Biomechanical Analysis of Tibial Motion and ACL Graft Forces After ACLR With and Without LET at Varying Tibial Slopes

Background: Lateral extra-articular tenodesis (LET) is being performed more frequently with anterior cruciate ligament (ACL) reconstruction (ACLR) to decrease graft failure rates. The posterior tibial slope (PTS) affects ACL graft failure rates. The effect of ACLR + LET on tibial motion and graft forces with increasing PTS has not been elucidated. Hypothesis: LET would decrease anterior tibial translation (ATT), tibial rotation, and ACL graft force versus ACLR alone with increasing tibial slope throughout knee range of motion. Study Design: Controlled laboratory study. Methods: Twelve fresh-frozen cadaveric knees (mean donor age, 40.5 years; all female) were tested in 4 conditions (intact, ACL cut, ACLR, and ACLR + LET) with varying PTSs (5°, 10°, 15°, and 20°) at 3 flexion angles (0°, 30°, and 60°). Specimens were mounted to a load frame that applied a 500-N axial load with 1 N·m of internal rotation (IR) torque. The amount of tibial translation, IR, and graft force was measured. Results: Increasing PTS revealed a linear and significant increase in graft force at all flexion angles. LET reduced graft force by 8.3% (–5.8 N) compared with ACLR alone at 30° of flexion. At the same position, slope reduction resulted in reduced graft force by 17% to 22% (−12.3 to −15.2 N) per 5° of slope correction, with a 46% (−40.7 N) reduction seen from 20° to 5° of slope correction. For ATT, ACLR returned tibial translation to preinjury levels, as did ACLR + LET at all flexion angles, except full extension, where ACLR + LET reduced ATT by 2.5 mm compared with the intact state ( P = .019). Conclusion: Increased PTS was confirmed to increase graft forces linearly. Although ACLR + LET reduced graft force compared with ACLR alone, slope reduction had a larger effect across all testing conditions. No other clinically significant differences were noted between ACLR with versus without LET in regard to graft force, ATT, or IR. Clinical Relevance: Many authors have proposed LET in the setting of ACLR, revision surgery, hyperlaxity, high-grade pivot shift, and elevated PTS, but the indications remain unclear. The biomechanical performance of ACLR + LET at varying PTSs may affect daily practice and provide clarity on these indications.