not demonstrate a statistically significant reduction in graft failure, although point estimates favored ACLR + LET. While interference screws provide high ultimate failure loads, prior biomechanical and clinical studies have raised concerns regarding tunnel convergence, particularly in anatomic ACLR, with reported rates as high as 70%.[49,50]
Staple fixation also demonstrated a significant reduction in graft failure; however, this benefit must be balanced against the higher rate of hardware irritation and reoperation for removal, as reflected in several included studies.[32,33,44]This trade-off is clinically important and should be discussed during surgical decision-making, particularly in thin or highly active patients.
When stratified by ACL graft source, HT autografts demonstrated a significant reduction in failure rates with LET augmentation, whereas BPTB grafts did not show a statistically significant benefit. This finding is consistent with existing literature suggesting that LET provides the greatest relative advantage in grafts with higher intrinsic rotational laxity, such as hamstring constructs.[14,19,21]
In primary ACLR, LET augmentation resulted in a significant and clinically meaningful reduction in graft failure, with minimal heterogeneity across studies. In contrast, while revision ACLR demonstrated a trend toward benefit, statistical significance was not achieved. This likely reflects limited sample size and reduced statistical power, rather than a true absence of effect. Prior meta-analyses that included ALLR and other extracapsular procedures have reported significant reductions in revision graft failure, suggesting that LET may confer similar benefits when adequately powered studies are available.
Collectively, these findings support the growing role of LET as an adjunct to ACLR in high-risk populations, including young athletes, patients with high-grade pivot shift, generalized ligamentous laxity, and those undergoing revision reconstruction. While anchor-based fixation may offer technical advantages, such as reduced tunnel convergence and lower hardware irritation, the fixation method should be individualized based on patient anatomy, activity level, and surgeon experience.
Strength
This systematic review highlights several strengths that reinforce the validity and clinical relevance of its findings. The primary strength lies in the comprehensive synthesis of available evidence evaluating the effect of LET augmentation on graft survivorship following ACLR, with a particular focus on femoral fixation techniques. By performing detailed subgroup analyses based on fixation method, graft type, reconstruction setting, and study level, this study provides nuanced insights that extend beyond prior meta-analyses, many of which pooled heterogeneous extra-articular procedures.
Limitations
Despite the strengths, several weaknesses must be acknowledged. The available literature remains limited by heterogeneity in patient selection, surgical technique, and ACL graft choice, all of which may independently influence graft survivorship. The relatively small number of studies directly comparing femoral fixation methods restricts the ability to draw definitive conclusions regarding the superiority of one technique over another. In addition, many included studies report short- to mid-term follow-up, limiting assessment of long-term outcomes such as osteoarthritis progression or sustained functional benefit. Incomplete reporting of rotational laxity, return-to-sport rates, and patient-reported outcome measures further constrains comprehensive outcome assessment.
Future direction
This study also identifies important opportunities for future research. There is a clear need for high-quality, prospective trials directly comparing femoral fixation methods for LET, with standardized surgical techniques and clearly defined patient risk profiles. In addition, future investigations integrating LET fixation strategies into personalized ACLR treatment algorithms, based on patient age, activity level, graft type, and laxity patterns, may help optimize outcomes while minimizing complications.
This systematic review was conducted in accordance with the PRISMA 2020 guidelines. The PRISMA 2020 checklist was followed to ensure transparent and comprehensive reporting of the study.
CONCLUSION
Our systematic review and meta-analysis demonstrate that augmentation of ACLR with a modified Lemaire LET is associated with a significant reduction in graft failure compared with isolated ACLR. Among the evaluated femoral fixation techniques, suture anchor and staple fixation were associated with the greatest reduction in graft rupture rates, while other fixation methods showed a trend toward improved graft survivorship without reaching statistical significance. The protective effect of LET was most pronounced in primary ACLR, supporting its role in enhancing rotational stability and reducing graft strain in high-risk patients. Overall, these findings support the selective use of modified Lemaire LET as an effective adjunct to ACLR, particularly in primary procedures at increased risk of failure. Further high-quality, prospective studies directly comparing femoral fixation techniques are warranted to better define the optimal fixation strategy and to clarify long-term clinical and radiographic outcomes.
Author contributions:
CD: Conceptualized and designed the study, conducted the literature search, performed data extraction and statistical analysis, and drafted the manuscript. VS: Contributed to study design, supervised the methodology, resolved disagreements during study selection and data synthesis, and critically revised the manuscript for important intellectual content; JD: Assisted with data extraction, quality assessment, and interpretation of results, and contributed to manuscript editing. All authors reviewed, and approved the final manuscript.
Declarations
Ethical approval:
Institutional Review Board approval is not required.
Declaration of patient consent:
Patient’s consent not required as patients identity is not disclosed or compromised.
Conflicts of interest:
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
Availability of data and materials:
All data analyzed during this study are included in this published article. Further details are available from the corresponding author on reasonable request.
Financial support and sponsorship: Nil.
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