Illustration of ACL revision surgery with lateral extra-articular tenodesis.

ACL Revision Surgery: Is Adding a Lateral Extra-Articular Tenodesis the Answer?

Lena Kashyap in Health & Wellness January 2026 • 4 min read.

"Explore the complexities of revision ACL reconstruction and the potential benefits of incorporating a lateral extra-articular tenodesis to improve outcomes and reduce failure rates."

Anterior cruciate ligament (ACL) ruptures continue to be a significant concern in sports medicine, and while primary ACL reconstruction has become a common procedure, failure rates remain relatively stable. Despite advancements in graft selection, surgical techniques, and rehabilitation protocols, a considerable number of patients still experience graft failure, leading to the need for revision surgery.

Revision ACL reconstruction presents a greater challenge due to factors such as altered anatomy, presence of scar tissue, and potential for underlying biomechanical issues. Failure rates for revision ACL reconstruction have been reported to be higher than those of primary ACL reconstruction, making it imperative to explore strategies to improve outcomes and reduce the risk of re-failure.

One such strategy that has gained attention is the addition of a lateral extra-articular tenodesis (LET) to revision ACL reconstruction. LET involves augmenting the primary ACL graft with an additional stabilization procedure on the outside of the knee. The goal is to improve rotational stability and reduce stress on the ACL graft, potentially leading to better long-term results. Whether this "magic bullet" can truly lower failure rates needs careful examination.

What the Research Says About Revision ACL Reconstruction and LET

Illustration of ACL revision surgery with lateral extra-articular tenodesis.

A recent study by Redler, Iorio, Monaco, and colleagues investigated the outcomes of revision ACL reconstruction with hamstring autografts combined with LET. The study involved a retrospective review of patients who underwent this procedure over a 16-year period. The results showed continued improvement in clinical and radiological outcomes from preoperative assessment to long-term follow-up.

The study also identified meniscectomy as a factor related to worsened radiological grades and poor clinical outcomes, reinforcing the importance of preserving meniscal tissue whenever possible. Although the study provides valuable insights, the authors themselves acknowledge the need for further research to refine patient selection criteria and surgical techniques.

Patient Demographics: The study's patient population, with a majority of male participants and an average age of 34, differs from some current practices where a higher proportion of revision ACL surgeries are performed on younger female athletes.
Importance of Timing: The length of time between the initial injury and revision surgery seems to play a crucial role in knee function. Longer intervals may lead to more irreversible chondral and meniscal damage, impacting overall outcomes.
Meniscal Management: Given that the majority of patients in this study did not undergo meniscal repairs, the findings underscore the significance of addressing meniscal pathology during revision ACL reconstruction.

It is crucial to consider potential drawbacks, such as the risk of overconstraining the knee. Surgeons need to be cautious not to excessively limit knee motion, which can lead to other complications. Furthermore, the biomechanics of LET, particularly the degree of knee rotation during tensioning and fixation, warrant further investigation.

Moving Forward in ACL Revision Surgery

The question of whether to add a lateral extra-articular tenodesis to revision ACL surgery remains a topic of ongoing debate. While studies like the one discussed here offer valuable insights, the best approach to this complex problem has yet to be fully elucidated. Further research, including prospective randomized controlled trials and biomechanical studies, is needed to refine patient selection criteria, optimize surgical techniques, and ultimately improve outcomes for patients undergoing revision ACL reconstruction. Collaboration and knowledge-sharing among surgeons and researchers are essential to advancing our understanding and treatment of this challenging condition.

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Everything You Need To Know

What is the primary challenge addressed by revision ACL reconstruction, and how does the addition of Lateral Extra-Articular Tenodesis (LET) aim to help?

Revision Anterior Cruciate Ligament (ACL) reconstruction is often more complex than primary reconstruction due to factors like altered anatomy and scar tissue. The goal of revision ACL surgery is to address the initial graft failure. Adding a Lateral Extra-Articular Tenodesis (LET) to revision ACL reconstruction is a strategy to improve outcomes by augmenting the primary ACL graft with an extra stabilization procedure on the outside of the knee. This is intended to increase rotational stability and reduce stress on the ACL graft, potentially leading to fewer re-failures.

What key findings emerged from the Redler, Iorio, Monaco, and colleagues' study on revision ACL reconstruction with LET, and what implications do these findings have on patient care?

The study by Redler, Iorio, Monaco, and colleagues found continued improvement in clinical and radiological outcomes from pre-operative assessment to long-term follow-up when using hamstring autografts combined with Lateral Extra-Articular Tenodesis (LET). A critical finding was the impact of meniscectomy on worsened radiological grades and poor clinical outcomes. This reinforces the importance of preserving meniscal tissue whenever possible. The results also emphasized the significance of timing, as longer intervals between the initial injury and revision surgery may lead to increased chondral and meniscal damage.

Why is patient selection crucial in revision ACL surgery, and how does the study's patient demographic data influence treatment decisions?

Patient selection is crucial because the success of revision ACL reconstruction depends on various factors, including the patient's age, activity level, and the extent of damage in the knee. The study revealed that the patient population primarily consisted of males, with an average age of 34. This contrasts with current trends where more revision ACL surgeries may be performed on younger female athletes. This difference highlights the need for surgeons to consider demographic factors and tailor their approach based on the specific characteristics of each patient to ensure the best possible outcome.

What are the potential drawbacks of incorporating LET into revision ACL surgery, and what precautions should surgeons take to mitigate these risks?

While Lateral Extra-Articular Tenodesis (LET) shows promise, potential drawbacks include the risk of overconstraining the knee, which could limit motion and lead to other complications. Surgeons must be cautious not to excessively limit knee motion during the procedure. The biomechanics of LET, particularly the degree of knee rotation during tensioning and fixation, require further study to optimize surgical techniques. Careful attention to detail and further research is critical.

What further research is needed to advance the field of revision ACL reconstruction, and how can collaboration among medical professionals improve patient outcomes?

Further research, including prospective randomized controlled trials and biomechanical studies, is needed to refine patient selection criteria and optimize surgical techniques for revision Anterior Cruciate Ligament (ACL) reconstruction. Collaboration and knowledge-sharing among surgeons and researchers are essential to advancing understanding and treatment of this challenging condition. Continued investigation into the best surgical approach, including the role of Lateral Extra-Articular Tenodesis (LET), will help improve outcomes and reduce failure rates in revision ACL surgeries.