Hamstring Anterior Cruciate Ligament Reconstruction With Anterolateral Ligament Reconstruction Is Associated With Fewer Reoperations Than Bone−Patellar Tendon−Bone Plus Modified Lemaire Tenodesis—A Matched-Pair Analysis From the SANTI Study Group Database

PURPOSE: To compare combined anterior cruciate ligament reconstruction (ACLR) with hamstring tendon (HT) + anterolateral ligament reconstruction (ALLR) and bone-patellar tendon-bone with modified Lemaire lateral extra-articular tenodesis (BPTB + LET). METHODS: Patients who underwent primary ACLR with BPTB + LET between January 2003 and December 2021 with a minimum follow-up of 2 years were propensity matched 1:4 with patients who underwent HT + ALLR during the same period. Graft rupture (defined as symptomatic graft rupture leading to revision surgery), reoperation rates (including any subsequent surgical intervention on the index knee), and postoperative side-to-side knee laxity were compared. Multivariable analysis using the Cox model was performed to examine the relationship between graft rupture, reinterventions, surgical procedure type, and all potential explanatory variables. RESULTS: The study included 365 patients: 73 in the BPTB + LET group and 292 in the HT + ALLR group, with a mean follow-up of 162.6 ± 70.4 months for the BPTB + LET and 74.1 ± 33.5 months for the HT + ALLR group. The HT + ALLR group had a significantly lower reoperation rate than the BPTB + LET group (10.6% vs 24.7%; P < .0001). Graft rupture rates were not significantly different between the groups (3.4% in the HT + ALLR group vs 5.5% in the BPTB + LET group; P = .22). The BPTB + LET group had greater rates of secondary meniscal surgeries (12.3% vs 4.5%; P = .0006) and infections (4.1% vs 0.7%; P = .0075). Postoperative side-to-side knee laxity was comparable between groups (0.2 mm; P = .8495). Kaplan-Meier analysis demonstrated superior reoperation-free survival in the HT + ALLR group at all the time points. Multivariate Cox analysis confirmed that the BPTB + LET technique was independently associated with increased reoperation risk (hazard ratio 2.57; 95% confidence interval 1.15-5.74; P = .0209). CONCLUSIONS: Primary ACLR using HT + ALLR was associated with significantly lower reoperation rates compared with BPTB + LET. Specifically, the BPTB + LET group had significantly increased reoperation rate because of secondary meniscal procedures and infections. There were no significant differences in graft rupture rates between the 2 groups. LEVEL OF EVIDENCE: Level III, retrospective comparative case-series.