Summary
The risk of ACLR failure can be significantly reduced by adding a lateral extra-articular tenodesis (LET), even in smokers
Abstract
Purpose
Smoking is associated with a known increased risk for failure of ACL reconstruction (ACLR). The protective effect on ACLR failure of an associated lateral extra-articular tenodesis (LET) in smokers is however unknown.
Methods
This is a retrospective evaluation on a single center cohort of 748 patients treated with a primary quadrupled semitendinosus ACLR procedure between 2010 and 2015 and a minimal follow-up of 2 years. Of these, 211 (28%) patients underwent an associated LET procedure. Patients were categorized based on their smoking habits at the time of the primary surgery (N=126, 16.8%). Primary outcome was graft failure, defined as the need for revision surgery for symptomatic ACL instability.
Results
The cohort consisted of 537 patients with an isolated ACLR of which 96 (18%) smokers and 441 (82%) non-smokers and 211 patients with a combined ACL and LET procedure of which 30 (14%) smokers and 181 (86%) non-smokers. Demographic characteristics between smokers and non-smokers did not significantly differ at baseline except from smokers being 2.1 years younger (p= 0.045). In the isolated ACLR group, revision reconstruction surgery was performed in 22 (4.1%) patients: failure rate was significantly higher in smokers (9.4%, 9/96) compared to non-smokers (2.9%, 13/441) (p= 0.008, OR: 3.41, 95% CI: 1.41 - 8.22). In the combined ACL and LET group, revision reconstruction was performed in only 3 patients. Failure occurred only in non-smokers (1.7%), while no failures were observed in smokers (0%). Among smokers under the age of 25, failure rate in the isolated ACLR group was 31% (9/29), whereas no failures occurred in the ACLR + LET group (0/14). Adding a LET proved to be protective against ACLR failure in smokers, with a failure rate of 9.4% in the isolated ACL group compared to 0% in the ACL + LET group.
Conclusions
The risk of ACLR failure can be significantly reduced by adding a lateral extra-articular tenodesis (LET), even in smokers. Smoking is a known risk factor for graft failure due to its detrimental effect on microvascularity and tissue healing. However, an extra-articular procedure such as LET, performed in a well-vascularized extra-articular area and protected from the synovial fluid, appears to be less affected by the negative impact of smoking. This protective effect was particularly evident in young smokers under 25 years old: while 31% failed after isolated ACLR, none experienced failure when an LET was added.