• Alberto Grassi, Juan Pablo Zicaro, Matias Costa-Paz, Kristian Samuelsson, Adrian Wilson, Stefano Zaffagnini, Vincenzo Condello, and ESSKA Arthroscopy Committee.
• IIa Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1/10, 40136, Bologna, Italy. alberto.grassi3@studio.unibo.it.
• Knee Surg Sports Traumatol Arthrosc. 2020 Feb 1; 28 (2): 418-431.

BackgroundResidual rotational instability remains a controversial factor when analysing failure rates of anterior cruciate ligament (ACL) reconstruction. Anatomical and biomechanical studies have demonstrated a very important role of anterolateral structures for rotational control. Revision ACL is considered one of the main indications for a lateral extra-articular tenodesis (LET). Yet, few series evaluating these procedures are published.PurposeTo perform a systematic review of studies that assessed outcomes in patients treated with revision ACL surgery associated with a lateral extra-articular procedure.Study DesignSystematic review.MethodsA comprehensive literature search was performed in February 2018 using PubMed, Scopus, Web of Search and Cochrane. Inclusion criteria were series of ACL revision reconstructions associated with lateral extra-articular procedures. Clinical outcomes (Lysholm, subjective IKDC, KOOS, Cincinnati and WOMAC), joint stability measures (Lachman test, pivot-shift, arthrometer assessment and navigation assessment), graft type, reported chondral and meniscal injury, radiographic outcomes, complications and failures were recorded. Articles were assessed for level of evidence and methodology using a modification of the ACL Methodology Score (AMS) system.ResultsTwelve studies met the inclusion criteria out of the 231 abstracts; 9 retrospective evaluations, two prospective cohorts and one combination of two populations (a retrospective and prospective series). A total of 851 patients evaluated with a mean age of 28.8 years (range 16-68 years) and a weighted mean follow-up of 4.9 years (range 1-10 years). The mean time from primary ACL reconstruction to revision was 5.3 years (reported in 7 studies, including 710 patients). The Lysholm, IKDC, and KOOS scores indicated favorable results in studies that reported these outcomes. Objective evaluations reported 86% objective A and B IKDC results, 2.6 mm mean side-to-side arthrometric difference and 80% negative pivot-shift. About 74% of patients returned to their previous sport (evaluated in six studies). Few studies reported radiological evaluation. Fifty-nine complications (8.0%) and 24 failures (3.6%) were reported. The mean modified ACL Methodology Score was 55.5 (range 32-72).ConclusionGood mid-term results were obtained for combined revision ACL reconstruction and lateral extra-articular procedures. Despite the fact that in clinical practice LET are a common indication associated with revision ACL, there are no high-level studies supporting this technique.Level Of EvidenceIV.

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