The Impact of Lateral Extra-Articular Tenodesis on Knee Range of Motion After Pediatric Anterior Cruciate Ligament Reconstruction

Abstract

Background: Lateral extra-articular tenodesis (LET) is increasingly used to augment anterior cruciate ligament (ACL) reconstruction (ACLR) in pediatric patients to improve graft survival and rotational stability. However, concerns remain regarding postoperative knee stiffness after augmentation. Purpose: To determine whether LET augmentation is associated with increased risk of restricted knee range of motion (ROM) after pediatric ACLR and to identify patient and surgical factors associated with postoperative stiffness. Study Design: Case-control study; Level of evidence, 3. Methods: The authors reviewed 412 pediatric patients who underwent primary ACLR (2013-2025) at a single tertiary referral center. Restricted knee ROM was defined as a loss of flexion ≥15° or extension ≥5° at 3 months postoperatively compared with the contralateral limb. Exposures included LET utilization, demographic factors, socioeconomic measures (Area Deprivation Index and insurance status), graft characteristics, meniscal procedures, time to initiation of physical therapy, and time from injury to surgery. Multivariable logistic regression models were used to identify independent predictors of restricted knee ROM. Results: Restricted knee ROM occurred in 12.9% of procedures overall (16.8% with LET vs 10.2% without). LET was independently associated with increased odds of restricted motion (adjusted odds ratio [AOR] 2 [95% CI, 1.01-3.95]; P = .046). Female sex was associated with increased risk (AOR, 4.23 [95% CI, 2.09-8.55]; P < .001). Age at surgery, time to initiation of physical therapy, graft type, meniscal procedures, socioeconomic deprivation, insurance status, and time from injury to surgery were not independently associated with restricted knee ROM. Seven patients underwent manipulation under anesthesia, and 3 underwent lysis of adhesions. Overall, manipulation under anesthesia or lysis of adhesions was required in 8 patients and was more common after LET. Conclusion: LET augmentation during pediatric ACLR is associated with an increased risk of early restricted knee ROM, although most cases are mild and resolve with nonoperative management. Female sex represented an additional risk factor for postoperative stiffness.