Lateral extra-articular tenodesis versus anterolateral ligament reconstruction in ACL reconstruction: A systematic...

Residual anterolateral rotatory laxity and graft failure remain important challenges following anterior cruciate ligament reconstruction (ACLR). Lateral extra-articular procedures (LEAPs), including Lateral Extra-articular Tenodesis (LET) and Anterolateral Ligament Reconstruction (ALLR), have gained renewed interest as adjuncts to ACLR; however, evidence comparing their effectiveness remains limited. The objective was to evaluate and compare the clinical and functional outcomes of LET and ALLR when performed in conjunction with ACLR.

A systematic review (PROSPERO: CRD420251082815) was conducted according to PRISMA 2020 guidelines. PubMed, EMBASE, and Scopus databases were searched for studies published within the last 10 years. Randomized controlled trials, cohort studies, and case-control studies comparing LET and/or ALLR combined with ACLR and reporting clinical or functional outcomes were included. Risk of bias was assessed using the ROBINS-I tool, and methodological quality was evaluated using the CASP checklist. Due to limited direct comparative evidence and heterogeneity among studies, a qualitative synthesis was performed.

Seventeen studies met the inclusion criteria. Both LET and ALLR combined with ACLR demonstrated improved rotational stability, reduced pivot shift, and decreased instrumented anterior laxity compared with isolated ACLR. The addition of a LEAP was associated with lower graft failure rates. LET provided slightly superior control of rotatory instability, whereas ALLR was associated with faster return to sport, likely due to its anatomical reconstruction and less extensive soft-tissue dissection. Functional outcomes assessed using Lysholm, IKDC, KOOS, and Tegner scores were generally comparable. Hardware-related complications and reoperations were slightly more frequent with LET, although overall adverse event rates remained low.

Augmentation of ACLR with either LET or ALLR improves knee stability and graft integrity, particularly in high-risk patients. ALLR may facilitate earlier return to sport, whereas LET may offer greater biomechanical restraint. Further high-quality randomized controlled trials with long-term follow-up are needed to establish definitive recommendations.