Lateral Extraarticular Procedures (LEAPs)

What are Lateral Extraarticular Procedures (LEAPs)?

Lateral extraarticular procedures (LEAPs) are surgical techniques often performed alongside anterior cruciate ligament (ACL) reconstruction to improve rotational stability of the knee. These procedures target the lateral (outer) side of the knee, specifically structures such as the anterolateral capsule and iliotibial band (ITB), to control excessive internal rotation and pivot shift that can persist even after ACL reconstruction. In simpler terms, LEAPs act as an additional stabilizing reinforcement on the outside of the knee, helping prevent the tibia (shin bone) from rotating too much relative to the femur (thigh bone).

What are the Common Types of Lateral Extraarticular Procedures (LEAPs)?

The common types of LEAPs include the following:

• Lateral Extra-articular Tenodesis (LET) – uses a strip of the iliotibial band (ITB) to limit internal rotation of the tibia; commonly performed using the Modified Lemaire or MacIntosh technique.
• Anterolateral Ligament Reconstruction (ALLR) – reconstructs the anterolateral ligament using a graft to restore natural knee rotational control.

What are the Indications for Lateral Extraarticular Procedures (LEAPs)?

LEAPs are typically used in patients at higher risk of graft failure or persistent instability, such as athletes in pivoting sports, those with generalized ligamentous laxity, or revision ACL surgeries.

What Happens During Lateral Extraarticular Procedures (LEAPs)?

In general, LEAPs typically involve the following steps:

• The patient is positioned, and the knee is examined under anesthesia to assess laxity. Standard ACL reconstruction is performed first.
• A small incision is made on the outer side of the knee, near the lateral femoral epicondyle and iliotibial band (ITB).
• A strip of the ITB or a graft (e.g., hamstring tendon) is prepared for use in the procedure.
• Graft Placement:
  • In Lateral Extraarticular Tenodesis (LET), the ITB strip remains attached near Gerdy’s tubercle (on the tibia) and is routed under or over the lateral collateral ligament (LCL), then anchored to the femur.
  • In Anterolateral Ligament (ALL) Reconstruction, the graft is anchored between the femur and tibia to mimic the natural ALL’s path.
• The graft is tensioned and fixed with screws or anchors to ensure proper alignment and rotational control.
• The incision is closed, and sterile dressings are applied.
• The entire procedure adds only a short amount of time to ACL surgery but significantly enhances rotational stability and helps reduce the risk of graft failure in high-risk patients.

What Happens After Lateral Extraarticular Procedures (LEAPs)?

After LEAPs, patients usually follow a rehabilitation plan similar to that of ACL reconstruction, with some adjustments to protect the additional lateral repair. In the immediate postoperative period, the knee is placed in a brace to limit excessive movement, and crutches are used to reduce weight-bearing for the first few weeks. Pain, swelling, and stiffness are common but gradually improve with rest, icing, medications, and physical therapy. Rehabilitation focuses on restoring knee motion, strength, and stability while avoiding early twisting or pivoting movements. As healing progresses, patients transition to more advanced exercises for balance and agility. Most people can return to sports in 6–9 months, depending on recovery progress and the specific combination of procedures performed.

What are the Risks and Complications of Lateral Extraarticular Procedures (LEAPs)?

Risks and complications of Lateral Extraarticular Procedures (LEAPs) include the following:

• Infection at the surgical site
• Knee stiffness or limited range of motion
• Persistent pain or swelling
• Graft failure or loosening
• Injury to nearby nerves or blood vessels
• Over-constraint of the knee, leading to altered mechanics

What are the Benefits of Lateral Extraarticular Procedures (LEAPs)?

Benefits of LEAPs include the following:

• Improves rotational control of the knee
• Reduces risk of ACL graft re-tear
• Enhances stability during pivoting or cutting movements
• Better functional outcomes for athletes in pivoting sports