Lateral Extra-articular Procedures With Anterior Cruciate Ligament Reconstruction: International Consensus

The risk of anterior cruciate ligament (ACL) graft failure is increased in select patient populations. Lateral extra-articular procedures including anterolateral ligament reconstruction and lateral extra-articular tenodesis seek to reduce ACL graft failure rates and more reliably restore normal knee kinematics. An international consensus meeting was convened in 2024, and through a modified Delphi consensus process, 53 international experts debated 20 surgical indications. A lateral extra-articular procedure was "strongly recommended" in patients undergoing ACL reconstruction with a hamstring autograft in young/active patients, patients with grade III pivot-shift findings, patients with knee hyperextension, and skeletally immature patients; it was "recommended" for revision ACL reconstruction and chronic ACL deficiency; and it "should be considered" in young/active patients receiving patellar or quadriceps tendon autografts, athletes returning to pivoting sports, patients with grade 3 Lachman findings, patients with a posterior tibial slope greater than 12°, and patients with a history of a contralateral ACL injury.