An ACL (Anterior Cruciate Ligament) tear is one of the most common knee injuries, particularly among athletes involved in football, cricket, basketball, kabaddi, skiing, and other pivoting sports. ACL reconstruction is often recommended when the knee is unstable, especially in active patients who want to return to sports.
In some patients, the surgeon may recommend an additional procedure called LET procedure or Lateral Extra-Articular Tenodesis along with ACL reconstruction.
But does every ACL reconstruction require LET? No. LET is an additional stabilising procedure that may be considered in selected patients when the risk of rotational instability or ACL graft failure is higher.
What Is the LET Procedure?
The LET procedure (Lateral Extra-Articular Tenodesis) is a surgical technique performed on the outer side of the knee to provide additional control of rotational movement.
During ACL reconstruction, the torn ACL is replaced with a graft to restore stability. While the reconstructed ACL primarily addresses forward movement and rotational stability of the knee, some patients may have significant rotational instability that could benefit from additional lateral stabilization.
In LET, a strip of tissue from the iliotibial band (IT band) is used and secured near the outer aspect of the knee. The objective is to help control excessive internal rotation and provide additional stability.
LET is generally performed in addition to ACL reconstruction, rather than as a replacement for the reconstructed ACL.
Is LET Needed in Every ACL Reconstruction?
No, LET is not necessary in every ACL reconstruction.
Many patients with an isolated ACL tear can achieve excellent stability with appropriately performed ACL reconstruction and structured rehabilitation.
The decision to add LET depends on several factors, including the patient’s age, activity level, degree of knee instability, associated injuries, and risk factors for graft failure.
Therefore, LET should not be considered a routine requirement for every ACL surgery. Instead, the surgeon evaluates each knee individually and determines whether additional lateral stabilization is appropriate.
When May the LET Procedure Be Recommended?
There are certain situations in which an LET procedure during ACL reconstruction may be considered.
- High-Grade Rotational Instability
Some patients have significant rotational instability, sometimes identified clinically by a high-grade pivot-shift test. In such cases, additional lateral stabilization may help control abnormal rotational movement.
- Young and Highly Active Athletes
Young athletes participating in high-demand pivoting or contact sports may have a higher risk of reinjury or graft failure. Depending on the overall clinical picture, LET may be considered as part of the reconstruction strategy.
Sports such as football, basketball, kabaddi, rugby, and similar activities involve frequent cutting, pivoting, and sudden changes in direction.
- Revision ACL Reconstruction
Patients undergoing revision ACL reconstruction may have additional risk factors for instability or graft failure. In selected revision cases, LET can be considered to provide additional rotational stability.
- Generalized Ligamentous Laxity
Patients with increased ligamentous laxity may demonstrate greater rotational instability. In carefully selected patients, an additional extra-articular stabilizing procedure may be useful.
- High Risk of ACL Graft Failure
The surgeon may consider LET when several risk factors for graft failure are present. The decision is not based on one factor alone; the patient’s age, sport, knee examination, previous surgery, associated injuries, and rehabilitation plan all need to be considered.
What Are the Potential Benefits of LET?
The main purpose of adding LET to ACL reconstruction is to provide additional rotational control of the knee.
In appropriately selected patients, LET may help reduce residual rotational instability and may reduce the risk of ACL graft failure or reinjury in certain higher-risk groups.
However, LET is an additional surgical procedure and is therefore not something that should automatically be added to every ACL reconstruction.
Are There Any Risks or Disadvantages?
Like any surgical procedure, LET has potential risks. These can include pain around the outer side of the knee, stiffness, irritation, infection, and other complications.
Modern surgical techniques have evolved considerably, and appropriate patient selection and surgical technique are important in minimizing complications.
Another important consideration is that adding LET can increase the complexity of the operation. Therefore, its potential benefits need to be balanced against the individual patient’s needs and risk factors.
How Does the Surgeon Decide Whether LET Is Needed?
There is no single rule that applies to every ACL patient.
The surgeon may consider:
- Age and activity level
- Type of sport
- Degree of rotational instability
- Pivot-shift grade
- Generalized ligamentous laxity
- Previous ACL reconstruction
- Associated meniscus or ligament injuries
- Risk of returning to high-risk sports
- Other individual anatomical and clinical factors
A detailed clinical examination, MRI findings, and assessment of the patient’s goals are important before deciding whether LET should be added.
Conclusion (LET Procedure)
The LET procedure is an additional stabilization technique that may be performed along with ACL reconstruction in selected patients. It is particularly considered when there is significant rotational instability or a higher risk of ACL graft failure.
However, LET is not required in every ACL reconstruction. Patients with an isolated ACL tear and lower-risk features may not need an additional lateral stabilization procedure.
The best approach is individualized treatment. Your surgeon should evaluate your knee instability, activity level, sports requirements, previous injuries or surgeries, and other risk factors before recommending LET.
If you have an ACL tear and have been advised to undergo reconstruction, ask your orthopedic or sports injury specialist whether you have specific risk factors that could make an additional LET procedure appropriate for you.
Frequently Asked Questions
Is LET mandatory with ACL reconstruction?
No. LET is not mandatory for every ACL reconstruction. It is considered selectively based on individual risk factors.
Does LET replace ACL reconstruction?
No. LET is generally an additional procedure performed alongside ACL reconstruction to provide extra rotational stability.
Is LET useful for athletes?
It may be considered in selected athletes, particularly those with higher-risk features such as significant rotational instability or participation in high-demand pivoting sports.
Is LET performed during revision ACL surgery?
LET may be considered in selected revision ACL cases, particularly when additional rotational stability is required.
Can LET prevent another ACL tear?
LET may reduce the risk of graft failure or reinjury in appropriately selected higher-risk patients, but it cannot guarantee that another ACL injury will never occur. Rehabilitation, neuromuscular training, and a safe return-to-sport program remain extremely important.
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