Adding LET to ACL Reconstruction in Children and Adolescents at High Risk for Re-Tears

Research has long demonstrated that adolescents who have undergone reconstruction of a torn anterior cruciate ligament (ACL) – particularly those in eighth and ninth grades – have the highest re-tear rates if they return to a pivoting or high-risk high school sport. In the New York City metro area alone, more than 80% of ACL injuries in adolescents stem from participation in sports such as basketball, soccer, lacrosse, skiing, and football.

Reconstruction is the current standard-of-care surgical treatment for ACL tears, with approximately 300,000 ACL reconstructions performed annually in the US. If the surgery fails, a revision procedure is necessary, which may result in higher rates of failure and lower rates of return to sport.

“Reconstruction alone has not been sufficient for kids who haven’t finished growing yet and want to stay active in sports,” said Daniel W. Green, MD, MS, FAAP, FACS, a pediatric orthopedic surgeon at Hospital for Special Surgery (HSS) who has conducted research on ACL tears and re-tears in this young patient population.

“The risk of re-injury has been too high, leading to devastating consequences for a young athlete,” added Frank A. Cordasco, MD, MS, a sports medicine surgeon at HSS, who noted that this continues to be an important area of clinical research for sports medicine surgeons worldwide.

Applying an Innovation from France

About a decade ago, surgeons in France innovated on the standard ACL reconstruction procedure after identifying elite soccer players as high risk for re-tear. They added lateral extra-articular tenodesis (LET) to the reconstruction and successfully demonstrated that this combination decreased the re-tear rate in adult soccer players by nearly 50%.

Dr. Green and Dr. Cordasco were among the first physicians to apply this European technique to teenage athletes in North America. At the 2022 Annual Meeting of the American Academy of Orthopaedic Surgeons, they shared the results of a new study evaluating the safety and efficacy of performing a LET procedure using a modified Lemaire technique (MLT) in conjunction with an ACL reconstruction in children and adolescents who were at an increased risk for a failed ACL reconstruction.

The study followed 61 patients aged 11 to 19 who underwent simultaneous ACL reconstruction and LET for a minimum of 2 years. Nearly all patients – 97% – participated in organized sports, with soccer being the most popular. Patients with 1 or more of the following factors were identified as high risk for a re-tear:

  • Participant in high-risk competitive sports, such as football, lacrosse, soccer, or basketball, or sports that involved grade 3 pivot shift
  • Hyperlaxity in the knee
  • Recurvatum of the knee
  • Had undergone revision ACL reconstruction
  • Had undergone contralateral ACL reconstruction
  • Chronic ACL insufficiency

Depending on the patient’s skeletal maturity, the ACL reconstruction was performed either by using a full-thickness quadriceps tendon autograft, a bone-patellar tendon-bone autograft, an all-epiphyseal technique, or a complete transphyseal technique.

At a minimum 2-year follow-up, the researchers evaluated patient-reported outcome measures as well as data on returning to sports and any additional surgeries. The results were overwhelmingly positive:

  • Median Single Assessment Numeric Evaluation (SANE) score of 95%, where 100% represents normal function
  • Mean Pediatric International Knee Documentation Committee (Pedi-IKDC) score of 91, where 100 is interpreted to mean no limitations on daily living or sports activities
  • Median score of 27/30 on the HSS Functional Activity Brief Scale (HSS Pedi-FABS), which is a validated 8-item instrument to quantify the activity of children

Most patients – nearly 92% – returned to sport. One patient underwent revision ACL surgery and 3 had subsequent contralateral ACL reconstructions.

“The findings suggest that concomitant LET and [ACL reconstruction] in adolescent patients with risk factors for failed [ACL reconstruction] is associated with favorable patient-reported outcomes, high return to sports participation, and low ACL re-rupture rate at 2 years follow-up,” the study authors concluded.

Building on Earlier Research

This study expanded upon work that Drs. Cordasco and Green published in 2020 that showed LET can be performed safely in skeletally immature athletes who underwent a quadriceps autograft ACL reconstruction. [1]

“We are proud to have published one of the first surgical-technique papers describing how this procedure can be safely performed in young patients who still have open growth plates,” said Dr. Green, who explained that this study is also unique in that it reports on 2-year clinical outcomes in children who underwent ACL reconstruction plus LET.

“Not only does this technique not disturb children’s growth plates or cause postoperative stiffness, but we also found that this demonstrates a remarkably low re-tear rate in this high-risk group,” said Dr. Cordasco.


Green DW, Cordasco FA, Perea SH, Brusalis C. A Modified Lemaire Lateral Extra-Articular Tenodesis in High-Risk Adolescents Undergoing Anterior Cruciate Ligament Reconstruction: Safe and Effective Two-Year Clinical Outcome Study (Paper 737). Presented at the American Academy of Orthopaedic Surgeons’ 2022 Annual Meeting, March 22-26, 2022, Chicago, Illinois.


  1. Schlichte LM, Aitchison AH, Green DW, Cordasco FA. Modified Lemaire lateral extra-articular tenodesis in the pediatric patient: an adjunct to anterior cruciate ligament reconstruction. Arthrosc Tech. 2019 Dec 18;9(1):e111-e116. doi: 10.1016/j.eats.2019.09.010. eCollection 2020 Jan.

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