Anterior cruciate ligament reconstruction with lateral extra-articular tenodesis in patients at high risk of rotational instability

Background: Despite advances in anterior cruciate ligament (ACL) reconstruction, residual rotational instability and graft failure remain concerns, particularly in high-risk patients. Lateral extra-articular tenodesis (LET) may improve rotational control and protect the ACL graft. To evaluate clinical outcomes of combined ACL reconstruction and LET using a modified Lemaire technique in patients at high risk of rotational instability. Methods: This prospective observational study included 30 patients with primary ACL rupture and high-grade (grade 2 or 3) pivot shift treated at National Institute of Traumatology and Orthopaedic Rehabilitation (NITOR), Dhaka, from July 2022 to June 2025. All underwent arthroscopic ACL reconstruction combined with modified Lemaire LET. Functional outcomes were assessed using IKDC and Lysholm scores, while knee stability was evaluated by pivot-shift and Lachman tests. Preoperative and final follow-up outcomes were compared, with p<0.05 considered statistically significant. Results: Mean age was 25.8±6.4 years and 66.7% were male. Mean IKDC score improved from 52.6±9.8 to 87.3±7.4 and Lysholm score from 58.9±10.6 to 91.2±6.8 (both p<0.001). At final follow-up, 86.7% had negative pivot-shift and 80.0% negative Lachman tests. Good-to-excellent outcomes were achieved in 86.7% by IKDC and 90.0% by Lysholm criteria. Overall, 83.3% returned to sports or previous activity and graft failure occurred in 3.3%. Conclusions: Combined ACL reconstruction with modified Lemaire LET provided favorable functional recovery, improved knee stability and low graft failure, supporting its use in appropriately selected high-risk patients.