Nationwide • Evidence-based
Lateral extra-articular tenodesis (LET): the operation that protects your ACL graft
A small extra procedure, added to an ACL reconstruction, that cuts the risk of the new graft re-rupturing by around two thirds in young pivoting athletes. Mr Osman Riaz performs around 60 LET procedures a year — one of the highest volumes in the UK.
~65%
reduction in graft re-rupture when LET is added (STABILITY trial)
10–15% → 2–4%
re-rupture risk in high-demand athletes under 24
60
LET procedures a year by Mr Riaz
What is a lateral extra-articular tenodesis?
An ACL reconstruction rebuilds the ligament inside the knee. A lateral extra-articular tenodesis adds a second restraint on the outside of the knee to control rotation — the exact movement that tears ACLs and then re-tears grafts.
In the modified Lemaire technique that Mr Riaz uses, a strip of your iliotibial band (ITB) is left attached at one end, passed underneath the lateral collateral ligament, and fixed to the femur. It acts as a checkrein against excessive internal rotation and pivot shift.
It is performed through a small separate incision on the outer thigh at the same sitting as the ACL reconstruction. It does not lengthen your recovery meaningfully, and it uses your own tissue.
Why it matters
Why add anything to an ACL reconstruction?
Because a well-performed ACL reconstruction still fails more often than most patients realise — and in the group most eager to get back to sport, it fails most of all. Around 1 in 10 young athletes re-ruptures a hamstring graft. Rotational control is the missing piece: the graft inside the knee resists forward slide well, but resists twist less well. LET adds that twist control.
The STABILITY trial
The landmark randomised trial of ACL reconstruction with versus without LET in young, high-risk patients found a ~65% reduction in graft re-rupture when LET was added, with significantly better rotational stability. It is the single strongest piece of evidence in this field and it changed practice internationally.
What it means for you
In high-demand athletes under 24, published re-rupture rates fall from roughly 10–15% down to 2–4% with the addition of a LET. For a young footballer, that is the difference between a meaningful chance of going through the whole thing again and a small one.
Patient selection
Who should have a LET?
Not everyone needs one — and a surgeon who adds it to every knee is not individualising care. These are the groups where the balance clearly favours it:
🏋 Under 24 and playing pivoting sport
Football, rugby, netball, basketball, skiing. This is the highest-risk group and the one where the evidence is strongest.
👩 Female athletes in cutting sports
Higher ACL injury and re-injury risk from anatomical and neuromuscular factors. LET or ALL reconstruction is strongly worth considering.
⚽ Professional and elite athletes
Extreme physical demands and a career riding on the knee. The additional rotational security is usually worth it.
🔄 A previous ACL graft that failed
In revision ACL surgery a LET is close to standard practice — and slope should be measured too.
🧺 Marked rotational laxity or hyperextension
A high-grade pivot shift, generalised ligament laxity or genu recurvatum on examination.
🩹 Complex or multi-ligament injury
Where several structures are damaged and extra lateral restraint helps protect the reconstruction.
The two techniques
LET or ALL reconstruction?
Both add rotational control on the outside of the knee. They differ in how they get there, and the choice depends on your anatomy, your graft and whether you are having primary or revision surgery.
| Lateral extra-articular tenodesis (LET) | Anterolateral ligament (ALL) reconstruction | |
|---|---|---|
| Tissue used | A strip of your own iliotibial band, left attached distally | A separate tendon graft |
| Route | Passed under the lateral collateral ligament and fixed to the femur | Reconstructs the anatomical course of the ALL |
| Technique | Modified Lemaire — the technique used in the STABILITY trial | Anatomic reconstruction |
| Evidence base | The strongest — randomised trial data | Good biomechanical and clinical data, less randomised evidence |
| Mr Riaz’s usual choice | Yes — his standard adjunct, ~60 a year | Used in selected cases and revision settings |
Practicalities
What it means for your recovery
Adding a LET does not add a second recovery. It is done at the same anaesthetic, through a small extra incision on the outer thigh, and rehabilitation follows the same ACL pathway.
What you will notice: a second, smaller scar on the outside of the thigh, and some lateral tightness or aching for the first several weeks as that area settles. Occasionally patients feel a little tightness on deep flexion early on, which resolves with rehabilitation.
Return to sport is governed by the ACL reconstruction and your rehabilitation progress — typically 9 to 12 months, criteria-based rather than calendar-based. Our ACL rehabilitation protocols are free for you and your physiotherapist to download.
Honest trade-offs
- A second small incision and scar on the outer thigh
- Lateral soreness and tightness for the first few weeks
- Slightly longer operating time
- A theoretical concern about over-constraining the knee — not borne out in the randomised evidence
- A modest additional cost — see ACL surgery cost
Common questions
Your questions about LET
Does everyone having an ACL reconstruction need a LET?
No. It is most clearly worthwhile in young pivoting athletes, female athletes in cutting sports, professional athletes, revision cases and knees with marked rotational laxity. In an older, lower-demand patient the balance is different, and adding it routinely to every knee is not individualised care.
How much does a LET reduce the risk of re-rupture?
The STABILITY randomised trial found roughly a 65% reduction in graft re-rupture when LET was added in young, high-risk patients. In high-demand athletes under 24, published rates fall from about 10-15% to 2-4%.
Will a LET slow down my recovery or limit my movement?
It should not. Rehabilitation follows the standard ACL pathway and return to sport is still typically 9-12 months, criteria-based. Some patients notice lateral tightness or aching for the first few weeks, which settles. The randomised evidence has not shown a meaningful loss of movement.
What is the difference between LET and ALL reconstruction?
A LET uses a strip of your own iliotibial band passed under the lateral collateral ligament and fixed to the femur. An ALL reconstruction uses a separate tendon graft to rebuild the anterolateral ligament along its anatomical course. LET has the stronger randomised evidence base and is Mr Riaz’s standard adjunct.
Does adding a LET cost more?
There is a modest additional cost for the extra operating time. It is small relative to the cost of a second ACL reconstruction if the first graft fails.
Related reading
ACL reconstruction • Which ACL graft is right for you? • Revision ACL surgery • ACL surgery cost • ACL rehabilitation protocols • Why do ACL grafts fail?
Discuss whether you need a LET
Spire Elland 01422 702951 • The Huddersfield Hospital 01484 533131. Around 60 LET procedures a year — UK-wide referrals and second opinions welcome.
