Delphi Expert Consensus Identifies Revision Surgery, High‐Grade Pivot Shift, and High‐Risk Athletes in Pivoting Sports as Indications for Anterolateral Ligament Reconstruction or Lateral Extra‐articular Procedures in Anterior Cruciate Ligament Recons

PURPOSE: To conduct a Delphi expert consensus on the biomechanics, indications and contraindications, surgical techniques, and complications associated with augmenting anterior cruciate ligament (ACL) reconstruction (ACLR) with either anterolateral ligament reconstruction (ALLR) or lateral extra-articular procedure (LEAP). METHODS: Forty panel members were included. In Round 1, the panel addressed 18 open-ended questions on ALLR or LEAP in ACL surgery, followed by 8 semi-open-ended questions in Round 2. They assessed 27 potential indications for ALLR/LEAP, ranking their relevance and importance. In Round 3, 73 items on biomechanics, surgical techniques, contraindications, and complications were presented for final voting. RESULTS: Unanimous consensus supports LEAP or ALLR for high-grade pivot shifts and revision ACL surgery. Very strong consensus confirms LEAP resists internal tibial rotation, reduces ACL stress with ACLR, and requires femoral fixation posterior and proximal to the lateral epicondyle. Strong consensus supports additional surgery for hyperlaxity and high-risk athletes in pivoting sports. Consensus highlights risks of overconstraint, altered knee mechanics, and technical challenges. Young athletes are suitable candidates. Disagreement remains on routine LEAP/ALLR for all ACL patients, regardless of activity or compliance. CONCLUSIONS: This Delphi Expert Consensus has established that high-grade pivot shift, revision surgery, and participation in high-risk athletes in pivoting sports are indications for anterolateral augmentation procedures in ACLR. Generalized joint hyperlaxity and young age were identified as relative indications. The routine use of LEAP or ALLR in all ACL-deficient or low-demand patients is not recommended. LEAP primarily functions to resist internal tibial rotation and can reduce graft strain when performed in conjunction with ACLR. However, LEAP may overconstrain internal knee rotation and is considered a nonanatomic approach to rotational stability. For optimal biomechanical function, the femoral tunnel or fixation point for LEAP should be placed posterior and proximal to the lateral femoral epicondyle. LEVEL OF EVIDENCE: Level V, expert opinion.