Clinical Outcomes of Combined Lateral Extra-articular Tenodesis and Intra-articular Anterior Cruciate Ligament Reconstruction in Addressing High-Grade Pivot-Shift Phenomenon

Purpose: To evaluate the clinical outcomes of combined lateral extra-articular tenodesis (LET) and intra-articular anterior cruciate ligament (ACL) reconstruction (ACLR) in addressing the high-grade pivot-shift phenomenon. Methods: The PubMed/Medline database was searched for articles reporting clinical outcomes of combined LET and intraarticular ACLR in treating ACL injuries with high-grade pivot shift. High-grade pivot shift was defined as the presence of moderate to severe rotational instability shown by a grade II or III manual pivot shift preoperatively (grade 0, normal; grade I, glide; grade II, clunk; and grade III, locking, according to International Knee Documentation Committee [IKDC] form). The postoperative manual pivot-shift grading during the clinical follow-up visit was the primary outcome variable. Moreover, the prevalence of residual pivot shift (grade I, II, or III), distribution of objective IKDC scores, and anterior knee stability were also compared between patients with and without an additional LET procedure. Results: Seven studies were included. Overall, 326 patients (326 knees) with high-grade pivot shift underwent combined LET and intra-articular ACLR with a mean follow-up period of 46.2 months (range, 24 to 76 months). There were 274 patients (84.1%) with grade 0, 42 (12.9%) with grade I, and 10 (3.0%) with grade II pivot shift at the final follow-up. Among the 5 comparative studies, the prevalence of residual pivot shift was significantly lower (P < .05) in patients with LET plus ACLR (13.3%, 30 of 226) than those with isolated ACLR (27.2%, 67 of 246). However, the distribution of objective IKDC scores and anterior knee stability showed no significant differences between groups. Conclusions: The combination of LET and intraarticular ACLR was effective in eliminating the high-grade pivot-shift phenomenon. For ACL injuries with high-grade pivot shift, LET plus ACLR provided a significant reduction in the prevalence of residual pivot shift but no differences in objective IKDC scores and anterior knee stability compared with isolated ACLR at short-term follow-up. Level of Evidence: Level IV, systematic review of Level I, III, and IV studies.