Lateral Extra-Articular Tenodesis (LET) and ALL Reconstruction in Bath & Bristol

Lateral extra-articular tenodesis (LET) and anterolateral ligament (ALL) reconstruction are procedures designed to improve control of knee rotation and reduce the risk of ongoing instability after an ACL injury. They are most commonly performed alongside ACL reconstruction in selected patients who have higher risk of persistent rotational instability or re-injury.

Mr Simon Abram, Consultant Specialist Knee Surgeon, offers specialist assessment and surgical planning for LET and ALL reconstruction in Bath and Bristol. The key is selecting the right patients for these procedures and integrating them into an overall ACL and return-to-sport strategy.

What do LET and the ALL do?

The ACL is the main stabiliser that prevents the shin bone sliding forward and helps control knee rotation. However, rotational control of the knee is shared between multiple structures on the outside (lateral side) of the knee.

The anterolateral ligament (ALL) is a structure on the outer front part of the knee that contributes to rotational stability. LET uses a strip of tissue (usually part of the iliotibial band) to reinforce rotational control on the outside of the knee. Both approaches aim to reduce excessive internal rotation of the tibia, which is one of the movements that can make the knee feel unstable during pivoting sports.

Why are LET and ALL reconstruction used?

ACL reconstruction can restore stability for many patients. In some knees, however, there is a higher risk of:

Persistent rotational instability (the knee still feels like it “shifts” on pivoting)
Re-injury to the reconstructed ACL (graft failure)
Difficulty returning safely to pivoting sport

Adding LET or ALL reconstruction can reduce rotational “give” and, in selected higher-risk groups, may reduce the chance of graft failure and recurrent instability.

Who may benefit from LET or ALL reconstruction?

These procedures are not routine for every ACL reconstruction. They are usually considered when there are features suggesting higher risk of rotational instability or re-injury, such as:

High-grade pivot shift on examination (suggesting significant rotational instability)
Returning to pivoting/contact sport (football, rugby, netball, basketball, skiing)
Young, high-demand athletes at higher risk of re-injury
Generalised joint laxity or hypermobility patterns
Revision ACL reconstruction (re-do surgery after a previous ACL reconstruction)
High-risk knee anatomy or additional factors that increase rotational forces
Associated meniscus deficiency or injuries that reduce secondary stability

In clinic, the decision is based on a combination of your injury history, exam findings, imaging, and your sport and lifestyle goals.

LET vs ALL reconstruction: what’s the difference?

Lateral Extra-Articular Tenodesis (LET)

LET reinforces the outer side of the knee using a strip of the iliotibial band (or a similar structure) to act as a check-rein against excessive rotation. It is designed to complement the ACL graft, particularly in pivoting movements.

ALL reconstruction

ALL reconstruction aims to reconstruct the anterolateral ligament using a graft placed along the anatomical course of the ALL. Like LET, it is typically performed with ACL reconstruction in selected cases to improve rotational stability.

Both procedures share the same overall goal: improving rotational control and reducing the risk of ongoing instability. The choice between them depends on the clinical scenario, surgeon preference and the overall stabilisation strategy.

Assessment and planning (Bath & Bristol)

Mr Simon Abram offers specialist ACL and rotational stability assessment in Bath and Bristol, including consideration of whether an additional lateral procedure is appropriate.

Assessment usually includes:

History: giving-way episodes, sport demands, previous ACL surgery, and injury pattern
Examination: rotational stability tests (including pivot shift), overall laxity, and knee alignment
Imaging: MRI to assess ACL injury and associated meniscus/cartilage injuries; x-rays where relevant

If LET or ALL reconstruction is being considered, it is planned as part of a comprehensive package: addressing meniscus injuries, optimising rehabilitation, and ensuring return-to-sport progression is criteria-based.

What happens during surgery?

LET or ALL reconstruction is usually performed at the same time as ACL reconstruction. The procedure typically involves:

Reconstructing the ACL in the usual way
Adding a lateral reinforcement (LET or ALL graft) to improve rotational control
Confirming stability through range of motion at the end of the operation

These are commonly performed through small incisions, alongside the keyhole and minimally invasive techniques used for ACL reconstruction.

Recovery and rehabilitation

Rehabilitation remains the most important driver of outcome. In most cases, the overall rehab pathway is similar to standard ACL reconstruction, but early on may be little slower as the additional scar and soft tissues heal.

Key rehab priorities include:

Early swelling control and regaining full extension
Progressive strengthening (quadriceps, hamstrings, glutes and hip control)
Neuromuscular training and landing mechanics
Gradual return to running and change-of-direction drills when criteria are met
Return to sport based on objective testing and confidence, not dates alone

If your procedure includes additional meniscus repair or other work, your early rehabilitation may be modified to protect healing tissues.

Risks and considerations

All surgery carries risks. Adding a lateral procedure can introduce additional considerations, which are discussed in clinic. Potential issues include:

Infection, blood clots, stiffness, swelling
Lateral knee discomfort or sensitivity during early recovery
Persistent instability if the underlying problem is not fully addressed (for example alignment, meniscus deficiency, or high-risk movement patterns)

A personalised discussion covers expected benefits, alternatives, and how the plan is tailored to your goals and risk profile.

Frequently asked questions

Do I need a lateral tenodesis with my ACL reconstruction?

No. Many people do very well with ACL reconstruction alone. LET or ALL reconstruction is usually reserved for higher-risk cases where additional rotational control is likely to improve stability and reduce re-injury risk.

Will LET or ALL reconstruction help me return to sport?

In selected patients, adding a lateral procedure can improve rotational stability and confidence in pivoting movements. Return to sport still depends on rehabilitation milestones and objective testing.

Is LET only for revision ACL surgery?

No. LET and ALL reconstruction can be used in revision settings, but they may also be considered in primary ACL reconstruction for higher-risk patients (for example young pivoting athletes with high-grade rotational instability).

Can I be assessed for LET or ALL reconstruction in Bath or Bristol?

Yes. Mr Simon Abram offers specialist assessment and surgical planning for ACL injuries in Bath and Bristol, including whether LET or ALL reconstruction is appropriate as part of an ACL stabilisation strategy.