Extra-articular Tenodesis for ACL Reconstruction: Who Needs it and is there a Superior Technique?

To provide a comprehensive overview of the indications for lateral extra-articular tenodesis in addition to anterior cruciate ligament reconstruction (ACLR), followed by a discussion on the existing techniques with their perceived advantages and disadvantages. Recent evidence has shifted lateral extra-articular tenodesis (LET) from a routine “add-on” to a selective adjunct for patients at higher risk of residual rotatory instability and ACL graft failure after isolated ACLR. Level I clinical evidence suggests that adding an iliotibial (ITB) – based LET can meaningfully reduce graft rupture rates while improving control of pivot shift – type instability. The 2025 International Consensus on lateral extra-articular procedures (LEAPs) supports LET/anterolateral augmentation particularly for revision ACLR, high-grade pivot shift, generalized laxity or hyperextension/recurvatum, and young athletes returning to pivoting/contact sports. The consensus also mentions that modern LEAPs have low complication rates, do not typically require altered rehabilitation, and have not shown a consistent signal for increased lateral compartment osteoarthritis when contemporary technique principles are followed. Finally, despite the variety of described constructs (modified Lemaire variants, other ITB-based tenodeses, and anatomic ALL reconstruction), current literature does not demonstrate a single universally superior technique. Instead, success appears to be linked to correct patient selection, adherence to key technical principles (appropriate graft routing & low-tension fixation), and age or skeletal – maturity – appropriate modifications. When applied selectively in high-risk patients, adding a lateral extra-articular tenodesis to ACL reconstruction can improve rotational control and reduce re-injury, but current evidence does not support a single universally superior LET construct. Optimal results depend on appropriate indications, careful technique, and tailoring the approach to patient factors such as age, sport demands, laxity profile, and skeletal maturity.