Revision ACL reconstruction using a modified iliotibial band–allograft technique for combined ACL and lateral extra‐articular procedure achieves comparable outcomes to bone–patellar tendon–bone with modified Lemaire

PURPOSE: In revision anterior cruciate ligament reconstruction (R-ACLR), adding a lateral extra-articular procedure (LEAP) reduces graft failure and postoperative laxity. Iliotibial band (ITB)-based techniques may avoid patellar tendon harvesting morbidity, but evidence in adults, particularly in revision cases, remains limited. We compared clinical outcomes at ≥2 years after R-ACLR using a modified ITB-allograft (ITB-AG) technique versus bone-patellar tendon-bone with lateral extra-articular tenodesis (BPTB-LET). It was hypothesized that no difference in retear rates between techniques would be found. METHODS: A retrospective analysis of prospectively collected data was performed on consecutive adult patients (≥18 years) undergoing R-ACLR between 2018 and 2023. Patients were included if they received ITB-AG or BPTB-LET R-ACLR, if surgery occurred within 24 months of graft failure and follow-up was ≥2 years. Exclusions were multiligament injury, concomitant osteotomy or refusal to participate. Primary outcome was graft retear, and secondary outcomes were International Knee Documentation Committee (IKDC) subjective score, Lysholm score, complications, side-to-side anterior laxity and pivot-shift grade. Comparisons between groups were performed using Student's t test or Mann-Whitney U test for continuous variables and chi-square or Fisher exact test for categorical variables, with statistical significance set at p < 0.05. RESULTS: One hundred ninety-five patients were analysed (BPTB-LET, n = 105; ITB-AG, n = 90). Groups were similar at baseline; follow-up was 38 ± 9 months for BPTB-LET and 34 ± 7 months for ITB-AG (p = 0.0005). Meniscal tears and repairs were more frequent with ITB-AG; graft diameter was slightly smaller with ITB-AG (8.8 ± 0.7 mm for ITB-AG vs. 9.3 ± 0.5 mm for BPTB-LET; p = 0.0001). Retear rates were not different (5.7% BPTB-LET vs. 4.4% ITB-AG; p = 0.7551). IKDC was higher with ITB-AG (90.7 ± 10.8 vs. 88.3 ± 10.1; p = 0.0026); 97% (BPTB-LET) and 93% (ITB-AG) achieved the IKDC Patient Acceptable Symptom State (p = 0.3073). Lysholm was higher with ITB-AG (94.6 ± 10.8 vs. 90.8 ± 9.0; p < 0.00001). A negative pivot-shift was found in 98.9% (ITB-AG) versus 66.7% (BPTB-LET) (p < 0.00001), while KT-1000 anterior laxity did not differ significantly (p = 0.1164). Complication rates were similar (4.7% vs. 5.5%; p = 1). CONCLUSION: At midterm follow-up, a modified ITB-AG technique provided comparable graft survival to BPTB-LET, with similarly low complication rates. Patient-reported outcome measures were statistically higher and a greater proportion of patients demonstrated a negative pivot-shift test in the ITB-AG group, although the clinical relevance of these differences remains uncertain. LEVEL OF EVIDENCE: Level III.