The Effect of Lateral Extra-articular Tenodesis Femoral Fixation Methods on Graft Failure Rates in Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis

Background: Anterior cruciate ligament reconstruction augmented with modified-Lemaire lateral extra-articular tenodesis (ACLR+LET) improves rotational stability of the knee in patients with a moderate to high risk of graft failure. Early biomechanical data suggest divergent pullout strengths among various LET fixation methods, but their clinical significance remains to be determined. Purpose: To evaluate graft rupture rates in ACLR+LET compared with ACLR alone, stratified by the method of LET femoral fixation. Study Design: Systematic review and meta-analysis; Level of evidence, 3. Methods: A systematic review was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines. A comprehensive search was conducted across PubMed, Embase, Scopus, and CENTRAL for studies that referenced Lateral Extra-articular Tenodesis and Modified Lemaire . A meta-analysis was performed with a significance threshold of .05. Results: A total of 1199 studies were screened, and 17 met the final inclusion criteria. Across these studies, 2527 patients who underwent ACLR were analyzed; 1254 underwent ACLR with LET augmentation. LET augmentation significantly reduced graft rupture rates compared with ACLR alone (odds ratio [OR], 2.90 [95% CI, 1.89-4.46]). Among ACLR+LET subgroups, anchor fixation demonstrated the greatest reduction in graft failure (OR, 4.93; P < .001), followed by staple fixation (OR, 3.04; P < .001). Other fixation methods—including button, suture, and screw—showed potential benefit, but individual results were not statistically significant ( P > .05). Further analysis revealed that LET significantly reduced graft failure in primary ACLR (OR, 3.44; P = .00). LET-specific hardware removal was rare (0.82% [95% CI, 0.07%-2.10%]), with the highest rates seen in staple fixation, followed by anchor, and no events reported in the button and screw groups (1.58% vs 1.10% vs 0% vs 0%; P = .702). Conclusion: ACLR+LET significantly reduces the risk of primary graft failure compared with ACLR alone. Among LET femoral fixation methods, anchor and staple fixation demonstrate the lowest ACL graft failure rates, with similar hardware removal rates.