Surgical Treatment and Complications of Lateral Extra-articular Procedures in the Anterior Cruciate Ligament-Reconstructed Knee: Part II of an International Consensus Statement
- PMID: 40544924
- DOI: 10.1016/j.arthro.2025.06.013
Surgical Treatment and Complications of Lateral Extra-articular Procedures in the Anterior Cruciate Ligament-Reconstructed Knee: Part II of an International Consensus Statement
Abstract
Purpose: To establish international expert consensus on surgical techniques, complications, and rehabilitation protocols for lateral extra-articular procedures (LEAPs) performed adjunctively with anterior cruciate ligament reconstruction.
Methods: Fifty-five knee surgeons from 17 countries on 5 continents completed a 3-round modified Delphi process. In the final round, 16 statements on LEAP techniques and complications were scored on a 5-point Likert scale; ≥75% "agree/strongly agree" constituted consensus. When appropriate, strength of recommendation was graded. Statements lacking support were revised until consensus or abandonment.
Results: Six statements achieved unanimous consensus (100%), 2 had strong consensus (90%-99.9%), and 3 reached consensus (75%-89.9%); 4 were removed. Key technical recommendations were as follows: (1) in iliotibial band procedures, the graft strip should pass beneath the lateral collateral ligament; (2) an anatomic technique is mandatory for anterolateral ligament reconstruction; and (3) no single LEAP is clinically superior to another. Unanimous agreement indicated that modern LEAPs do not increase lateral compartment osteoarthritis risk, carry a low complication rate, and do not necessitate changes to rehabilitation or return-to-play timelines.
Conclusions: Consensus defined core surgical principles and confirmed the safety of adding LEAPs to anterior cruciate ligament reconstruction. When an iliotibial band graft is used, it should be routed deep to the lateral collateral ligament and fixed between 0° and 60° of knee flexion under low tension. For anterolateral ligament reconstruction, femoral fixation should be in full extension at a posterior-proximal point relative to the lateral epicondyle. Although no single LEAP proved superiority, adherence to these principles permits safe, effective surgery without altering standard rehabilitation or return-to-sport protocols and without increasing osteoarthritis risk.
Level of evidence: Level V, expert opinion.
Copyright © 2025. Published by Elsevier Inc.
Conflict of interest statement
Disclosures The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: A.J.K. is a consultant or advisor for Arthrex. R.B.L. has received financial support from Arthrex; is a consultant or advisor for Smith & Nephew; has received speaking and lecture fees from Arthrex and Smith & Nephew; and has received funding grants from Smith & Nephew. R.L. has received funding grants from Ossur, Smith & Nephew, Arthroscopy Association of North America, and American Orthopaedic Society for Sports Medicine; is a consultant or advisor for Ossur, Smith & Nephew, and Responsive Arthroscopy; has received travel reimbursement from Smith & Nephew; has received speaking and lecture fees from Foundation Medical, LLC; and has a patent with royalties paid to Ossur. T.L. is a consultant or advisor for Smith & Nephew and Medacta International SA; has received speaking and lecture fees from Smith & Nephew, Arthrex, and Medacta International SA; has received funding grants from Smith & Nephew and Arthrex; has received travel reimbursement from Smith & Nephew, Arthrex, and Medacta International SA; and has received nonfinancial support from Smith & Nephew. W.L. is a consultant or advisor for Arthrex. G.M. is a consultant or advisor for Smith & Nephew; has received funding grants from Smith & Nephew; and is a board member of the Journal of Bone and Joint Surgery, International Society of Arthroscopy, Knee Surgery, and Orthopaedic Sports Medicine, and European Society of Sports Traumatology, Knee Surgery and Arthroscopy. R.M. has equity or stocks with MEND; is a board member of the International Society of Arthroscopy, Knee Surgery, and Orthopaedic Sports Medicine; and has a book published with Springer and Demos Health with royalties paid to the author. C.P. is a consultant or advisor for Arthrex and is employed by Public Assistance Hospitals Paris. D.P. has received speaking and lecture fees from Smith & Nephew and Arthrex; is a consultant or advisor for Smith & Nephew; has received travel reimbursement from Smith & Nephew; has equity or stocks with Personalised Surgery; is a board member of AJSM, OJSM, APSMART, JISAKOS, and the International Society of Arthroscopy, Knee Surgery, and Orthopaedic Sports Medicine; and has received funding grants from Zimmer Biomet. P.S. is a consultant or advisor for Arthrex; receives funding grants, nonfinancial support, speaking and lecture fees, and travel reimbursement from Arthrex; and is a stockholder for Spinal Simplicity. S.S. holds committee positions for AANA, AAOS, ACLSG, AOSSM, Biologic Alliance, ICRS, and Ortho Summit (OSET); is on the editorial board for Orthopedics Today, Current Reviews in Musculoskeletal Medicine, and VJSM; is a course chair of ISMF and the PFF Masters Course; is also on the board of directors for ISAKOS and ACL Study Group; is a paid educational consultant for Arthrex, Kinamed, and LifeNet; is a paid advisory board member for Ostesys, Reparel, Sarcio, Sparta Biomedical, Vericel, and Vivorte; is on design teams and receives royalties from ConMed and DJO; holds stock and stock options for Epicrispr BioTech, Icarus Medical, Moximed, Sarcio, and Reparal; holds stock options only for Arcuro Medical, Kyniska Robotics, Sparta Biomedical, and Vivorte; holds restricted stock awards (RSA) for BioEnthesis and Sparta Biomedical; receives research support from Allosource, JRF, Kinamed, Miach Orthopaedics, Octane Biotherapeutics, Organogenesis, Ossio, Smith & Nephew, and University of Pittsburg. T.S. reports administrative support was provided by Arthrex, is a consultant or advisor for CONMED, has received speaking and lecture fees from CONMED, and has a patent with royalties paid to CONMED. P.V. is a consultant or advisor for CONMED. A.W. is a board member of the American Journal of Sports Medicine, Anterior Cruciate Ligament Study Group, and International Society of Arthroscopy, Knee Surgery, and Orthopaedic Sports Medicine; has received nonfinancial support from the Anterior Cruciate Ligament Study Group; has equity or stocks with Innovate Orthopaedics Limited, DocComm, and Fortius Clinic; is a consultant or advisor for Smith & Nephew; and has received speaking and lecture fees, travel reimbursement, and funding grants from Smith & Nephew. S.W.Y. has received travel reimbursement from Arthrex, has received research support from Stryker and Smith & Nephew, and is a consultant for Stryker. F.C. is a Chair, Board of Trustees, JSES. R.F. is the Editor in Chief of JCJP and Associate Editor for JSES. All other authors (A.C., V.M., D.B., E.C., E.H., G.H., C.K., M.K., H.K., P.M., T.N., H.O., V.B.d.C.P., E.S., S.T., J.X.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
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