No Significant Difference in Return-to-Sport Rates Between Anterior Cruciate Ligament Reconstruction With Lateral Extra-Articular Tenodesis and Isolated Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis

Background: Although anterior cruciate ligament (ACL) reconstruction (ACLR) remains the standard to treat ACL ruptures, athletes remain at higher risk of graft rerupture. Concomitant lateral extra-articular tenodesis (LET) has gained popularity by improving rotatory stability, yet no synthesis of expected return-to-sport (RTS) rates in athletes undergoing ACLR with LET (ACLR+LET) exists. Purposes: To synthesize RTS outcomes in athletes undergoing ACLR+LET and compare RTS rates, patient-reported outcome measures, and adverse event rates between isolated ACLR (iACLR) and ACLR+LET in the athletic population. Study Design: Systematic review and meta-analysis; Level of evidence 4. Methods: Studies reporting RTS after primary single-bundle iACLR and ACLR+LET using an iliotibial band autograft at a minimum 12-month clinical follow-up were included. Primary outcomes were RTS and return to previous level (RTPL), while secondary outcomes were patient-reported outcomes and adverse events. Study quality was assessed using the Cochrane Risk of Bias 2 and Methodological Index for Non-Randomized Studies tools, while RTS criteria were assessed using the Return to Play Quality of Evidence tool. Meta-analyses and sensitivity analyses were performed using R with the “Metafor” package. Results: Fourteen studies were included, encompassing 1791 patients (38% female; mean age, 23.5 ± 8.5 years); 840 patients (709 athletes) underwent iACLR and 951 patients (901 athletes) underwent ACLR+LET. Grafts, surgical techniques, and rehabilitation protocols varied, and athletes participated in a variety of competitive and noncompetitive sports. Patients with iACLR reported a mean overall RTS rate of 88.2% ± 1.8% (344/390) and mean RTPL rate of 79% ± 16.2% (264/334), while patients with ACLR+LET reported a mean RTS rate of 88.2% ± 10.4% (591/670) and RTPL rate of 76.9% ± 16.5% (333/433). RTS did not significantly differ between the iACLR and ACLR+LET groups (OR, 0.84; 95% CI, 0.55-1.27; I 2 = 0%; P = .41), nor did RTPL (OR, 1.20; 95% CI, 0.78-1.84; I 2 0%; P = .40). Patients with ACLR+LET reported superior side-to-side laxity and flexion differential (both P < .001) and reduced graft rerupture risk (OR, 0.31; 95% CI, 0.17-0.57; I 2 = 0%; P < .001). Conclusion: There is no significant difference in RTS rates between the iACLR and ACLR+LET groups. However, ACLR+LET is associated with superior rotational stability and significantly lower graft rupture risk in an athletic population, supporting its use in high-risk patients where durability is critical.