Lateral extra‐articular tenodesis does not affect tibiofemoral axial rotation in primary ACL reconstruction in professional soccer players

PURPOSE: Increased tibiofemoral (TF) rotation has been linked to a higher risk of graft failure following anterior cruciate ligament reconstruction (ACLR). This study evaluated whether isolated ACLR or the addition of lateral extra-articular tenodesis (LET) influences TF rotation in professional soccer players. METHODS: A retrospective review was conducted on professional soccer players who underwent ACLR between January 2012 and August 2024. Inclusion criteria were primary ACL injury and availability of pre- and postoperative magnetic resonance imaging (MRI). Players were grouped based on whether LET was performed in addition to ACLR, thus forming two groups who either underwent ACLR or ACLR + LET. Demographic and anatomical variables, including age, medial and lateral posterior tibial slope (PTS), knee flexion during MRI, tibial tubercle-trochlear groove (TTTG) distance, and TF rotation, were compared. A subgroup analysis was performed in players with available pre-injury MRI, allowing assessment across three time points: pre-injury, preoperative, and postoperative. Statistical analyses included appropriate parametric and nonparametric tests for group comparisons, repeated measures, and reliability assessment, with significance set at p < 0.05. RESULTS: Ninety-eight professional soccer players (mean age 23.2 ± 4.2 years) were included, of whom 70 (71.4%) underwent concomitant LET. Preoperatively, groups did not differ in age, medial or lateral PTS, knee flexion, TTTG distance, or TF rotation (all p > 0.05). Across all players, TF axial rotation did not change significantly from pre- to postoperative imaging (6.3 ± 6.0° vs. 6.3 ± 5.8°, p = 0.876). TTTG distance increased from 8.7 mm to 9.4 mm (p = 0.026), and knees were slightly more extended postoperatively (18.2° ± 5.8 vs. 16.4° ± 6.1, p = 0.006). No significant differences in delta values for knee flexion, TTTG, or TF rotation were observed between ACLR and ACLR + LET groups (all p > 0.05). In 16 players with MRI at all three time points, no significant changes in TTTG or TF rotation occurred (both p > 0.05). CONCLUSION: Resting TF rotation remained unchanged after ACLR, regardless of LET augmentation, suggesting LET does not modify baseline rotational alignment in professional soccer players. LEVEL OF EVIDENCE: Level III, retrospective comparative study.