Lateral Extra-articular Procedures Reduce the Risk of Revision of Anterior Cruciate Ligament Reconstruction in Elite
Riccardo D'Ambrosi1,2, Alessandro Carrozzo3, Edoardo Monaco4
1IRCCS Ospedale Galeazzi-Sant'Ambrogio, Milan, Italy.
Background:
Lateral extra-articular procedures (LEAPs) have gained increasing attention as an adjunct to anterior cruciate ligament reconstruction (ACLR), particularly in individuals at high risk for reinjury. When combined with ACLR, LEAPs contribute to the restoration of normal knee kinematics and provide a significant reduction in residual anterior laxity compared with isolated ACLR. This added stability provides a protective effect on the intra-articular graft, promoting improved healing and integration while reducing mechanical stress on the reconstructed anterior cruciate ligament (ACL). As a result, these techniques have been demonstrated to result in improved performance after ACLR, higher graft survival, and lower revision rates, even in elite athletes who are at significant risk for reinjury.
Purpose/Hypothesis:
The aim of this study was to systematically compare the existing evidence on ACL rerupture rates by performing a meta-analysis comparing combined ACLR and LEAP versus isolated ACLR in elite athletes. The primary hypothesis of this systematic review and meta-analysis was that the addition of LEAP would reduce the rate of revision ACLR in elite athletes.
Study Design:
Systematic review and meta-analysis; Level of evidence, 3.
Methods:
The method followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The PubMed, Embase, and Cochrane Library databases were searched to identify potentially relevant comparative studies that analyzed rerupture rate in elite athletes after isolated ACLR versus ACLR plus LEAP. The MINORS (Methodological Index for Non-Randomized Studies) score was used for quality assessment. The main outcome measure was ipsilateral ACL rerupture.
Results:
A total of 586 elite athletes received an isolated ACLR, whereas 417 athletes received combined ACLR plus LEAP. Rerupture was reported by 9.3% (95% CI, 5.5%-14.0%) of athletes. In the ACLR group, 14.0% (95% CI, 7.9%-21.5%) reported a rerupture, whereas in the ACLR plus LEAP group, the reinjury rate was 5.0% (95% CI, 1.2%-10.8%), with a statistically significant difference between the 2 groups (P = .042). Pooled odds ratio (OR) showed a 65% reduced risk of a new rupture episode in the ACLR plus LEAP group compared with the ACLR group, with an OR of 0.35 (95% CI, 0.20-0.59; P < .001).
Conclusion:
In elite athletes, adding an anterolateral procedure during ACLR significantly reduced the rerupture rate and reduced the risk of rerupture by >60%. Despite the few studies considered, our study seems to indicate that surgeons should carefully consider LEAP when treating an elite athlete in order to significantly reduce the risk of rerupture.
Registration:
PROSPERO: CRD42025637843.
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