Combined ACL reconstruction and superficial Lemaire lateral extra-articular tenodesis in high-risk patients: Excellent short-term rotatory stability and patient-reported outcomes

Background Residual rotatory instability following isolated anterior cruciate ligament (ACL) reconstruction remains a significant concern, particularly in high-risk patients. Lateral extra-articular tenodesis (LET) is advocated to address this. This study evaluates the short-term outcomes of combined ACL reconstruction and the modified superficial Lemaire LET technique in a rigorously defined high-risk cohort. Methods A prospective case series of 49 consecutive high-risk patients (mean age: 23.34 ± 7.89 years) underwent combined ACL reconstruction with a hamstring autograft and a superficial Lemaire LET between 2023 and 2024. Inclusion criteria were a high-grade pivot-shift (Grade 3), young age (10°), or a lateral femoral notch sign. Outcomes were assessed pre- and postoperatively via objective stability tests (pivot-shift, Lachman, GNRB arthrometer) and patient-reported outcome measures (PROMs): IKDC, KOOS, Lysholm, and Tegner scores. Results Postoperatively, pivot-shift grade improved significantly from 2.27 ± 0.47 to 0.31 ± 0.31 (p < 0.05; Cohen's d = 5.1). The anterior drawer test was negative in all patients. No significant side-to-side difference in anterior tibial translation was found via GNRB (4.23 ± 1.55 mm vs. 3.97 ± 1.37 mm, p = 0.193). All PROMs showed significant improvement (p < 0.05): IKDC (63.54 to 90.85), KOOS (67.55 to 96.06), Lysholm (67.85 to 95.85), and Tegner activity level (3.75 to 6.75). Importantly, 85.7% (n=42) of patients returned to their pre-injury Tegner level or higher. Conclusion The addition of a modified superficial Lemaire LET to ACL reconstruction in high-risk patients results in excellent restoration of rotatory stability, significant improvements in patient-reported outcomes, and a high rate of return to sport. These promising short-term results support the selective use of this combined approach, potentially mitigating the known risk of graft failure and residual laxity in this challenging cohort. Level of Evidence Therapeutic Level IV.