If you’ve torn your anterior cruciate ligament (ACL), one of the biggest decisions before surgery is choosing the right graft — the tissue used to replace your torn ligament. Surgeons commonly use either your hamstring tendon or your patellar tendon (the tendon connecting your kneecap to your shinbone).
In recent years, another surgical addition called a lateral extra-articular procedure (LEP) has gained attention. This added step reinforces the outside of the knee to improve rotational stability — in simple terms, it helps prevent the knee from giving way again, especially during twisting or pivoting movements.
But which graft works best when this LEP procedure is added to ACL reconstruction?
What the study looked at
A new research review analyzed 13 high-quality studies involving almost 1,700 patients who had ACL reconstruction combined with LEP. The goal was to find out:
Which graft (hamstring or patellar tendon) gives better stability and lower failure rates
How patients’ knee function and satisfaction compared between options
Whether adding LEP truly makes a difference
What the results showed
The results were encouraging — especially for patients who had hamstring tendon grafts combined with LEP:
The chance of the graft tearing again was reduced by about 72%
The risk of overall graft failure was reduced by around 73%
The odds of clinical failure (feeling unstable or having poor knee function) dropped by 52%
Patients also had less residual knee instability (less “pivot shift” sensation)
Patients who had patellar tendon grafts with LEP also did well, showing a 70% lower rate of clinical failure compared to ACL reconstruction alone.
Both graft types showed better knee scores (Lysholm scores) — meaning improved comfort and function — compared to ACL reconstruction without LEP.
What this means for patients
For most active patients, especially those involved in sports that require sudden twisting or turning, adding an LEP to ACL reconstruction can significantly improve knee stability and reduce the risk of re-injury.
Both hamstring and patellar tendon grafts remain excellent choices, but current evidence suggests that hamstring grafts with LEP may offer the best protection against re-tear.
The bottom line
Adding a lateral extra-articular procedure to ACL reconstruction — regardless of graft type — appears to make the knee stronger and more stable after surgery.
While more long-term studies are still needed, this combined approach is becoming an increasingly popular option among knee surgeons aiming to help athletes and active individuals get back to their sport safely.
