Anterior cruciate ligament (ACL) injuries are one of the common causes of knee instability and functional disability in young active individuals.¹ The incidence of ACL injuries has increased  over recent years due to increased participation in recreational and competitive sports activities. ACL tears often lead to knee instability, recurrent giving-way episodes, pain, functional impairment, and limitation of physical activities. If left untreated, chronic ACL deficiency leads to secondary meniscal injuries, chondral damage, and early osteoarthritic changes, thereby significantly affecting quality of life and long-term knee function^2,3.The anterior cruciate ligament plays an important role in maintaining both anteroposterior and rotational stability of the knee joint by preventing anterior translation of the tibia and controlling rotational movements during dynamic activities^4-5. Although arthroscopic ACL reconstruction has now  become the gold standard treatment for symptomatic ACL-deficient knees, residual rotational instability remains a major concern following isolated intra-articular reconstruction. Chronic pivot shift and rotational laxity have been associated with inferior functional outcomes, delayed return to sports, reduced patient satisfaction, and increased risk of graft failure⁶. Among various lateral augmentation procedures, iliotibial band (ITB) tenodesis or lateral extra-articular tenodesis (LET) is the most preferred. As it  reinforces the anterolateral structures of the knee and acts as a secondary restraint to internal tibial rotation, thereby reducing stress on the reconstructed ACL graft⁷.  Clinical studies have  shown that addition of LET to ACL reconstruction lowers graft rupture rates and improves postoperative knee stability, particularly in high-risk patients such as young athletes, individuals with generalized ligamentous laxity, high-grade pivot shift, revision ACL surgery, and patients returning to high-demand physical activities.Functional outcome assessment following ACL reconstruction is commonly done by using validated scoring systems such as the International Knee Documentation Committee (IKDC) score, Lysholm knee score, and Tegner activity scale, which help evaluate knee function, symptoms, activity level, and return to sports^8,9-10. Clinical stability is  assessed by using Lachman test, anterior drawer test, and pivot shift test.¹¹ Considering the increasing interest in combined ACL reconstruction and ITB tenodesis procedures, the present study was conducted to evaluate the functional outcomes, rotational stability, and postoperative complications following arthroscopic single-bundle ACL reconstruction with iliotibial band tenodesis in patients with ACL deficiency associated with high-grade pivot shift.¹² The study also aimed to assess improvement in functional scores  following surgical intervention over the follow-up period.

AIM

To evaluate functional outcomes of combined ACL reconstruction with iliotibial band tenodesis.

METHODOLOGY

This prospective interventional study was conducted in the Department of Orthopaedics at Dr. S.P. Medical College and Associated Hospitals  from January 2024 to December 2025. A sample size of 40 patients with anterior cruciate ligament (ACL) tear along with high-grade pivot shift were included in the study. Patients  Age 18–45 years, ACL tear, high-grade pivot shift were involved .Patients with Multiligament injuries, osteoarthritis, prior surgery were excluded from the study.Institutional Ethics Committee approval obtained.All patients underwent detailed clinical evaluation, radiological assessment, and preoperative functional scoring. Arthroscopic ACL reconstruction using hamstring autograft was performed. Femoral and tibial tunnels were created anatomically. ITB tenodesis was performed using the modified Lemaire technique to augment rotational stability. Later , all patients followed a  rehabilitation protocol.Early mobilization with a range of motion exercises initiated on day 1. Progressive weight-bearing allowed. Strengthening exercises introduced gradually. Return to sports permitted after 6–9 months.

RESULT

Table 1: Baseline Characteristics of Patients (n = 40)

The present study included 40 patients, with the majority belonging to the 26–35 years age group (45%), followed by 18–25 years (38%) and 36–45 years (17%). Male patients predominated the study population, accounting for 80% of cases.Sports-related trauma was the most common mode of injury (60%), followed by road traffic accidents (25%) and fall/twisting injuries (15%). Right knee involvement was observed in 57.5% of patients, while 42.5% had left knee involvement.

Table 2: Comparison of Functional Outcome Scores Before and After Surgery

Significant improvement was observed in all functional outcome scores following combined ACL reconstruction with ITB tenodesis. The mean IKDC score improved from 46.2 preoperatively to 86.5 postoperatively, while the Lysholm score increased from 52.4 to 91.2 and the Tegner activity level improved from 3.1 to 6.5.

Table 3: Pivot Shift Test Outcome

A marked reduction in pivot shift grade was observed postoperatively following combined ACL reconstruction with ITB tenodesis. Preoperatively, most patients had Grade 2 and Grade 3 pivot shift, whereas postoperatively 31 patients achieved Grade 0 stability and none demonstrated Grade 2 or Grade 3 pivot shift.

Table 4: Functional Outcome Based on Lysholm Knee Score

Based on Lysholm knee scoring, the majority of patients achieved excellent to good functional outcomes following combined ACL reconstruction with ITB tenodesis. Excellent results were observed in 45% of patients, good in 40%, fair in 12.5%, and poor outcome in only 2.5% of cases.

Table 5: Postoperative Complications

Postoperative complications were minimal in the present study, with most patients (87.5%) having an uneventful recovery following combined ACL reconstruction with ITB tenodesis. Knee stiffness and persistent instability were observed in 5% of patients each, superficial infection in 2.5% of cases, while no graft failure was reported during follow-up.

DISCUSSION

The mean age in our study was 27.5 years. 80% of total cases were male, while females were 20% of patients. 60% of patients had Sports-related injuries , while Road traffic accidents were seen in  25% of cases,  fall or twisting injuries contributed to 15% of cases.57.5% of patients had  Right knee involvement  , while left knee involvement was  in 42.5% of patients. This is inconsistent with the study by Arora M et al¹³ who reported the mean age of the study population was 22.4 ± 2.7 years and 84% were males.

The mean IKDC score improved from pre operative 46.2 to 86.5 postoperatively.Similarly, the mean Lysholm score increased from 52.4 to 91.2 after surgery. The Tegner activity level also improved from 3.1 preoperatively to 6.5 postoperatively,indicating marked improvement in knee function and stability..Similarly Lutz C, et al¹⁴ reported a mean follow-up of 43.1 months, the subjective IKDC, Lysholm, ACL-RSI and objective IKDC scores were significantly improved (59.8 vs. 94.5 p < 0.0001, 75 vs. 99 p < 0.0001, 60 vs. 93 p < 0.0001, IKDC A 0% vs. 72%, B 12% vs. 27%, C 60% vs. 1% D 28% vs. 0% p < 0.0001). The Tegner activity level was 9 (3–10) before the accident and 9 (3–10) at the last review.

Improvement was observed in rotational knee stability  following combined ACL reconstruction with ITB tenodesis which was assessed by the pivot shift test. Preoperatively, none of the patients had Grade 0 pivot shift, while Grade 2 pivot shift was present in 22 patients and Grade 3 in 10 patients, indicating severe rotational instability. Grade 1 pivot shift was observed in 8 patients before surgery. Postoperatively, 31 patients achieved Grade 0 pivot shift, which showed restoration of rotational stability. The remaining 9 patients showed only Grade 1 pivot shift, while no patient had Grade 2 or Grade 3 instability after surgery..Hassan et al¹⁵ reported that preoperatively, in group A 18 (90%) patients were grade ӀӀӀ (gross), one (5%) patient was grade ӀӀ (clunk), and one (5%) patient was grade Ӏ (smooth gliding). In group B, 16 (80%) patients were grade ӀӀӀ (gross), three (15%) patients were grade ӀӀ (clunk) and one (5%) patient was grade Ӏ (smooth gliding). P value more than 0.05. Postoperatively, in group A all patients were normal (grade 0), while in group B 15 (75%) patients were grade Ӏ (smooth gliding) and five (25%) patients were grade ӀӀ (clunk) and the difference between the two groups was statistically significant (P<0.05

Functional outcome was assessed based on the Lysholm knee scoring system demonstrating favorable postoperative results in the majority of patients. Excellent outcomes  were achieved in 18 patients (45%). Good outcomes were  in 16 patients (40%). Fair results were  in 5 patients (12.5%) with scores between 65–83. Only one patient (2.5%) had a poor functional outcome with a score below 65. Bezawada PR et al¹⁹ Among 30 patients included in this study, 20 (66.6%) were males and 10 (33.3%) were females. The indications for LEAT were young, high-demand sports activity in 6 (20%) cases, hyperextension of the knee >10° in 12 (40%) cases, chronic ACL injuries (>3 months) in 8 (26.66%) cases, and revision ACLR in 4 (13.33%) patients.All the patients returned to their normal preinjury level with a Tegner Lysholm knee function score of 94.73 ± 3.79 (maximum score 100; score >90 = excellent function) at a mean follow-up of 3 ± 1.2 years.

Postoperative complications  were minimal in the present study.  87.5%, did not develop any postoperative complication and had satisfactory recovery during follow-up. Knee stiffness was  in 2 patients (5%), while persistent instability was also noted in 2 patients (5%).1 patient (2.5%) have Superficial surgical site infection  and was managed successfully with appropriate treatment.  No case of graft failure was reported during the study period. The procedure demonstrated a favorable safety profile with low complication rates and satisfactory postoperative outcomes.Lutz C, et al¹⁴ Ten patients had graft rupture (5.6%). Four (2.4%) patients had a contralateral ACL rupture, and seven (4%) underwent a reoperation with meniscectomy.

CONCLUSION

Our study showed that combined anterior cruciate ligament (ACL) reconstruction with iliotibial band (ITB) tenodesis provides improvement in functional outcomes, knee stability, and rotational control in patients. Postoperative improvement was observed in IKDC, Lysholm, and Tegner activity scores.A reduction in pivot shift grade was observed postoperatively, confirming the effectiveness of ITB tenodesis in controlling residual rotational instability. The majority of patients achieved excellent to good functional outcomes based on Lysholm knee scoring. In addition, postoperative complications were minimal, and no graft failure was observed during the follow-up period, suggesting that the combined procedure is safe and effective.Combined ACL reconstruction with iliotibial band tenodesis provides superior functional outcomes and rotational stability. It is recommended in patients with high-grade instability and high functional demands

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