Lateral Extra-Articular Tenodesis (LET) and ALL Reconstruction in ACL Surgery
Anterior cruciate ligament (ACL) reconstruction has long been the gold standard for restoring knee stability after ligament rupture. Yet even with modern anatomic techniques, up to 25–30% of patients may continue to experience rotational instability—often described as the “pivot-shift” sensation of the knee giving way during cutting or twisting movements. Recent biomechanical and clinical research has identified the anterolateral complex (ALC)—a group of structures on the outer side of the knee including the anterolateral ligament (ALL) and portions of the iliotibial band (IT band)—as critical secondary stabilizers that control internal tibial rotation. When both the ACL and these anterolateral structures are injured, persistent instability and higher graft-failure rates can result. To address this, surgeons increasingly perform Lateral Extra-Articular Tenodesis (LET) or ALL reconstruction in conjunction with ACL reconstruction, particularly in high-risk or revision settings.
Lateral Extra-Articular Tenodesis (LET) is a surgical technique that reinforces the lateral (outer) side of the knee using a small strip of the patient’s IT band. This graft is passed deep to the lateral collateral ligament (LCL) and fixed to the femur near the lateral epicondyle, recreating the stabilizing effect of the anterolateral structures and protecting the reconstructed ACL graft from excessive rotational strain. Dr. Patel utilizes a modified Lemaire LET technique, often performed through a small incision using an all-suture knotless anchor for secure yet minimally invasive fixation.
Persistent “pivot-shift” laxity and recurrent ACL graft rupture are often due to unrecognized or unaddressed injury of the anterolateral complex. Adding LET or ALL reconstruction to ACL surgery can:
- Reduce graft failure rates – Randomized controlled trials (such as the landmark STABILITY Study) demonstrated that adding LET decreased graft rupture rates by 67% and reduced persistent rotational laxity by nearly 40% in young, high-risk athletes.
- Improve rotational control – Biomechanical studies show that LET restores native knee kinematics better than ACL reconstruction alone.
- Enhance outcomes in revision surgery – In patients undergoing revision ACL reconstruction, combining LET reduces failure from 21% to 5% and improves stability and patient-reported outcomes.
- Lower risk for young athletes – Patients under 25 returning to cutting/pivoting sports benefit most, as they have the highest risk for reinjury.
Dr. Patel may recommend augmenting ACL reconstruction with LET or ALL reconstruction in patients who meet one or more of the following criteria:
- Revision ACL surgery (previous graft failure)
- High-grade pivot shift (grade 2–3)
- Generalized ligamentous laxity or genu recurvatum >10°
- Age <25 returning to cutting or pivoting sports (soccer, basketball, skiing, etc.)
- Lateral compartment bone bruising or Segond fracture
- Chronic ACL deficiency with anterolateral instability
- STABILITY Trial (Getgood et al., 2020): LET reduced graft rupture from 11% to 4% and persistent instability from 40% to 25% at two-year follow-up.
- Alm et al., 2020 (The Knee): In revision ACLR with high-grade instability, adding LET decreased failure rates from 21% to 5% and improved functional scores.
- Ferretti et al., 2018 (Arthroscopy): Mid-to-long-term follow-up demonstrated durable outcomes and low re-rupture rates with LET augmentation.
- ESSKA Systematic Review (Grassi et al., 2019): Combined revision ACL + LET procedures achieved 80% negative pivot-shift rates and only 3.6% failure over ~5 years.
- Biomechanical Validation (Inderhaug et al., 2017): Deep Lemaire LET restored normal rotational kinematics without over-constraint when tensioned appropriately.
Dr. Patel’s approach integrates the latest evidence and technology:
- Minimally invasive incision lateral to the knee
- All-suture, knotless fixation for soft-tissue-friendly reinforcement
- Performed concurrently with ACL reconstruction
- Rehabilitation: identical to isolated ACL reconstruction protocols—early range of motion, progressive strengthening, and gradual return to sport at ~9 months
Most patients experience no additional recovery time compared to ACL reconstruction alone.
When properly indicated and performed, LET or ALL reconstruction carries a low risk of complications. Potential concerns such as over-constraint or stiffness have been minimized through refined tensioning techniques and anatomical graft placement.
Dr. Ronak M. Patel is a fellowship-trained sports medicine orthopaedic surgeon who has performed thousands of ACL and revision ACL reconstructions. He was among the early adopters of knotless LET augmentation techniques and continues to contribute to national research and education on advanced ligament reconstruction methods. His individualized approach combines cutting-edge surgical precision with evidence-based decision-making to optimize stability, reduce failure, and accelerate safe return to sport.
Patients who have suffered an ACL injury should seek prompt evaluation to prevent further knee instability and long-term joint damage. Board-certified orthopedic surgeon Dr. Ronak Patel provides expert diagnosis and advanced treatment for ACL injuries at his offices in Westmont, Western Springs, and Elmhurst, Illinois, as well as Munster, Indiana. If you are experiencing knee pain, swelling, instability, or difficulty returning to activity after a knee injury, contact Dr. Patel’s practice to schedule a consultation and receive a thorough evaluation and personalized treatment plan.
At a Glance
Ronak M. Patel M.D.
- Double Board-Certified, Fellowship-Trained Orthopaedic Surgeon
- Team physician to the Chicago Hounds (MLR) and past team physician to the Cavaliers (NBA), Browns (NFL) and Guardians (MLB)
- Published over 50 publications and 10 book chapters
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