Surreal illustration of ACL reconstruction with LET.

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

Samir D’Costa in Health & Wellness November 2025 • 4 min read.

"Explore the complexities of revision ACL surgery and whether incorporating a lateral extra-articular tenodesis can improve outcomes. A critical look at a recent study and its implications."

Anterior cruciate ligament (ACL) ruptures are increasingly common, and while reconstructive surgery aims to restore stability, failure rates remain significant. Despite advancements in graft selection, surgical techniques, and rehabilitation protocols, primary ACL reconstruction failure rates can still reach up to 15%. Consequently, the demand for revision ACL surgeries is also growing.

Revision ACL reconstructions present unique challenges and often have higher failure rates—reported to be as high as 25%. Current research focuses on refining surgical approaches and identifying methods to improve outcomes. One promising technique involves adding a lateral extra-articular tenodesis (LET) to the revision ACL surgery. This has sparked debate whether this is the 'magic bullet' for lowering failure rates.

This article explores the complexities surrounding revision ACL surgery and examines the potential benefits and limitations of incorporating a lateral extra-articular tenodesis (LET). We'll delve into a recently published study that investigates the mid- to long-term clinical and radiological outcomes of revision ACL reconstruction with hamstring autografts and concomitant LET.

A Closer Look at Revision ACL Reconstruction with LET

Surreal illustration of ACL reconstruction with LET.

A recent study by Redler, Iorio, Monaco, and others, published in Arthroscopy, examined the outcomes of revision ACL reconstruction using hamstring autografts combined with lateral extra-articular tenodesis (LET). The retrospective study included 132 patients who underwent revision ACL surgery over a 16-year period. The procedures involved either ipsilateral or contralateral doubled gracilis and semitendinosus autografts, along with a concomitant LET.

The study reported a 90% follow-up rate with an average follow-up of 10 years, 78% of patients were male, and the average patient age was 34 years. The authors concluded that revision ACL reconstruction with doubled gracilis and semitendinosus autograft and LET provided continued improvement in clinical and radiological outcomes from preoperative assessment. However, the study also found that meniscectomy was associated with worsened radiological grades and poorer clinical outcomes.

Patient Demographics: Predominantly male patients (78%) with an average age of 34 years.
Surgical Technique: Revision ACL reconstruction using doubled gracilis and semitendinosus autograft combined with LET.
Follow-Up: 90% follow-up rate with an average of 10 years.
Outcomes: Continued improvement in clinical and radiological outcomes.
Negative Factors: Meniscectomy was related to worsened radiological grades and poorer clinical outcomes.

While the study suggests potential benefits of LET in revision ACL reconstruction, questions remain about its applicability to different patient populations. The authors highlight the discrepancy between their study population and the higher-risk group of female patients younger than 30 years who participate in high-level sports.

The Ongoing Debate

The role of LET in both primary and revision ACL reconstruction remains a topic of ongoing debate and research. While studies like the one discussed here provide valuable insights, questions persist regarding patient selection, surgical techniques, and long-term outcomes. Further research, including level 1 prospective randomized control trials, is needed to determine the optimal use of LET in ACL reconstruction.

About this Article -

This article was crafted using a human-AI hybrid and collaborative approach. AI assisted our team with initial drafting, research insights, identifying key questions, and image generation. Our human editors guided topic selection, defined the angle, structured the content, ensured factual accuracy and relevance, refined the tone, and conducted thorough editing to deliver helpful, high-quality information.See our About page for more information.

Everything You Need To Know

Why are revision ACL surgeries becoming more common, and what are the challenges associated with them?

Revision Anterior Cruciate Ligament (ACL) surgeries are increasing due to the significant failure rates of primary ACL reconstructions, which can reach up to 15% despite advancements in graft selection, surgical techniques, and rehabilitation. Revision ACL reconstructions present unique challenges and have even higher failure rates, reported to be as high as 25%. These challenges often involve addressing issues such as graft failure, instability, and the overall condition of the knee joint, making the revision process more complex than the initial reconstruction.

What is a lateral extra-articular tenodesis (LET), and why is it being considered in revision ACL surgery?

A lateral extra-articular tenodesis (LET) is a surgical technique that involves reinforcing the knee joint by creating an extra-articular support structure. It's being considered in revision Anterior Cruciate Ligament (ACL) surgery to potentially improve outcomes by providing additional stability to the knee. The goal is to reduce the risk of re-rupture and improve overall joint function. The LET procedure aims to address rotational instability, which is often a contributing factor in ACL graft failure.

What did the recent study by Redler, Iorio, Monaco, and others reveal about using hamstring autografts and lateral extra-articular tenodesis (LET) in revision ACL reconstruction?

The recent study by Redler, Iorio, Monaco, and others indicated that revision Anterior Cruciate Ligament (ACL) reconstruction using doubled gracilis and semitendinosus autografts combined with lateral extra-articular tenodesis (LET) provided continued improvement in clinical and radiological outcomes. The study followed 132 patients over a 16-year period and found a 90% follow-up rate with an average follow-up of 10 years. However, the study also found that meniscectomy was associated with worsened radiological grades and poorer clinical outcomes. The study suggests the potential benefits of LET in revision ACL reconstruction, but also recognizes the need for further research.

What are the limitations of the study on revision ACL reconstruction with LET, particularly concerning patient demographics and applicability?

The study's limitations include a predominantly male patient population (78%) with an average age of 34 years. The authors acknowledge that their findings may not be directly applicable to higher-risk groups, such as female patients younger than 30 years who participate in high-level sports. This discrepancy raises questions about the generalizability of the study's conclusions and highlights the need for further research to determine the effectiveness of lateral extra-articular tenodesis (LET) in diverse patient populations undergoing revision Anterior Cruciate Ligament (ACL) reconstruction.

What further research is needed to determine the optimal use of lateral extra-articular tenodesis (LET) in ACL reconstruction, and what are the broader implications for patient care?

Further research, including level 1 prospective randomized controlled trials, is needed to determine the optimal use of lateral extra-articular tenodesis (LET) in Anterior Cruciate Ligament (ACL) reconstruction. These studies should focus on patient selection, surgical techniques, and long-term outcomes. Understanding the specific patient populations that benefit most from LET and refining surgical protocols will lead to more effective and personalized treatment strategies. The broader implications for patient care include improved outcomes, reduced re-rupture rates, and enhanced quality of life for individuals undergoing ACL reconstruction.