A prospective study of bone-tendon-bone ACL reconstruction with and without lateral extra-articular tenodesis: 19-year clinical and radiological follow-up

OBJECTIVES: Anterior cruciate ligament (ACL) arthroscopic reconstruction with a patellar tendon graft (BTB) is a well-known and reliable surgical option for control of anterior laxity, at short and middle term. Most of those patients are young and practice sports, often at high level. Few studies have evaluated the long term effects of ACL reconstruction, and more specifically lateral tenodesis, on knee function. It has been shown that chronic anterior instability, when left untreated, evolves towards femorotibial osteoarthritis in the 10 to 20 years after ACL rupture. This study aims to compare long-term survival and femorotibial arthritis between ACL reconstruction with and without lateral tenodesis. METHODS: 121 consecutive knees (120 patients) presenting with an ACL rupture between 1998 and 1999 were included in this prospective randomized monocentric study. For the 61 knees in group BTB, an isolated patellar tendon plasty with outside-in technique was performed. For 60 knees in group BTB-T, the intra-articular plasty was associated with a lateral tenodesis with gracilis tendon. Patients were reviewed at 1 year, 6 years and 19 years post-operatively. RESULTS: 80 patients were contacted with a minimum follow-up of 19 years. 43 patients had a clinical examination and the 37 other patients were evaluated through a telephone questionnaire. We had standard X-rays for 45 patients and laximetry (TELOS™) for 42 patients. 41 patients (34%) were lost to follow-up. 16 knees (20%) had experienced a graft failure, 5 of which had had an iterative ACL plasty. The difference between group BTB (27.5%) and group BTB-T (13.2%) concerning graft failure was not statistically significant (p = 0.38). 32 patients (71%) had femorotibial osteoarthritis (IKDC grade C or D). There was no difference between groups BTB and BTB-T concerning medial femorotibial osteoarthritis. Lateral femorotibial osteoarthritis was significantly increased in groupe BTB-T (59%) compared to group BTB (21%) and to the contralateral knee (5%). 36 patients (45%) had had a lateral or medial meniscectomy. Mean subjective IKDC score was 81.8/100, comparable between groups BTB and BTB-T. 67% still practiced pivot sports. CONCLUSION: At 19 years follow-up after patellar tendon ACL plasty, lateral tenodesis did not significantly improve graft survival in our study. Lateral femorotibial osteoarthritis was significantly increased in patients with a lateral tenodesis. However, a follow-up bias may be that lesions of the lateral meniscus were more frequent in BTB-T patients for whom we obtained X-rays. Functional scores were stable at over 80/100 and two thirds of patients still practiced pivot sports. ACL graft survival was 80% at 20 years follow-up.