Lateral Extra-articular Tenodesis Provides Similar Anterior Stability But Is Superior to Anterolateral Ligament Reconstruction for Internal Rotation Resistance When Combined With Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis

Abstract

Background:

While both lateral extra-articular tenodesis (LET) and anterolateral ligament reconstruction (ALLR) address rotational knee instability, their techniques and targeted anatomy differ, potentially leading to variations in effectiveness and stability.

Purpose:

To conduct a systematic review and meta-analysis of basic science laboratory-based cadaveric studies comparing anterior tibial translation (ATT) and resistance to internal tibial rotation between ALLR and LET, both in combination with anterior cruciate ligament (ACL) reconstruction (ACLR).

Study Design:

Systematic review and meta-analysis; Level of evidence, 4.

Methods:

A systematic review of MEDLINE, Embase, Scopus, and Google Scholar, including all biomechanical studies comparing ALLR with LET in conjunction with ACLR published between 2000 and 2024, was conducted. Study quality was evaluated using the Critical Appraisal Skills Programme (CASP) checklist for qualitative research and the Biomechanics Objective Basic Science Quality Assessment Tool (BOBQAT). The I² statistic was used to assess heterogeneity within and between studies. The mean effect size was calculated, and a prediction interval was established to determine whether 95% of comparable populations would fall within the true effect size range. Publication bias was analyzed through funnel plots and the Egger test.

Results:

The CASP checklist determined that all 7 studies were valuable. Based on the BOBQAT, 5 studies were classified as moderate quality, while 2 were rated as fair quality. The Egger regression intercept was −0.681 (P = .81), and the funnel plot displayed symmetry, indicating no publication bias. Comparisons of ATT between ALLR and LET across all flexion angles revealed no significant differences. Comparisons of internal tibial rotation resistance demonstrated significant differences at all flexion angles, favoring LET. When compared with the ACL-intact state, ALLR effectively restored knee stability for both ATT and internal tibial rotation resistance, close to the native state. In contrast, LET also restored knee stability for ATT and internal tibial rotation resistance but resulted in significant overconstraint of internal tibial rotation resistance at 30° and 60° of flexion.

Conclusion:

This meta-analysis demonstrated that LET provided superior resistance to internal rotation but was associated with a degree of overconstraint. No significant biomechanical differences in ATT were observed between LET and ALLR when combined with ACLR. ALLR effectively restored both ATT and internal tibial rotation resistance to near-native knee levels.