Lateral extra-articular augmentation in revision ACL reconstruction
Journal of ISAKOS Joint Disorders & Orthopaedic Sports Medicine · 19 Oct 2026
† Impact is the editorial-priority score. All scores are out of 100. Clinical is a stored clinical-importance score from the earlier method; it has not been recalculated.
Why it matters
Revision ACL surgery fails more often than primary reconstruction, and this adds multicentre, minimum 5-year observational support for adding a lateral extra-articular procedure to reduce re-rupture and rotational laxity.
The evidence
This three-centre retrospective cohort of 300 adults having a first-time revision ACL reconstruction compared revision alone with revision plus a lateral extra-articular procedure (either a Lemaire-type lateral tenodesis or an anterolateral ligament reconstruction). After statistical weighting to balance measured differences between groups, the augmented knees had fewer graft failures over a mean of about 6 years: 19 of 200 (9.5%) versus 20 of 100 (20.0%), hazard ratio 0.46 (95% CI 0.28 to 0.74). They also had less residual pivot shift, with only small differences in patient-reported scores and no clear difference in return to sport.
Graft failure: Hazard ratio 0.46 (95% CI 0.28 to 0.74; ratio). The interval favours the first group; the size of the benefit needs clinical interpretation.
Why this rigour score?
Retrospective cohortDesign starting point: 29.6
Raised the score
- Post-adjustment balance demonstrated+4.3
- Compared against current standard of care+3.4
Lowered the score
No negative adjustments recorded.
Methods at a glance
Recorded assessment- Confounding adjustmentInverse-probability weighting / doubly robust
- Covariate balance confirmedMet
- Outcome assessors blindedNot reported
- Comparable start of follow-upMet
- Adequate statistical powerCalculation absent
- Prospective registrationNot met
Not reported does not mean not done. Checks have different weights; this is not a count of boxes ticked.
See the full score breakdown
- Study design starting point
- 29.6
- Post-adjustment balance demonstrated
- +4.3
- Aligned time zero
- +2.5
- Compared against current standard of care
- +3.4
- 60-month follow-up
- +3.4
- Consecutive enrolment
- +2.5
- Journal prior (not an observed method)
- +0.8
- Final rigour score rounded
- 47 / 100
Study design sets the starting point and a ceiling of 72. Recorded methods then adjust the score. Points are shown to one decimal place; the final score uses unrounded values.
Checklist from the stored appraisal. “Not met” describes the recorded criterion; it does not always produce a deduction. This overview supports reading the full study.
For journal club
1.Which revision ACL patients (for example high-grade pivot shift, pivoting athletes, generalised laxity) would you counsel to add a lateral extra-articular procedure, and how would you explain an absolute failure reduction of about 10 percentage points?
2.Given no clear difference between LET and ALL reconstruction, how would graft availability, lateral-sided pain risk, and surgeon familiarity guide your choice of augmentation technique in a revision knee?
Original publication title
Lateral extra-articular augmentation is associated with improved graft survival after revision anterior cruciate ligament reconstruction