# Using a Residual Pivot Shift as the Indication to Perform a Lateral Extra-articular Tenodesis During ACL Reconstruction Using Autologous Hamstring Grafts Is Associated With Improved Surgical Outcomes: A Retrospective Review of 4755 Cases

## TL;DR

Using a residual pivot shift as a guide to add a lateral extra-articular tenodesis during ACL surgery is linked to better outcomes, including fewer re-ruptures and meniscal tears.

## Contribution

This study shows that using residual pivot shift as an intraoperative indicator for adding LET improves surgical outcomes in ACL reconstruction.

## Key findings

- Patients with incomplete pivot shift correction had lower ACL re-rupture rates after adding LET.
- Residual pivot shift was associated with higher graft rupture rates.
- PROMs were similar between groups despite differences in re-rupture rates.

## Abstract

There is no consensus regarding the appropriate indications for the addition of lateral extra-articular tenodesis (LET) to anterior cruciate ligament (ACL) reconstruction (ACLR).

To determine if incomplete correction of the pivot shift during ACLR is an appropriate intraoperative indication to add the LET, in terms of clinical outcome.

Cohort study; Level of evidence, 3.

From January 2018, incomplete correction of the pivot shift relative to the contralateral knee was used as the indication to add LET to ACLR. Patients presenting before this date comprised group A and those after group B. Study criteria included first-ever ACL rupture, participating in pivoting sports, no other significant ligament injury, and surgery within 3 months of injury. Outcomes of interest were recurrent instability, meniscal tears, and patient-reported outcome measures (PROMs): Tegner activity score (TAS), Knee injury and Osteoarthritis Outcome Score subscales for sport and recreation (sport/rec) and knee-related quality of life, subjective International Knee Documentation Committee score, and Lysholm knee score. Statistical analysis was performed.

Group A (2258 patients; 51% male) and group B (2497 patients; 58% male) were similar regarding age, body mass index, knee dominance, time to surgery, graft diameter, and preinjury TAS (P > .05). Group A had a lower male-to-female ratio (P < .05) and lower posterior tibial slope (P = .01). After 2 years, group A had a higher incidence of ACL rerupture than group B (101/2258 [4.5%] vs 75/2497 [3%]; P = .01), with a significant sex and group interaction (P = .04). Males in group A (4.4%) had a higher rate of recurrence than males in group B (2.4%) at 2 years (P = .03), while in females the rate of recurrence was similar (4.5% vs 3.8%; P = .42). Group A had a higher incidence of experiencing a subsequent ipsilateral meniscal tear (58/2258 [2.6%] vs 35/2497 [1.4%]; P = .02). All PROMs were similar (P > .05). Pivot-shift grade before surgery did not correlate with risk of recurrence (P = .991). Uncorrected residual pivot shift was associated with a higher ACL graft rupture rate (P < .001).

Using incomplete correction of the pivot shift during ACL surgery as the primary indication to perform LET is associated with lower rates of recurrent ACL rupture, and ipsilateral meniscal tears. Pivot-shift grade before surgery was not associated with risk of recurrence, while residual pivot shift after surgery was.