The Lateral Extraarticular Tenodesis: Should We Be Adding It to Every ACL Reconstruction Surgery?

For most of the last two decades, the standard ACL reconstruction has been a single-graft operation: take a piece of hamstring, patellar, or quadriceps tendon, run it through the femur and tibia in roughly the same position as the native ligament, and let biology do the rest. It works well for a large majority of patients. But a meaningful subset, mostly younger athletes returning to pivoting and cutting sports, kept coming back with the same problem: the graft was intact on imaging, yet the knee still gave way during a cut or a plant-and-pivot move. Surgeons have spent the past several years building an evidence base around a second procedure, done at the same time as the ACL graft, to solve exactly that failure mode. It is called a lateral extra-articular tenodesis, or LET, and the newest round of literature makes a stronger case for it than anything published before.

The Problem LET Is Trying to Fix

An isolated ACL graft restores the ligament that resists forward sliding of the tibia. What it does not fully replicate is the anterolateral complex, a set of soft tissue structures on the outer side of the knee that resist internal rotation of the tibia relative to the femur. In a patient with a high-grade pivot shift, meaning the knee visibly rotates and shifts under an examiner's stress test, that rotational instability tends to persist even after a technically sound ACL reconstruction. Left unaddressed, it is one of the more consistent predictors of graft rupture and of patients quietly avoiding the cutting and pivoting moves their sport requires.

LET addresses this directly. A strip of iliotibial band is tensioned along the lateral femur to act as a checkrein against internal rotation, essentially a reinforcement belt working alongside the primary graft rather than replacing it. The concept is not new. What has changed is the strength and volume of data behind it.

I just had a patient that was about 1 year out of a quadriceps autograft ACL reconstruction with a recurrent medial meniscal tear and a pivot-shift. The reconstructed ACL was seemingly intact. We repaired the meniscus (again) and added the LET reconstruction, restoring the rotational stability.

What the STABILITY Trial Actually Showed

The clearest evidence remains the STABILITY trial, a multicenter, randomized, blinded trial that enrolled 618 patients between 14 and 25 years old who were at high risk of graft failure, meaning they had a high-grade pivot shift, a strong desire to return to pivoting sports, or generalized ligamentous laxity (Getgood et al., Am J Sports Med, 2020). Patients were randomized to hamstring autograft ACL reconstruction alone or the same reconstruction plus LET using a modified Lemaire technique.

At two years, the difference was not subtle. Clinical failure, a composite of graft rupture or persistent rotatory laxity, occurred in 40 percent of the ACL-alone group compared with 25 percent of the ACLR-plus-LET group. Graft rupture specifically occurred in 11 percent of the ACL-alone group versus 4 percent of the combined group. A companion analysis from the same trial found no increase in adverse events or complication rates with the added procedure (STABILITY Study Group, J ISAKOS, 2023), and a separate functional-outcomes analysis found no meaningful difference in hop testing or return-to-sport readiness between groups, meaning the added tenodesis did not slow patients down or compromise function (Getgood et al., Arthroscopy, 2020). In plain terms: added protection against the injury recurring, without a real cost in recovery or performance.

The 2026 Data Adds Two More Reasons to Take LET Seriously

Two studies published this year push the case further. The first is a systematic review and meta-analysis in the American Journal of Sports Medicine comparing LET with the anterolateral ligament reconstruction (ALLR) technique, the other major option for addressing rotational instability (Am J Sports Med, 2026). Pooling cadaveric biomechanical studies, the analysis found the two techniques restore anterior stability equally well, but LET outperformed ALLR specifically at resisting internal tibial rotation, the exact failure mode that causes the pivot-shift instability surgeons are trying to eliminate. For a patient asking which augmentation technique is better, this is the most direct head-to-head comparison available.

The second is a systematic review and meta-analysis published in the Journal of Bone and Joint Surgery examining a question that matters more to patients than surgeons often acknowledge: what happens to the knee joint a decade or more down the road (Gkekas et al., J Bone Joint Surg Am, 2026). Combining ACL reconstruction with LET was associated with a significantly lower rate of long-term osteoarthritis compared with isolated ACL reconstruction, with the protective effect holding up across two different radiographic grading systems. Rotational instability that goes uncorrected does not just risk a second tear. Over years of cutting, pivoting, and everyday loading, it appears to accelerate wear on the joint itself.

Taken together with the JBJS “What's New in Sports Medicine 2026” specialty update, which specifically flagged the expanding evidence base for lateral extra-articular procedures as a meaningful adjunct to reduce ACL failure risk (Al-Hourani et al., J Bone Joint Surg Am, 2026), the direction of the literature is consistent across three separate research groups and three separate outcomes: graft survival, rotational control, and long-term joint health.

Who Benefits from an LET?

None of this means every ACL reconstruction should automatically include a tenodesis. The STABILITY trial specifically enrolled high-risk patients, and that risk stratification matters clinically. The patients who benefit most tend to share one or more of these features:

• Age under 25, particularly adolescents and young adults returning to competitive pivoting sports
• A high-grade pivot shift on exam, grade 2 or higher
• Generalized ligamentous laxity, sometimes described by patients as being “double-jointed”
• A strong intention to return to soccer, basketball, or other cutting and pivoting sports at a competitive level
• A prior ACL graft failure, where revision reconstruction carries a higher baseline failure rate than a primary surgery

We have modified our practice based on this data to offer the LET to all athletes under 25. I encourage it in active patients under 30. Adding a second incision and a second procedure carries its own tradeoffs, including a slightly longer operative time and an additional surgical site, but the STABILITY data shows no meaningful increase in complications. Good surgical decision-making means matching the procedure to the risk profile, not applying it universally because the data looks favorable in aggregate.

The Practical Takeaway

Our patients in our Bethesda and Germantown offices (many of whom are high school, college and club-level athletes in soccer, basketball, lacrosse, and football) are EXACTLY the population the STABILITY trial targeted. If you or your child is facing ACL reconstruction and fall into a higher-risk category, this is a conversation worth having directly with your surgeon: ask whether LET is being considered and ask why or why not. The evidence base behind this adjunct procedure is no longer preliminary. It is a multicenter randomized trial with 618 patients, replicated meta-analyses now spanning both mechanical and long-term joint-health outcomes, and a 2026 specialty update from JBJS confirming the trend is continuing to build. For young and active patients, a lateral extra-articular tenodesis is no longer an experimental add-on; it is close to becoming standard care.