Commentary on JPOSNA® Quality Improvement Case Series: Isolated Lateral Extra-articular Tenodesis After Primary Anterior Cruciate Ligament Reconstruction

Aristides I. Cruz, Jr. MD, MBA

There has been a recent resurgence and clinical interest in performing lateral extra-articular tenodesis (LET) procedures since Claes et al. published their findings on the anterolateral ligament (ALL) in 2013. At the time of publication of those findings, many in the lay media heralded this “discovery” of a “new” ligament [1,2] when in fact it may be more apt to describe Claes et al.'s paper as a detailed investigation and description of what has been previously described by Segond and others [[3], [4], [5]]. Prior to the development of contemporary anterior cruciate ligament (ACL) reconstruction (ACLR), lateral extra-articular procedures were frequently used to increase rotational stability in ACL-deficient knees and a variety of procedures were described by various authors.

Lemaire described a method utilizing an iliotibial band (ITB) autograft. In Lemaire's description, a strip of ITB is left attached to Gerdy's tubercle and bone tunnels are drilled into the femur just above the lateral epicondyle and proximal to the lateral collateral ligament (LCL) insertion. A second tunnel is drilled through Gerdy's tubercle. The ITB graft is then passed under the LCL and into the femoral bone tunnel, back under the LCL, and then inserted into the Gerdy's tubercle tunnel (Fig. 1). The modified Lemaire procedure is similar to the originally described procedure except that only one bone tunnel is utilized to fix the ITB graft into the lateral femur, while the attachment to Gerdy's tubercle remains untouched [6]. In 1976, MacIntosh and Darby described an extra-articular procedure, where a strip of ITB autograft was tunneled subperiosteally on the lateral femoral condyle immediately posterior to the LCL. The strip of ITB was then tunneled through a second subperiosteal location at the distal insertion of the lateral intermuscular septum and looped distally deep to the LCL and fixed back onto itself at Gerdy's tubercle [7,8] (Fig. 2). Losee described a “sling and reef” operation, where a strip of ITB is detached proximally (with its Gerdy's tubercle insertion left intact) and passed through a femoral tunnel that originates at the lateral gastrocnemius insertion on the posterior femoral condyle and exits anterior and distal to the LCL insertion on the lateral femur (Fig. 3). The ITB graft is then sutured to itself at its insertion on Gerdy's tubercle.

Figure 1.

Lemaire lateral extra-articular tenodesis procedure. Image copyright ©2026 COSF.

Figure 2.

MacIntosh and Darby lateral extra-articular procedure. Image copyright ©2026 COSF.

Figure 3.

Losee lateral extra-articular procedure (“sling and reef”). Image copyright ©2026 COSF.

There is ample evidence that anatomic reconstruction of the ACL should be the primary treatment for ACL rupture. Additionally, biomechanical studies have shown that in the ACL-deficient knee, isolated LET procedures overconstrain the knee, restrict internal tibial rotation, and do not reproduce the normal resistance to anterior translation of an ACL-intact knee [9]. However, despite the limitations of isolated LET procedures, there has been increasing interest in performing LET procedures in conjunction with anatomic ACL reconstruction, particularly in cases where there may be increased risk of rotational instability [[10], [11], [12], [13]]. In the May 2025 issue of JPOSNA®, the Quality Improvement Case Series report by Randall et al. describes performing an LET procedure (modified Lemaire) to address symptomatic rotatory instability in a patient who had previously undergone quadriceps autograft, anatomic ACL reconstruction. Prior to the patient's ACL reconstruction, the authors describe the patient to have several signs of ligamentous laxity. They also describe the patient's preoperative magnetic resonance imaging (MRI) as demonstrating increased internal rotation of the tibia relative to the femur. While the specific indications for performing LET during primary ACL reconstruction remains a topic of considerable debate, many authors cite ligamentous laxity and increased internal tibial torsion (among other clinical risk factors for ACL reconstruction failure) as relative indications for performing combined ACL reconstruction and LET [[14], [15], [16]]. The experience of Randall et al. should continue to spur the ongoing interest of investigating the role of LET in optimizing outcomes following ACL reconstruction.

Jennifer J. Beck, MD

Getting rotational stability corrected is the goal of ACL surgery. The unique orientation of the ACL bundles has led to numerous surgical options, single- and double-bundle techniques, in attempts to restore this stability. We know that vertical grafts and misplaced tunnels, most commonly the femoral tunnel, will not correct the rotational element of an ACL, while it may control anterior to posterior tibial translation. As the ALL has resurfaced in sports medicine, we need to be careful about relying on this technique to protect us from improper ACL tunnel placement. While adding an anterolateral reconstruction can help reduce tibial internal rotation, it cannot overcome an ACL deficiency in a high-risk athlete. To be clear, I use modified Lemaire reconstructions routinely in my practice, especially in high-risk athletes. High risk in my clinical practice is anyone under 18 years of age, of female sex, having hyperlaxity based on knee hyperextension or Beighton scoring, having high grade pivot shift, having meniscus tears/deficiency especially medially, and having plans to return to high-risk sports. All of this to say preop planning and technical execution with anatomic reconstruction of the ACL are critical in this inherently high-risk pediatric sports medicine population.

There are two main takeaways from this case that I would like to discuss. First, this patient in my practice would have gotten an ALL procedure at their index surgery. Even with the now popularized quad tendon autograft, there are enough risk factors that I would have completed this procedure at the time of ACLR. For anyone taking care of this population, I would argue that you have to talk yourself OUT of doing an ALL procedure instead of IN to doing one [17]. Current evidence does not show an outcome difference based on technique [18]. The long-term, downstream effects of overloading the lateral compartment are the main risk; however, properly executed contemporary techniques hopefully are mitigating this concern. Biomechanical studies do show that the addition of an ALL procedure reduces internal tibia torsion to below native levels [19]. Despite this, I think the meniscal and chondral injuries due to a failed ACL in a teenager likely will result in higher arthrosis rates than the overconstrained lateral compartment from an ALL procedure, though no study has tested this.

Second, a hypercritical review of this femoral tunnel shows that the femoral tunnel in this case report may be more anterior and proximal than the native ACL fibers. This could result in a central rotation point with a negative Lachman exam and unimpressive pivot shift while still allowing for internal rotation. Before considering performing a staged LET procedure for continued rotational instability, hypercritical evaluation of the reconstruction tunnels and graft quality should be completed. If there is any concern, a revision ACLR should be performed in addition to the LET procedure. Undue internal rotation stress on an ACLR graft from improper tunnel placement can lead to laxity of the ACL graft tissue. In addition to careful imaging review, examination under anesthesia and arthroscopic evaluation can determine the need for ACL revision when complaints of continued internal rotation instability occur.

While the case presented resolved the patient's symptoms in the short term, I want to caution pediatric sports medicine surgeons or anyone doing ACL reconstructions that proper preoperative planning including the addition of adjuvant procedures such as ALL reconstruction or modified Lemaire tenodesis and technical execution of the ACLR should be priorities for this population. Adding a lateral extra-articular procedure to a poorly performed ACLR is not in the best interest of the patient.

Neeraj M. Patel, MD, MPH, MBS

Although the ALL of the knee was described by Segond in 1879 as a “pearly, resistant, fibrous band” [3] there has been an increasing interest in this anatomy after the ALL was formally identified in 2012 [20]. Biomechanical studies show that the anterolateral complex provides stability against internal rotation of the knee [[21], [22], [23], [24], [25], [26]]. While lateral extra-articular tenodesis (LET) procedures like the MacIntosh, Lemaire, and others were described long before the advent of arthroscopic, anatomic ACLR, they have regained popularity over the last decade or so. A 2018 study found that 38% of surgeons in the American Orthopaedic Society for Sports Medicine performed procedures like LET or anterolateral ligament reconstruction (ALLR) with primary ACL reconstruction [27]. In 2022, our group reported that 56% of surgeons in the Pediatric Research in Sports Medicine (PRiSM) Society performed these concomitant procedures [28]. With increasing literature in this area, it is likely that LET and ALLR are even more popular at present.

The case at hand brings to light a potential indication for LET or ALLR that is theoretically reasonable but minimally studied. In our survey of the PRiSM membership, the most common indications for these procedures in the setting of primary ACLR were high-grade pivot shift test, substantial knee hyperextension, generalized ligamentous laxity, and participation in high-risk sports [28]. There is growing evidence that the risk of ACL graft failure may be lower in patients who meet these indications and undergo a concomitant anterolateral augmentation procedure with ACLR. The Stability trial, a well-designed, multicenter, randomized controlled trial, found that adding LET at the time of hamstring autograft ACLR significantly lowered the risk of graft failure in young, high-risk patients [13]. A prospective cohort study by Sonnery-Cottet et al. [29] reported that combined hamstring autograft ACLR with ALLR resulted in significantly lower odds of graft failure than hamstring or patellar tendon ACLR alone. Clinical practice guidelines published by the American Academy of Orthopaedic Surgeons in 2022 suggest that LET or ALLR could be considered with ACLR in select patients to reduce graft failure based on high-quality evidence [30]. However, the present case offers quite a different indication.

The authors describe a 12-year-old girl who underwent isolated ACLR with quadriceps tendon autograft. The patient was a volleyball player with a Beighton score of 6 out of 9, including knee hyperextension. Notably, age, activity type/level, ligamentous laxity, and knee hyperextension are all factors that increase the risk of ACL graft failure [[31], [32], [33], [34]]. The patient rehabilitated successfully and was ultimately cleared to return to sports. She then experienced symptomatic instability without a positive pivot shift test. The authors report that the ACL graft appeared to be intact and in acceptable position on MRI and during arthroscopic evaluation. She reported resolution of her instability after secondary LET.

There is very little literature on isolated, secondary LET following ACLR. Helito et al. investigated 20 patients who experienced grade 1 pivot shift test with an intact ACL graft following ACLR. Addition of a secondary LET resulted in resolution of the pivot shift in 70% of cases and improvement of the Lysholm score [35]. Hoffer et al. [36] conducted a retrospective study of 47 patients with an intact or partially torn ACL graft and new medial meniscus tear. Patients were treated with isolated revision ACLR, revision ACLR with LET, or LET alone. While underpowered to study broader clinical outcomes, the authors found that those who underwent isolated revision ACLR reported lower patient-reported outcome measures than the other two groups, including those that received LET only.

Assessment of rotational stability in the setting of ACL injury starts preoperatively. Accurate grading of the pivot shift is important, as is identification of factors that may increase a patient's risk of graft failure. Since a high-quality pivot shift test is often challenging to obtain on an awake patient; it should be rechecked intraoperatively prior to beginning ACLR. In a high-risk patient, especially if a high-grade pivot shift was noted preoperatively, surgeons should consider gently rechecking rotational stability following the final tensioning of the ACL graft. Spencer et al. [24,37] suggest that an unaddressed anterolateral injury may underlie a positive pivot shift test following anatomic ACL reconstruction. Therefore, the addition of LET or ALLR could be warranted in this scenario.

Of course, the most critical technical components of ACLR related to rotational stability are anatomic graft position and optimal graft tensioning. Specifically, an excessively vertical femoral tunnel is known to reduce rotational stability and increase the risk of failure. To be clear, an isolated anterolateral procedure is not an acceptable solution for a malpositioned or lax graft. In these scenarios, revision ACLR is indicated. However, the authors present a less common situation in which the graft is intact and in acceptable position, yet the patient experiences rotational instability. It is possible that the patient sustained an injury to the anterolateral complex or had baseline laxity in this area that was not fully addressed by ACLR alone. Surgeons generally rely on severity of the pivot shift test as a proxy for this as the rate at which anterolateral injury is visualized on MRI is extremely variable [[37], [38], [39], [40]]. In this uncommon scenario, it may be reasonable to consider isolated secondary LET, especially since this is less morbid or complex than revision ACLR. Importantly, as in any situation where a relatively unstudied treatment is being offered, surgeons should have an open and honest conversation with families about the potential risks, benefits, and unknowns.

As procedures like LET and ALLR increase in popularity, their indications continue to be better understood. To date, there is very little data on isolated, secondary LET to address residual instability following ACLR. While there may be a narrow indication for this mild rotational laxity with a truly intact, properly tensioned, and anatomically positioned ACL graft, more evidence is needed, and surgeons should acknowledge this when exercising shared decision making with families.

Author contributions

Aristides I. Cruz, Jr.: Conceptualization, Writing – original draft, Writing – review & editing. Jennifer J. Beck: Conceptualization, Writing – original draft, Writing – review & editing. Neeraj M. Patel: Conceptualization, Writing – original draft, Writing – review & editing.

Funding

No funding was received for this paper.

Declaration of competing interests

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.