Lateral extra-articular tenodesis (LET) has gained popularity as an adjunct to anterior cruciate ligament reconstruction (ACLR) in high-risk athletes, particularly when combined with hamstring tendon grafts. However, its added value compared with established graft options such as bone–patellar tendon–bone (BPTB) remains unclear. The purpose of this study was to compare the mid-term clinical, functional, and radiographic outcomes between isolated BPTB ACL reconstruction and hamstring tendon ACL reconstruction combined with LET in competitive soccer players.

We hypothesized that the addition of LET within a surgical strategy combining hamstring tendon ACL reconstruction would not provide superior clinical outcomes nor reduce graft failure rates compared with isolated BPTB reconstruction.

This prospective cohort study included 140 competitive soccer players undergoing primary ACLR between 2018 and 2020: BPTB (n = 70) and hamstring tendon plus LET (n = 70), with a minimum follow-up of 5 years. Primary outcomes included International Knee Documentation Committee (IKDC) subjective score, Lysholm score, Tegner activity scale, graft failure, and reoperation rates. Secondary outcomes included objective knee stability, return to sport (RTS), and radiographic osteoarthritis.

Both groups demonstrated significant improvements from baseline (p < 0.001 for all). At final follow-up, no significant between-group differences were observed in IKDC (87.1 vs 88.3; p = 0.48), Lysholm (91.5 vs 92.0; p = 0.62), or Tegner scores (7.8 vs 7.9; p = 0.71), with small and clinically non-meaningful differences (IKDC + 1.2 [95% CI, −2.1 to 4.5]). Graft failure occurred in 4/70 (5.7%) versus 6/70 (8.6%) (RR, 1.50; 95% CI, 0.45–5.01; p = 0.48), and reoperation rates were 8/70 (11%) versus 9/70 (13%) (RR, 1.13; 95% CI, 0.46–2.76; p = 0.34). Return-to-sport rates were comparable (60/70 [85.7%] vs 56/70 [80.0%]; p = 0.46). Side-to-side difference improved to 1.8 mm versus 1.7 mm (p = 0.92). Radiographic osteoarthritis (Kellgren–Lawrence grade 1–2) was observed in 12/70 (17.1%) versus 17/70 (24.3%) (p = 0.30).

At mid-term follow-up, HT + LET did not demonstrate statistically significant superiority over isolated BPTB ACL reconstruction in clinical outcomes, knee stability, RTS, graft survival, reoperation, or radiographic osteoarthritis among competitive soccer players. As this was not an equivalence or non-inferiority study, smaller clinically relevant differences cannot be excluded. These findings should be interpreted as a comparison of two surgical strategies, rather than as evidence of the independent effect of LET.

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