For High-Risk ACL Patients, One Extra Step at Surgery Cuts Re-Tear Risk in Half
A study of 1,003 elite athletes found that adding a lateral extra-articular procedure to ACL reconstruction cut re-tears from 14% to 5%. The question every young athlete should ask their surgeon.
If you're a young athlete heading into ACL surgery, there's a question worth asking your surgeon that most patients never think to ask: are you doing anything extra to protect the reconstruction? For the right patients, the answer could be the difference between getting back to your sport and ending up back in the operating room.
A new study published in the American Journal of Sports Medicine followed 1,003 elite athletes and found that adding a lateral extra-articular procedure (LEAP) to a standard ACL reconstruction reduces re-tear risk by 65% — from 14% down to 5%. That confirms what I've been seeing in my own patients for years, and it's why I routinely add this procedure for high-risk cases.
What is a lateral extra-articular procedure?
A standard ACL reconstruction replaces the torn ligament inside the knee with a graft — typically from your own hamstring or patellar tendon. That handles the primary restraint. But for high-risk patients, the inside-the-knee reconstruction alone can leave the joint vulnerable to rotational forces before the graft fully matures.
A lateral extra-articular procedure adds a second layer of protection on the outside of the knee. The technique I use — the modified Lemaire — takes a strip of the IT band and reroutes it to reinforce rotational stability. It's done through the same incision, during the same surgery, under the same anesthesia. Recovery is essentially unchanged. But the mechanical environment the graft heals into is significantly more stable.
Who needs it?
I don't add a lateral procedure to every reconstruction — but for high-risk patients, I routinely recommend it. That includes:
- Young athletes under 25 returning to pivot sports like soccer, basketball, football, or skiing
- Patients with a steep tibial slope on imaging
- Those with significant pre-injury rotational laxity
- Anyone having ACL repair with the BEAR implant rather than traditional reconstruction. The BEAR implant has a somewhat higher re-tear rate than autograft reconstruction, and adding lateral reinforcement may be especially valuable during the healing phase.
The new study focused on elite athletes — the highest-risk group — but the biological rationale applies across anyone in that high-risk category. If you match the profile, this conversation is worth having before surgery, not after.
Frequently asked questions
Does this mean a longer recovery?
Not meaningfully. The lateral procedure adds operative time, but not additional rehab milestones. You're targeting the same return-to-sport timeline — with a better-protected graft.
How do I know if I'm a candidate?
We assess this at your consultation based on age, sport, imaging, and laxity exam. If you're a young athlete in a pivot sport, it's worth the conversation. It takes five minutes and could save you a second surgery.
Does every ACL surgeon offer this?
No. Lateral extra-articular procedures require additional training and experience, and aren't part of every surgeon's standard practice. I perform this regularly as part of my ACL practice for high-risk patients.
ACL surgery is one of the most consequential decisions a young athlete will make. Getting it right the first time — with the right graft, the right technique, and the right additional procedures for your anatomy and sport — matters enormously. If you or your athlete is facing an ACL injury, come in and let's build the best plan for a full, durable return to sport.
This article is general education, not medical advice for your situation. Every knee and hip is different — talk with your own doctor about your care.