ACL recon LET vs no LET

STABILITY Study (Getgood et al., 2020)

Lateral Extra-articular Tenodesis (LET) in ACL Reconstruction

🔗 https://pubmed.ncbi.nlm.nih.gov/31940222/

Getgood AMJ, et al. Lateral Extra-articular Tenodesis Reduces Failure of Hamstring Tendon Autograft Anterior Cruciate Ligament Reconstruction: 2-Year Outcomes From the STABILITY Study Randomized Clinical Trial. Am J Sports Med. 2020 Feb;48(2):285-297. doi: 10.1177/0363546519896333. Epub 2020 Jan 15. PMID: 31940222.

Key Points

  • This large randomised controlled trial looked at whether adding a lateral extra-articular tenodesis (LET) improves ACL reconstruction outcomes
  • Adding LET significantly reduced graft failure rates
  • Failure rates were reduced from around 11% to 4% at 2 years
  • The benefit was greatest in younger, higher-risk patients
  • Knee stability was improved without a meaningful increase in complications
  • University Hospitals Coventry and Warwickshire (UHCW) contributed to this international trial as one of only two UK centres

What was studied?

This was a large multicentre randomised controlled trial involving over 600 patients.

All patients had:

  • ACL reconstruction using a hamstring tendon graft

They were randomly assigned to:

  • Standard ACL reconstruction
  • ACL reconstruction plus lateral extra-articular tenodesis (LET)

LET is an additional procedure performed on the outside of the knee to improve rotational stability.

UHCW was one of only two UK centres contributing patients to this important international study.

What were the results?

Graft failure

Adding LET significantly reduced failure:

  • ACL reconstruction alone: ~11% failure rate
  • ACL + LET: ~4% failure rate

This represents:

  • A relative reduction in failure of around 60–65%
  • One of the most important findings in modern ACL surgery

Rotational stability

Patients who had LET:

  • Had better control of rotational instability
  • Were less likely to experience the knee “giving way”

This is particularly important for:

  • Cutting and pivoting sports (e.g. football, rugby, skiing)

Patient-reported outcomes

  • Both groups improved significantly
  • Overall patient-reported scores were similar between groups
  • The key difference was reduced failure risk rather than symptom scores

Complications and safety

  • No significant increase in major complications
  • Slight increase in early post-operative pain reported in LET group
  • No clear long-term downside identified

Who benefits most?

The benefit of LET was greatest in higher-risk patients, including:

  • Younger patients
  • Those returning to pivoting sports
  • Patients with high-grade rotational instability
  • Revision ACL case

What does this mean for patients?

For patients undergoing ACL reconstruction:

  • Standard ACL reconstruction works well for many patients
  • Adding LET can significantly reduce the risk of graft failure
  • This is particularly important in active or high-risk individuals

Treatment should be tailored based on:

  • Activity level
  • Sporting demands
  • Individual risk of re-injury

How this relates to my practice

This study has been highly influential in modern ACL surgery.

Having contributed to this trial through UHCW, I incorporate its findings into clinical decision-making, particularly when assessing patients at higher risk of graft failure.

In selected patients, adding LET can:

  • Improve rotational stability
  • Reduce the risk of re-injury
  • Support a safer return to sport