Indications for Lateral Extra‐articular Procedures in the Anterior Cruciate Ligament–Reconstructed Knee: Part I of an International Consensus Statement
Bertrand Sonnery‐Cottet, Alessandro Carrozzo, Adnan Saithna, Edoardo Monaco, Thaïs Dutra Vieira, Volker Musahl, Alan Getgood, Camilo Partezani Helito, The International Experts Panel, Asheesh Bedi, Dianne Bryant, Etienne Cavaignac, Jorge Chahla, Steven Claes, Frank Cordasco, Matt Daggett, Brian Devitt, Julian Feller, Christian Fink, Rachel Frank, Andrew Geeslin, Alberto Grassi, Daniel Green, Daniel Guenther, Mark Heard, Elmar Herbst, Graeme Hopper, Eivind Inderhaug, James Irrgang, Christopher Kaeding, Christopher Kittl, Mininder Kocher, Hideyuki Koga, Aaron J. Krych, Robert LaPrade, Bruce Levy, Robert Bruce Litchfield, Tim Lording, Walter Lowe, Peter MacDonald, Robert Marx, Gilbert Moatshe, Thomas Neri, Herve Ouanezar, Vitor Barion de Castro Padua, David Parker, Charles Pioger, Elvire Servien, Seth Sherman, Patrick Smith, Tim Spalding, Sachin Tapasvi, Peter Verdonk, Andy Williams, John Xerogeanes, Simon W. Young
Abstract
PURPOSE: To define expert consensus on whether and how lateral extra-articular procedures (LEAPs) should accompany anterior cruciate ligament (ACL) reconstruction to optimize outcomes in ACL-deficient knees. METHODS: Fifty-five knee surgeons from 17 countries on 5 continents completed a 3-round modified Delphi process. Twenty-one statements on patient selection for combined ACL reconstruction (ACLR) + LEAPs were graded on 5-point Likert scales; ≥75% "agree/strongly agree" signified consensus. Strength of recommendation was ranked, and statements failing the threshold were revised or discarded after discussion. RESULTS: One statement achieved unanimous agreement (100%): it is strongly recommended to add a LEAP for active patients ≤25 years receiving hamstring-autograft ACLR to reduce graft failure. Strong consensus (≥90%) supported LEAPs in primary ACLR when grade 3 pivot shift (97.9%), knee hyperextension (97.9%), skeletally immature status (79.5%), revision ACLR (91.5%), return to pivoting sports (93.2%), active patients ≤25 years using nonhamstring grafts (90.7%), grade 3 Lachman test (90%), and when multiple relative risk factors coexist (statement 36, 97.1%). Consensus (75%-89.9%) favored LEAPs for chronic symptomatic ACL deficiency (86.1%), posterior tibial slope >12° (85.7%), and a history of contralateral ACL injury (88.9%). Eight statements did not reach consensus regarding small-diameter autografts, female athletes, imaging signs of anterolateral injury (e.g., Segond fracture, lateral femoral-notch sign), and concomitant meniscal procedures. One statement on LEAPs with primary ACL repair was withdrawn because the project focused on reconstruction. CONCLUSIONS: International experts strongly recommend adding a LEAP in young active patients undergoing hamstring-autograft ACLR and in cases of high-grade rotational or anterior laxity, knee hyperextension, revision surgery, or returning to pivoting sports. Unresolved issues include small graft size, female athletes, imaging findings of rotational instability, and concurrent meniscal procedures, highlighting priorities for future research. LEVEL OF EVIDENCE: Level V, expert opinion.