Isolated anterior cruciate ligament reconstruction versus reconstruction with a lateral extra-articular procedure (LET or ALL reconstruction): a systematic review and meta-analysis

Lateral extra-articular procedures (LEAPs), including lateral extra-articular tenodesis (LET) and anterolateral ligament reconstruction (ALLR), are used with anterior cruciate ligament reconstruction (ACLR) to improve rotational control and reduce graft failure. Whether these distinct procedures improve patient-reported and functional outcomes compared with isolated ACLR (iACLR) remains uncertain. This PRISMA-guided systematic review included studies published from 2015 to 2025 comparing or reporting outcomes after iACLR and ACLR with a LEAP. Outcomes reported on common native scales were pooled as mean differences (MDs) using random-effects restricted maximum likelihood models; Kellgren-Lawrence stage 0 was pooled as a risk ratio (RR). We conducted subgroup analysis by procedure (LET, ALLR, mixed LEAP) and primary versus revision ACLR, leave-one-out analyses, Holm adjustment across nine outcome-level tests, and Egger testing only when at least 10 studies were available. Twenty comparative studies were included; the number contributing to each quantitative synthesis ranged from 2 to 14. Significant pooled differences favored augmentation for IKDC (MD = 2.24, 95% CI: 0.40 to 4.07; p = 0.0168) and Lysholm (MD = 2.08, 95% CI: 0.37 to 3.79; p = 0.0171), but neither remained significant after Holm correction (both adjusted p = 0.1347). KOOS quality of life showed a small difference (MD = 2.32, 95% CI: 0.78 to 3.87; Holm-adjusted p = 0.0291), while KOOS pain, symptoms, activities of daily living, sport/recreation, and Tegner were not different. The exploratory two-study Kellgren-Lawrence stage 0 analysis favored augmentation (RR = 1.24, 95% CI: 1.02 to 1.50; unadjusted p = 0.0294; adjusted p = 0.1763; risk difference = 14.5%, NNT = 7) and was not robust to multiplicity. Heterogeneity remained substantial for IKDC, Tegner, and Lysholm. Small-study asymmetry was detected for IKDC, Tegner, and Lysholm. Current evidence does not demonstrate a clinically important, consistent patient-reported benefit from adding a lateral extra-articular procedure to ACLR. Significant differences in IKDC and Lysholm did not survive multiplicity correction, and the pooled Lysholm difference was below a published 5.5-point minimal important clinical difference. The two-study radiographic osteoarthritis result should be considered hypothesis-generating rather than definitive. CRD420251019521.