Age and Surgical Volume Impact Likelihood and Technique of Lateral Extra-Articular Augmentation During Primary Anterior Cruciate Ligament Reconstruction

Purpose: To evaluate the current utilization trends of practicing surgeons performing and lateral extra-articular augmentation (LEA) at the time of primary anterior cruciate ligament reconstruction (ACLR).

Methods: The survey was distributed via e-mail in August 2023 to members of the Arthroscopy Association of North America who identified as knee surgeons and was available online on the Arthroscopy Association of North America website from January to September 2023. The 18-question survey was designed regarding surgeons' surgical utilization patterns of LEA during ACLR. Survey questions were created based on prior published research and recommendations regarding indications for LEA, as well as surgeon factors that have been shown to influence operative decision-making. Data were analyzed by surgeon geographics, procedure preferences, patient-based decision factors, surgeon-based decision factors, and surgeon age.

Results: The survey was completed by 165 sports medicine surgeons who identified as arthroscopic knee surgeons. Majority practice types included private practice (42.1%), academic centers (26.8%), and hospital systems (20.7%). Surgeon age was 50.36 years (range, 33-77 years). In total, 6.8% perform <20 ACLRs per year, 30.2% perform 20 to 40, 26.5% perform 40 to 60, 10.5% perform 60 to 80, and 25.9% perform >80 per year. Of the surgeons, 79.4% conduct LEA, with the modified Lemaire being the most common technique (43.5%), followed by other lateral extra-articular tenodesis (LET) techniques (42.0%) and anterolateral ligament reconstruction (ALL) (27.5%). Some surgeons (14.5%) use more than 1 technique. High-volume (>60 ACLR/year) surgeons were more likely to perform LEA (23.1% vs 10.0%, P = .061) and more likely to perform anterolateral ligament reconstruction (32.2% vs 16.5%, P = .034). Younger surgeons (age <50) were more likely to use the modified Lemaire (44.4% vs 24.3%, P = .014). Decision-making to perform LEA weighted highly on patient hyperlaxity, pivot-shift severity, knee hyperextension, sport type, and age, respectively. The most reported surgeon-related factor influencing LEA utilization was training bias (38.9%).

Conclusions: Most orthopaedic surgeons with diverse geographics, demographics, practice setting, and ACLR volume perform LEA. Younger surgeons perform more frequently LEA, and surgeons admit to training bias in decision-making. Patient factors highly impacting utilization of LEA are hyperlaxity, pivot-shift severity, knee hyperextension, sport, and age.

Clinical relevance: LEA procedures for ACLR have become increasingly utilized in populations at high risk for rerupture. However, there is not currently a clear standard of care with regard to LEA procedure type or indications for augmentation.