Similar graft failure rates in low-activity patients (Tegner activity scale ≤ 4) undergoing anterior cruciate ligament reconstruction with or without lateral extra-articular augmentation.

Purpose: To compare the outcomes of isolated anterior cruciate ligament reconstruction (ACLR) versus ACLR + lateral extra-articular procedures (LEAPs) at mid-term follow-up in a low activity population based on the Tegner activity scale (TAS ≤ 4).

Methods: This was a retrospective analysis comparing patients with a pre-injury TAS ≤ 4 who underwent primary isolated ACLR versus ACLR + LEAPs between 2012 and 2022. Propensity score matching based on age, sex, and presence of meniscal injury was used to establish two groups: ACLR alone and ACLR with LEAP. The primary outcome was the graft failure rate, compared between both groups as diagnosed by clinical instability and radiological rupture of the graft. No formal a priori sample size calculation was performed. Secondary outcomes included return to sport (RTS) metrics and Lysholm score, TAS, International Knee Documentation Committee (IKDC) score, ACL return to sport after injury scale (ACL-RSI) and Knee Injury and Osteoarthritis Outcome Score (KOOS) at the final follow-up for each patient.

Results: In the ACLR group, 170 patients were included, while in the ACLR + LEAPs group, 112 patients met the inclusion criteria. The mean age of patients was 30.9 years (standard deviation [SD] = 10.8) for ACLR and 27.8 years (SD = 10.5) for ACLR + LEAP, with similar demographics and injury characteristics across both groups (p > 0.05). The mean follow-up period was 42.74 (34.28) months for the ACLR group and 34.98 (29.32) months for the ACLR + LEAP group. Graft failure rates were similar between groups: 4.2% (6/140) in ACLR versus 5.3% (5/93) in ACLR + LEAP (p > 0.05). No significant differences were observed in post-operative IKDC scores (ACLR: 73.9 ± 24.5 vs. LEAP: 75.4 ± 22.7), Lysholm scores (86.5 ± 15.1 vs. 88.6 ± 11.0), ACL-RSI scores (55.0 ± 33.4 vs. 58.3 ± 32.9) or KOOS subscales: Pain (88.5 ± 15.2 vs. 90.3 ± 9.1), Symptoms (83.1 ± 17.4 vs. 80.8 ± 15.2), ADL (92.7 ± 13.9 vs. 94.5 ± 8.2), Sport (76.4 ± 25.5 vs. 75.0 ± 22.8) and QoL (72.2 ± 27.4 vs. 72.1 ± 24.6). However, the ACLR + LEAP group showed a greater improvement in activity level, with TAS increasing from 2.8 ± 1.3 to 5.2 ± 2.0, compared to 3.0 ± 1.2 to 4.4 ± 1.9 in the ACLR group (p = 0.004). RTS was achieved by 74.2% of ACLR patients and 77.4% of ACLR + LEAP patients (p > 0.05), with 5.8% vs. 12.6% returning to a higher level than preinjury, respectively.

Conclusion: Patients with a low TAS ≤ 4 who underwent isolated ACLR have a similar graft failure rate compared to those who underwent ACLR + LEAPs. This finding should be interpreted with caution, as the study was underpowered. Furthermore, the ACLR + LEAP group achieved a statistically significant, though modest, improvement in post-operative activity level.

Level of evidence: Level III, cohort study.