Posterior Tibial Slope ≥ 12°, Static Anterior Tibial Translation ≥ 5mm, Age<18 and Lateral Meniscus Tears Are Majors Risk Factors for Hamstrings Graft Rupture: a Cohort Analysis of ACL Reconstruction Using a Selective Approach to Lateral Extra-Articular Tenodesis

Objective: This study aimed to evaluate anterior cruciate ligament (ACL) graft rupture in a selective “à la carte” approach to lateral extra-articular tenodesis (LET), with a particular focus on the impact of posterior tibial slope (PTS) and static anterior tibial translation (SATT) on hamstring graft rupture rate. Methods: This retrospective, single-center, single-surgeon study included patients who underwent primary ACLR using hamstrings autograft between 2014 and 2017, with a minimum follow-up of six years. Demographic variables, ACL graft rupture, graft type, associated procedures, and time to rupture were recorded. Preoperative radiographs were used to measure PTS and SATT. Subgroup analyses were conducted based on age, PTS, and SATT. Univariate and multivariate analyses were performed to identify independent risk factors for graft rupture. Results: A total of 839 patients were eligible. Follow-up was obtained for 705 patients (mean age 30.5 ± 10.9 years; 38% female). Forty-one ACL graft ruptures were identified (5.8%). Among adult patients (≥18 years), the graft rupture rate was 4.5% in the ACLR + LET group versus 5.4% in the isolated ACLR group (p = 0.673). Risk factors significantly associated with graft rupture included PTS ≥ 12° (OR 3.0; 95% CI, 1.5–6.2; p = 0.001), SATT ≥ 5 mm (OR 2.7; 1.3–5.5; p = 0.006), age < 18 years (OR 2.3; 1.0–3.9; p = 0.017), and lateral meniscal injuries (OR 2.3; 1.1–5.0; p = 0.041). The lowest graft rupture rate (2%) was observed in adult patients with PTS < 12° and SATT < 5 mm, whereas the highest rate (29%) occurred in patients < 18 years with both PTS ≥ 12° and SATT ≥ 5 mm. Conclusions: A selective, “à la carte” approach to LET in ACLR yielded an overall low graft rupture rate (5.8%) at a minimum 6-year follow-up. PTS ≥ 12°, SATT ≥ 5mm, younger age, and lateral meniscal injury emerged as significant predictors of hamstrings graft rupture. Patients under 18 years of age with a PTS ≥ 12° and SATT ≥ 5 mm demonstrated the highest risk of graft rupture despite the systematic use of a LET in this population. Incorporating individualized anatomic and biomechanical factors into surgical decision-making may optimize outcomes and redefine the paradigm of primary ACLR.