Lateral Extra-Articular Procedures in Anterior Cruciate Ligament Reconstruction

By: Garrett Sohn, M.D., Southern California Orthopedic Institute Fellow

Theodore B. Shybut, M.D., FAANA

Member, AANA Communications and Technology Committee

With the American and European football seasons in full-swing, treating anterior cruciate ligament (ACL) injuries remains an ever-important topic for the arthroscopic surgery and sports medicine communities. Lateral extra-articular procedures (LEAPs) have become an essential consideration in the contemporary surgical management of these injuries. Clinical studies have shown decreased re-tear rates, and biomechanical studies have shown LEAPs increase rotational stability of the knee driving adoption by knee surgeons.^10-13 Lateral extra-articular tenodesis (LET) and anterolateral ligament reconstruction (ALLR) are the two most prevalent LEAPs that are employed today during concomitant ACL reconstruction (ACLR). The recent international consensus meeting conducted by Sonnery-Cottet et al. and recently published in Arthroscopy provides updated recommendations on indications, surgical techniques and complications in LEAPs.^5-6

The anterolateral ligament (ALL) gained worldwide attention in 2013 when Claes et al. published a cadaveric study examining the anatomy of the anterolateral structures of the knee – describing the ALL as the “new” ligament of the knee. This anatomic characterization was followed by a frenzy of anatomic, epidemiological and biomechanical studies to examine how the anterolateral complex played a role in rotational knee stability, particularly related to ACL injuries. However, the first description occurred over 130 years prior in 1879, when Paul Segond described a “pearly, resistant, fibrous band” at the anterolateral knee. In the 1970s and 1980s, surgeons utilized open lateral knee reconstructions to mitigate rotational instability in the ACL-deficient knee. Various techniques were described by surgeons such as Drs. Hughston, Andrews, Ellison, Lemaire and McIntosh. However, utilization of these procedures diminished as enthusiasm for arthroscopic ACL reconstruction exploded. At the 1989 American Orthopaedic Society for Sports Medicine Snowmass Consensus a select panel of renowned knee surgeons such as Drs. Andrews, Noyes, Steadman, Bergfield and Clancy met to discuss the topic of extraarticular reconstructions and provide recommendations for their use. The panel cautioned the use of routine extra-articular reconstructions and concluded that they do not provide substantial benefit over a proper ACLR and come with increased morbidity, higher complications and early osteoarthritis.

ACL surgery has evolved considerably since that time. Similarly, following Claes et al.’s 2013 paper, the sports medicine community renewed interest in the role of LEAPs. There are now numerous contemporary studies examining the use of either LET and ALLR alongside ACLR. The STABILITY trial, conducted by Getgood et al., is a pivotal study with regard to using LETs alongside ACLR. Published in 2020, this multicenter, prospective, randomized, clinical trial compared outcomes for autograft hamstring ACLR with or without a modified Lemaire LET utilizing iliotibial band autograft in 618 patients and examined outcomes over a 2-year period. The study concluded that the addition of LET to a single-bundle hamstring tendon autograft ACLR significantly reduced the risk of graft rupture and persistent rotatory laxity at two years following surgery.

Sonnery-Cottet et al. and the SANTI group have similarly also reported enhanced outcomes for ACL+LEAP as compared to isolated ACLR. Their 2017 prospective study of 502 patients compared primary ACLR with bone-patellar tendon-bone (B-PT-B) graft, quadrupled hamstring tendon (4HT) graft, and hamstring tendon graft combined with ALLR (HT+ALL). Survivorship data from Kaplan-Meier analysis was gathered from this cohort with a mean follow-up of 38.4 months. They found that the rate of graft rupture in the HT+ALL group was 2.5 times less than B-PT-B grafts and 3.1 times less than with 4HT grafts. There was no significant difference in the graft failure rate between 4HT and B-PT-B grafts. The HT+ALL graft was also associated with higher odds of returning to preinjury levels of sport than the 4HT graft but not compared with the B-PT-B graft.

Sonnery-Cottet et al. and the SANTI group also conducted a long-term cohort study comparing the results of ACLR with ACL+ALLR. A total of 86 matched pairs were followed for an average of 8.7 years. Results showed that patients who underwent ACL+ALLR had significant improvement in ACL graft survival and lower overall reoperation rates compared to isolated ACLR. Furthermore, the risk of revision ACLR was more than five times higher in the isolated ACLR group.

Despite these recent studies that suggest significant benefit when LEAPs are combined with ACLR, controversy still exists among surgeons. Moreover, although high-quality evidence exists, there was no consensus on surgical indications, techniques employed, complications and rehabilitation protocols following LEAPs performed concomitantly with ACLR. That is, until now.

In June 2025, an international consensus was published online in Arthroscopy. This two-part consensus addressed the use of LEAPs in ACLR, specifically providing expert commentary on indications for their use, surgical techniques employed, post-operative complication profiles and rehabilitation protocols following surgery. A steering committee consisting of Drs. Bertrand Sonnery-Cottet, Alan Getgood, Camilo Partezani Helito and Volker Musahl selected an international group of 58 participants from 17 countries across five continents. A three-round, modified Delphi consensus process was conducted, comprising of multiple rounds of anonymous surveys, evaluation and modification of statements and ultimate voting on individual statements to provide recommendations. Consensus was defined based on participants voting either “strongly agree” or “agree,” and levels of consensus were categorized as: unanimous consensus (100%), strong consensus (90%-99.9%), consensus (75%-89.9%) and no consensus (<75%). Following this, the strength of each recommendation was then ranked. The entire process was divided into two parts to ensure an in-depth review of the topic. Part I of the refined consensus statement analyzed indications for lateral extra-articular procedures in the ACL-reconstructed knee, and Part II addressed surgical treatment and complications.

Summary of Consensus Statements:

In Part I of the International Consensus Statement, one statement achieved unanimous agreement: it is strongly recommended to add a LEAP for young active patients (age  receiving hamstring-autograft ACLR to reduce graft failure. Strong consensus supported LEAPs in primary ACLR when grade 3 pivot shift, knee hyperextension, skeletally immature status, revision ACLR, return to pivoting sports, active patients <25 years-old using non-hamstring grafts, grade 3 Lachman test and when multiple relative risk factors coexist. Consensus favored LEAPs for chronic symptomatic ACL deficiency, posterior tibial slope >12 degrees and a history of contralateral ACL injury. Eight statements did not reach consensus regarding small-diameter autografts, female athletes, imaging signs of anterolateral injury (e.g., Segond fracture, lateral femoral-notch sign) and concomitant meniscal procedures. One statement on LEAPs with primary ACL repair was withdrawn because the project focused on reconstruction.

In Part II of the International Consensus Statement, six statements achieved unanimous consensus. Of these, notable unanimous statements included: 1) LEAP fixation can be performed using a staple, screw, suture or suture anchor; 2) in anterolateral ligament reconstruction, it is strongly recommended that the femoral fixation is placed proximal and posterior to the lateral femoral epicondyle; 3) in pediatric patients, it is mandatory to adapt the LEAP technique to avoid injury to the physes. Two statements had strong consensus and three reached consensus. Four statements were removed. Key technical recommendations were as follows: (1) in iliotibial band procedures, the graft strip should pass beneath the lateral collateral ligament; (2) an anatomic technique is mandatory for anterolateral ligament reconstruction; and (3) no single LEAP is clinically superior to another. Unanimous agreement indicated that modern LEAPs do not increase lateral compartment osteoarthritis risk, carry a low complication rate and do not necessitate changes to rehabilitation or return-to-play timelines.

Conclusion:

Treating ACL injuries remains an ever-important facet in the arthroscopic surgeon’s clinical practice. The restoration of anterolateral rotational stability in the ACL-deficient knee is paramount in the treatment of these patients. Historical anatomic studies of the anterolateral knee have propelled our understanding of the biomechanics and clinical outcomes following these injuries. Lateral extra-articular procedures have high-quality data that support their use in the appropriate setting, despite historical controversy. The recent international consensus statements featured in Arthroscopy are essential reading. Developed by experts, these guidelines can help surgeons in their ongoing efforts to optimize care of their ACL-injured athlete patients.

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