Long-term Outcomes After Anterior Cruciate Ligament Reconstruction With 3 Different Surgical Techniques: A Prospective Randomized Clinical and Radiographic Evaluation at a Minimum of 20 Years’ Follow-up
Authors: Lucidi Gian Andrea , Agostinone Piero , Di Paolo Stefano , Dal Fabbro Giacomo , Serra Margherita , Viotto Marianna , Grassi Alberto , Zaffagnini Stefano 
Published: January 2025

Background: In recent years, lateral extra-articular tenodesis (LET) has been shown to be promising in reducing the graft failure rate at short-term follow-up. However, there is a lack of studies investigating the incidence of complications and lateral osteoarthritis (OA) after this procedure, and only a few studies have reported long-term results after anterior cruciate ligament (ACL) reconstruction. Purpose/Hypothesis: This study aimed to compare the failure rate, clinical outcomes, and OA incidence of 3 different ACL reconstruction techniques: single-bundle quadrupled hamstring tendon (HT), bone–patellar tendon–bone (BPTB), and over-the-top HT plus LET (HT + LET). The authors hypothesized that the 3 techniques would have comparable clinical and radiographic outcomes at long-term follow-up. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: A total of 75 patients were included in this prospective study and randomized to undergo 1 of 3 ACL reconstruction techniques. At the last follow-up (minimum of 20 years), patient-reported outcome measure (PROM) scores, complications, and reoperations were collected, and an objective clinical evaluation was performed, including the measurement of anteroposterior (AP) laxity using an arthrometer and the quantification of the pivot shift (PS) using a triaxial accelerometer. Clinical failure was considered in patients with evidence of a graft rupture or those with a side-to-side difference in AP laxity >5 mm or with a side-to-side difference in the PS >1.5 mm/s2. At the last follow-up, patients also underwent a radiographic evaluation to assess the incidence of tibiofemoral and patellofemoral OA. Results: PROM scores were collected from 61 patients (81%) at a mean follow-up of 23.0 ± 1.1 years. Of the 75 patients, 37 (49%) completed the clinical evaluation, and 35 (47%) had radiographs obtained. Regarding the PROMs, the HT + LET group showed a slightly higher Tegner score than the BPTB group ( P = .023). All other PROM scores were not significantly different between groups. The revision and clinical failure rates were 16% and 37%, respectively, for the BPTB group, 10% and 25%, respectively, for the HT group, and 5% and 19%, respectively, for the HT + LET group, with no statistical difference between the groups. The side-to-side difference in AP laxity was lower in the BPTB group than in the HT group ( P = .049). The BPTB group showed a higher patellofemoral OA rate than the HT + LET group ( P = .029). There was no difference in the incidence of lateral OA between the 3 techniques. Conclusion: The 3 different surgical techniques achieved satisfactory clinical outcomes after ACL reconstruction at long-term follow-up. However, the BPTB group was associated with an increased incidence of patellofemoral OA. Also, the HT + LET group was associated with a slightly increased Tegner score at long-term follow-up, but there was no evidence of an increased risk of lateral OA for the HT + LET group.