The Role of Isolated Lateral Extra-Articular Tenodesis in Managing Residual Pivot Shift After Primary Anterior Cruciate Ligament Reconstruction and a New Medial Meniscal Tear

Background: Persistent mildly abnormal knee kinematics after anterior cruciate ligament (ACL) reconstruction (ACLR) is an ongoing clinical problem. Purpose: To compare the clinical outcomes of revision ACLR (rACLR), rACLR and lateral extra-articular tenodesis (LET), or isolated LET in patients with a grade ≥2 pivot shift after ACLR with an intact or partially torn graft and a new, symptomatic medial meniscal tear. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective review of all patients with a new, symptomatic medial meniscal tear diagnosed after a primary ACLR was performed. Patients were included if they demonstrated a grade ≥2 pivot shift on physical examination with an intact or partially torn ACL graft. Exclusion criteria included complete graft rupture. The senior author’s management evolved in a practice change design from rACLR to rACLR with LET, to isolated LET over the study period. The primary outcomes were the International Knee Documentation Committee (IKDC), Lysholm, and Tegner patient-reported outcomes (PROs) at 2 years postoperatively. Results: A total of 47 patients, with 16 in the rACLR group, 12 in the rACLR and LET group, and 19 in the isolated LET group were included. Baseline characteristics between groups were similar. At 2 years, the rACLR group IKDC score was 86.1 ± 6.6 and was lower than the rACLR and LET group (91.9 ± 4.4; P = .009; 95% CI, –10.4 to −1.2) and the isolated LET group scores (91.7 ± 3.0; P = .004; 95% CI, –9.7 to −1.6). The Lysholm score was lower in the rACLR group (85.8 ± 6.3) when compared with the rACLR and LET group (91.8 ± 4.6; P = .03; 95% CI, –11.8 to −0.39). There was no difference in any Tegner scores at 2 years ( P = .09). Conclusion: In patients with grade ≥2 pivot shift after an ACLR with an intact or partially torn graft and a new, symptomatic medial meniscal tear, the addition of an LET with or without rACLR led to improved PROs compared with an isolated rACLR. An isolated LET in this patient population should be considered an acceptable treatment option.