Trends in Anterolateral Ligament Reconstruction and Lateral Extra-Articular Tenodesis With Primary ACL...

The recent establishment of the SFA datalake represents a major step forward for the French Arthroscopy Society, providing a large-scale, structured platform designed to describe current practices and monitor emerging surgical trends. Lateral extra-articular procedures (LEAPs) performed alongside Anterior Cruciate Ligament Reconstruction (ACL-R) have recently become increasingly popular in France, driven by renewed interest in the role of anterolateral structures in the ACL deficient knee. However there the practices of such technique are not known, justifying the register to assess: 1) the trend in usage of these procedures, 2) if they were more frequently applied according to surgeon volume and meniscal repair strategies.

We hypothesized that extra-articular procedures, particularly anterolateral ligament reconstruction (ALLR) and lateral extra-articular tenodesis (LET), are increasingly adopted in primary ACLR across France and associated with surgeon volume and meniscal repair strategies.

We performed a retrospective analysis of the French Arthroscopic Society (SFA) ACL Registry from December 2021 to October 2024. A total of 8,407 patients undergoing primary ACLR were included. The primary objective was to report the proportion of ACLRs performed with a lateral extra-articular procedure (LEAP) and to describe its evolution over time and associated trends. Secondary objectives were to evaluate associations between LEAP and patient demographics, graft choice, meniscal repair, and surgeon volume.

Among 8,407 ACLRs, 82.5% (n = 6,932) were combined with a LEAP. The rate increased significantly over the study period, from 79.6% (n = 515/647) in 2021 to 88.8% (n = 1,848/2,081) in 2024 (p < 0.0001). LEAPs were more frequent in younger, more active patients with higher preoperative laxity and pivot-shift grades (p < 0.0001). High-volume surgeons (≥50 ACLRs/year) performed more LEAPs (83.5%, n = 4,971/5,952 vs. 73.2%, n = 1,961/2,679 (p < 0.0001)) and preferred ALLR (87.4%, n = 5,452/6,932) over Lemaire procedures (8.4%, n = 524/6,932) (p < 0.0001). Meniscal repair was more frequent with LEAP, especially for ramp lesions, which were systematically recorded from 2023 onward and were identified in 41.1% (n = 1,343/3,265) of medial tears and repaired in 44.9% (n = 3,112/6,932) of patients undergoing LEAP compared with 21.3% (n = 310/1,455) in the non-LEAP group (p < 0.0001).

Our findings demonstrate a widespread adoption of ALLR and LET in primary ACL reconstruction in France. This evolution likely reflects growing recognition of their potential role in improving stability, with possible implications for graft failure rates. High-volume surgeons were more likely to use LEAPs, with greater emphasis on meniscal preservation, particularly ramp repair. These results highlight an important evolution in ACL surgical practice in France, with extra-articular procedures now integrated into routine practice, and emphasize the need for ongoing follow-up and long-term comparative studies to refine indications and confirm outcomes.

IV; Retrospective cohort study.