Young ACL reconstruction: tenodesis linked to fewer revisions at any tibial slope

Design

Retrospective multicentre cohort, level of evidence 3

Population

780 patients aged 25 or under having primary ACL reconstruction at three centres

Primary outcome

Revision ACL reconstruction

Effect

With tenodesis OR 0.37 (0.22 to 0.62); steep slope revision 21.0% vs 9.2%, NNT 9

A cohort study at three high-volume centres included 780 patients aged 25 or under having primary ACL reconstruction, with at least two years of follow-up; 84 (10.8%) needed revision. Posterior tibial slope was measured on lateral radiographs.

A slope of 12° or more was present in 28.2% and was more common in those revised. Among patients with a steep slope, revision occurred in 21.0% without lateral extra-articular tenodesis and 9.2% with it (absolute risk reduction 11.8%, number needed to treat 9). With a slope under 12°, revision was 13.2% without and 5.4% with tenodesis (number needed to treat 13). In adjusted models, tenodesis was associated with lower odds of revision (OR 0.37, 95% CI 0.22 to 0.62), and each degree of slope with higher odds (OR 1.09).

This is observational, and surgeons chose which patients received tenodesis. But it agrees with randomised evidence in young, high-risk patients and suggests the benefit is not confined to steep slopes. Measuring slope on every preoperative radiograph costs nothing.

• Measure posterior tibial slope on the preoperative lateral radiograph for every primary ACL reconstruction.
• Consider lateral extra-articular tenodesis in patients aged 25 or under, whatever the slope.
• Flag a slope of 12° or more as an independent revision risk when counselling the patient.
• Discuss slope-reducing osteotomy only in the revision or very high-risk setting, where it has been studied.

Why it matters

It suggests tenodesis benefits young patients across slopes, not only those with a steep tibia.

Don't overread it

This is a non-randomised cohort; surgeon choice of who received tenodesis may explain part of the difference.

The statistics, in plain English

A number needed to treat of 9 means adding tenodesis to nine young patients with a steep slope was associated with one fewer revision. An odds ratio of 1.09 per degree means risk rises steadily with slope rather than jumping at a single cut-off.

Read the rest in the app

You have read your two free briefings this month. The app carries all 27 specialties, every morning, free — and this finding is waiting in it.

Get Daily Doctor — free

Scan to keep reading on your phone. No account needed to start.