Why I Add a Second Procedure to Many ACL Reconstructions — and Why the Data Backs It Up
Lateral extra-articular tenodesis (LET) cuts graft failure in high-risk ACL patients. What it is, what the STABILITY trial showed, and who I recommend it for.
When I sit down with a high-risk ACL patient — a young female athlete, someone with naturally loose joints, a patient coming in for their second or third reconstruction — one of the most important conversations I have is about what happens after we rebuild the ligament.
A standard ACL reconstruction does its job well for most patients. But for a meaningful subset, the rebuilt ligament fails again. And the question I've spent years thinking about is: what can we do at the time of the original surgery to prevent that?
The answer, for many of my patients, is a procedure called lateral extra-articular tenodesis — or LET. It's a supplemental technique I add to the primary reconstruction when the data says the risk of failure is high enough to warrant it. Here's what it is, why it works, and who I recommend it for.
What is a lateral extra-articular tenodesis?
The ACL is an internal stabilizer — it lives inside the knee joint and resists forward and rotational forces on the shinbone. But the knee also has an external stabilizer system along the outside of the joint: a complex of ligaments and connective tissue called the anterolateral complex. When the ACL tears, this external system takes on more stress. And even after a successful ACL reconstruction, some knees continue to have subtle rotational instability because the external complex has been stretched or damaged as well.
A LET addresses this directly. Using a strip of the iliotibial band — the thick band of tissue running along the outside of the thigh — I create a tether that reinforces the anterolateral side of the knee and controls that rotational movement. It's a relatively small additional step at the time of ACL reconstruction, but the effect on stability is significant.
The STABILITY trial: what the gold-standard study shows
The landmark evidence for LET comes from a multicenter randomized controlled trial led by Dr. Alan Getgood — the STABILITY study — which enrolled 618 patients between the ages of 14 and 25 across nine centers in Canada and Europe. All patients were at high risk for ACL graft failure: young, active, participating in pivoting sports. Half received standard ACL reconstruction with a hamstring graft; the other half received the same reconstruction plus a LET. The results were striking:
| Outcome | ACL reconstruction alone | ACL reconstruction + LET |
|---|---|---|
| Graft rupture | 11% | 4% |
| Clinical failure (rupture or persistent rotational instability) | 40% | 25% |
| Relative reduction in clinical failure | — | 38% |
| Patients treated to prevent one failure | — | ~7 |
STABILITY trial (Getgood et al.): 618 patients aged 14–25, multicenter randomized trial, Level 1 evidence. Winner of the O'Donoghue Sports Injury Research Award.
Adding LET reduced graft rupture by nearly two-thirds and reduced overall clinical failure by 38%. Put another way: for every seven patients in this high-risk group who received a LET, one failure was prevented. This study won the O'Donoghue Sports Injury Research Award — the highest honor in sports medicine research — and it fundamentally changed how surgeons think about ACL reconstruction in young, high-risk patients.
Who I recommend this for
I don't add a LET to every ACL reconstruction — for lower-risk patients, the standard procedure has excellent outcomes on its own. But there are specific situations where I routinely recommend it, and the research continues to validate these indications:
- Female athletes in cutting and pivoting sports with additional risk factors like hypermobility. Women are already at 3–6 times higher risk for ACL injury in sports like soccer and basketball, and the data shows they benefit meaningfully from the added rotational stability LET provides.
- Patients with generalized ligamentous laxity or hypermobility. If your joints are naturally loose, the reconstructed ligament is working against a more unstable baseline. The LET provides an external check on that rotational movement.
- Revision ACL patients. If you're coming in for a second or third reconstruction, failure rates are substantially higher than in a primary surgery. Adding LET in these cases is one of the most important tools I have. A 2025 study specifically looking at multiply-revised ACL patients using quadriceps tendon plus LET showed meaningful improvements and meaningful return-to-sport rates even in these complex cases.
- Cases where I'm using a hamstring graft instead of my preferred patellar tendon graft in high-risk patients. Hamstring grafts are excellent, but they do have a modestly higher retear rate compared to bone–patellar tendon–bone grafts. In high-risk patients where I'm using a hamstring graft, adding LET helps offset that difference.
A 2025 study in professional rugby players found that athletes who received LET at the time of their ACL reconstruction had 2.7 times greater career longevity compared to those who had reconstruction alone. That's the kind of data that matters when I'm talking to a 17-year-old who wants to play in college.
Frequently asked questions
Does adding LET make surgery longer or recovery harder?
The LET adds a relatively small amount of time to the procedure — typically 20 minutes. Recovery milestones and return-to-sport timelines are the same as standard ACL reconstruction. The STABILITY trial specifically confirmed that complication rates were not meaningfully different between the two groups.
Will you know before surgery if I need a LET?
Yes. I assess pivot-shift grade on exam and review imaging for factors like posterior tibial slope. For most high-risk patients the plan is made before surgery.
Is this the same as the LEAP procedure?
They're closely related — LEAP (lateral extra-articular procedure) is a term sometimes used interchangeably with LET and refers specifically to the modified Lemaire technique I use. The concept is the same: using a strip of iliotibial band to reinforce the outside of the knee and control rotation.
If you're facing an ACL reconstruction and want to understand whether a LET makes sense for your situation, that's exactly the kind of conversation I have in the clinic. The right plan depends on your age, sport, anatomy, and history — and getting it right the first time matters.
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.