Surgical Treatment and Complications of Lateral Extra‐articular Procedures in the Anterior Cruciate Ligament–Reconstructed Knee: Part II of an International Consensus Statement

PURPOSE: To establish international expert consensus on surgical techniques, complications, and rehabilitation protocols for lateral extra-articular procedures (LEAPs) performed adjunctively with anterior cruciate ligament reconstruction. METHODS: Fifty-five knee surgeons from 17 countries on 5 continents completed a 3-round modified Delphi process. In the final round, 16 statements on LEAP techniques and complications were scored on a 5-point Likert scale; ≥75% "agree/strongly agree" constituted consensus. When appropriate, strength of recommendation was graded. Statements lacking support were revised until consensus or abandonment. RESULTS: Six statements achieved unanimous consensus (100%), 2 had strong consensus (90%-99.9%), and 3 reached consensus (75%-89.9%); 4 were removed. Key technical recommendations were as follows: (1) in iliotibial band procedures, the graft strip should pass beneath the lateral collateral ligament; (2) an anatomic technique is mandatory for anterolateral ligament reconstruction; and (3) no single LEAP is clinically superior to another. Unanimous agreement indicated that modern LEAPs do not increase lateral compartment osteoarthritis risk, carry a low complication rate, and do not necessitate changes to rehabilitation or return-to-play timelines. CONCLUSIONS: Consensus defined core surgical principles and confirmed the safety of adding LEAPs to anterior cruciate ligament reconstruction. When an iliotibial band graft is used, it should be routed deep to the lateral collateral ligament and fixed between 0° and 60° of knee flexion under low tension. For anterolateral ligament reconstruction, femoral fixation should be in full extension at a posterior-proximal point relative to the lateral epicondyle. Although no single LEAP proved superiority, adherence to these principles permits safe, effective surgery without altering standard rehabilitation or return-to-sport protocols and without increasing osteoarthritis risk. LEVEL OF EVIDENCE: Level V, expert opinion.