We often hear about football players tearing their anterior cruciate ligament (ACL). This is one of the most important ligaments in the knee, and an ACL tear usually requires surgery for active people who want to return to sports.
Traditionally, surgeons repair the ACL by replacing it with a tendon graft. However, in recent years, there has been renewed interest in adding an extra procedure alongside the ACL surgery to make the knee more stable. These are called lateral extra-articular procedures (LEAPs).
The two most common types are:
- Lateral Extra-Articular Tenodesis (LET)
- Anterolateral Ligament Reconstruction (ALLR)
Think of these as “reinforcement straps” on the outer side of the knee. They are added to support the new ACL graft and reduce the risk of re-injury.
Why Are These Extra Procedures Considered?
In some patients, even after ACL reconstruction, the knee may still feel a bit unstable, especially when twisting or pivoting. Studies have shown that adding LET or ALLR can:
- Reduce the risk of the new ACL tearing again.
- Improve rotational stability (control of side-to-side twisting).
- Increase the chances of returning to sports at the same level.
Large clinical trials, such as the STABILITY trial, found that patients who had a LET alongside ACL surgery were less likely to suffer another ACL rupture compared to those who only had the ACL surgery.
Who Might Benefit Most from Lateral Extra-articular Procedures (LEAPs)?
According to an international group of experts who published updated guidelines in 2025, the patients who benefit the most from adding a LEAP include:
- Young, active patients (especially under 25 years old)
- Athletes in pivoting sports like football, basketball, or rugby
- Patients with a very unstable knee on examination
- Those having a repeat ACL surgery after a previous graft failure
- Patients with other risk factors (e.g., hyperextension of the knee, a steep tibial slope, or a history of ACL injury in the other knee)
Is Lateral Extra-articular Procedures (LEAPs) Safe?
The consensus also reassures us that these extra procedures:
- Do not increase the risk of arthritis in the knee.
- Do not prolong recovery time or delay return to sport.
- Carry a low complication rate when done properly.
In other words, they are generally safe when performed by experienced surgeons.
What Does This Mean for Patients?
If you are considering ACL surgery, it is worth discussing with your surgeon whether you are a candidate for one of these extra procedures. Not every patient needs them, but for those at higher risk of re-injury, they may provide extra protection and stability.
The bottom line: Adding a “reinforcement” procedure to ACL surgery may help prevent another injury and give you the best chance of returning to sports safely.
