The investigators compared two commonly used ACL grafts: hamstring tendon and bone–patellar tendon–bone autografts. More importantly, they examined what happened when a lateral extra-articular tenodesis (LET) was added to the ACL reconstruction.
The most striking finding was that graft choice appeared to matter far less than whether an LET was performed. In the adjusted analysis, hamstring versus patellar tendon graft was not a significant predictor of graft failure. In contrast, adding an LET was associated with an approximately 85% reduction in the risk of ACL graft failure.
The absolute numbers were impressive. At five years, the reported graft failure rates were only 0.8% for patellar tendon ACL reconstruction with LET and 0.9% for hamstring ACL reconstruction with LET, compared with 5.5% for isolated patellar tendon reconstruction and 8.2% for isolated hamstring reconstruction.
The authors therefore concluded that the addition of the LET appeared to be the dominant factor associated with improved graft survival, while the choice between hamstring and patellar tendon grafts was considerably less important.
This is something I have incorporated into my own practice for approximately the past decade. In patients at particularly high risk of ACL reconstruction failure, I strongly consider adding an LET at the time of surgery.
Who are these patients? They include very young athletes, patients involved in cutting and pivoting sports such as soccer and basketball, high-level or professional athletes, and patients undergoing revision surgery after a previous ACL reconstruction has failed.
The broader message is an important one and is consistent with the direction ACL surgery has been moving.
It is time to move past the endless debate over which ACL graft is “the best.” What matters is matching the operation to the individual patient and their risk profile.
For me, that means less fixation on graft choice and more attention to the patient in front of me. In a high-risk athlete—young, returning to a cutting or pivoting sport, competing at a high level, or recovering from a previous ACL failure—an LET can be an important part of giving the reconstructed ACL its best chance to withstand the demands of sport.
Reference
Rivarola H, Chahla J, Ramos P, et al. Association of Lateral Extra-Articular Tenodesis With Graft Failure and Return to Sport in Pivoting Athletes: A Multicenter Comparative Study of Augmented and Isolated ACL Reconstructions. Orthop J Sports Med. 2026;14(8):23259671261449998. doi:10.1177/23259671261449998. PMID: 42553396.