# Similar graft rerupture rates after ACL reconstruction with or without lateral extra‐articular procedure in patients over 40 years

## TL;DR

Adding a lateral extra-articular procedure to ACL reconstruction in patients over 40 does not significantly reduce graft rerupture rates compared to ACL reconstruction alone.

## Contribution

This study is the first to compare ACLR with and without LEAP in patients over 40 years at midterm follow-up, finding no significant difference in graft rerupture rates.

## Key findings

- Graft rerupture rates were low and not significantly different between ACLR alone and ACLR+LEAP groups.
- Functional outcomes, return-to-sport rates, and reoperation rates were comparable between the two groups.
- A subgroup analysis using hamstring grafts showed no reruptures in the ACLR+LEAP group compared to 2.8% in the ACLR alone group.

## Abstract

To compare the outcomes of isolated anterior cruciate ligament reconstruction (ACLR) versus ACLR+ lateral extra articular procedures (LEAP) at midterm follow up in patients older than 40 years old.

This was a retrospective cohort study based on prospectively collected data of patients aged over 40 years who underwent ACLR, with or without LEAP, from 2012 to 2022. Patients were matched by age, sex, preinjury Tegner score, and follow‐up duration to minimize selection bias. LEAP was reserved for higher‐risk individuals—specifically those with high pivot shift, valgus alignment, recurvatum, chronic lesions, suturable meniscal tears, or high activity levels. The primary outcome was graft rerupture rate, defined as the recurrence of subjective instability associated with abnormal anterior laxity on clinical examination (Lachman grade ≥2 and/or pivot shift grade ≥2) and confirmed by magnetic resonance imaging or intraoperative findings. Secondary outcomes included return‐to‐sport (RTS) rates, time to RTS, and functional scores, including the International Knee Documentation Committee (IKDC) score, Knee injury and Osteoarthritis Outcome Score (KOOS), Anterior Cruciate Ligament–Return to Sport after Injury (ACL‐RSI) score, Lysholm score, and Tegner Activity Scale (TAS).

A total of 216 patients were analyzed (142 ACLR, 74 ACLR + LEAP) at a mean follow‐up of 59.6 versus 64.5 months respectively (p > 0.05). The mean age was 44.7 (SD = 3.4) versus 44.4 (SD = 3.5) years, respectively (p > 0.05). Graft rerupture rates were low in both groups, with no significant difference (2.8% in ACLR vs. 1.3% in ACLR + LEAP, p > 0.05). Functional outcomes and non‐graft‐rupture related reoperation rates were also comparable. Return to the same sport was reported in 54.9% of the ACLR group and 59.5% of the ACLR + LEAP group (p > 0.05), with similar time to RTS. A subgroup analysis of patients undergoing ACLR using hamstring grafts only showed no reruptures in the ACLR + LEAP group compared to a 2.8% rerupture rate in the ACLR alone group (p > 0.05).

No significant reduction in overall graft rerupture risk was observed with the addition of LEAP to ACLR in patients over 40 years old. Functional outcomes and reoperation rates were comparable between groups.

Cohort study, level of evidence 3.

Level III, cohort study.