Combined ACL reconstruction and superficial Lemaire lateral extra-articular tenodesis in high-risk patients: Excellent short-term rotatory stability and patient-reported outcomes

Residual rotatory instability following isolated anterior cruciate ligament (ACL) reconstruction remains a significant concern, particularly in high-risk patients. Lateral extra-articular tenodesis (LET) is advocated to address this. This study evaluates the short-term outcomes of combined ACL reconstruction and the modified superficial Lemaire LET technique in a rigorously defined high-risk cohort. A prospective case series of 49 consecutive high-risk patients (mean age: 23.34 ± 7.89 years) underwent combined ACL reconstruction with a hamstring autograft and a superficial Lemaire LET between 2023 and 2024. Inclusion criteria were a high-grade pivot-shift (Grade 3), young age (<20 years) and/or participation in pivoting sports, generalized ligamentous laxity (Beighton ≥4), genu recurvatum (>10°), or a lateral femoral notch sign. Outcomes were assessed pre- and postoperatively via objective stability tests (pivot-shift, Lachman, GNRB arthrometer) and patient-reported outcome measures (PROMs): IKDC, KOOS, Lysholm, and Tegner scores. Postoperatively, pivot-shift grade improved significantly from 2.27 ± 0.47 to 0.31 ± 0.31 (p < 0.05; Cohen's d = 5.1). The anterior drawer test was negative in all patients. No significant side-to-side difference in anterior tibial translation was found via GNRB (4.23 ± 1.55 mm vs. 3.97 ± 1.37 mm, p = 0.193). All PROMs showed significant improvement (p < 0.05): IKDC (63.54 to 90.85), KOOS (67.55 to 96.06), Lysholm (67.85 to 95.85), and Tegner activity level (3.75 to 6.75). Importantly, 85.7% (n=42) of patients returned to their pre-injury Tegner level or higher. The addition of a modified superficial Lemaire LET to ACL reconstruction in high-risk patients results in excellent restoration of rotatory stability, significant improvements in patient-reported outcomes, and a high rate of return to sport. These promising short-term results support the selective use of this combined approach, potentially mitigating the known risk of graft failure and residual laxity in this challenging cohort. Therapeutic Level IV.