Lateral extra-articular procedures combined with anterior cruciate ligament reconstruction may improve graft healing quality but not clinical outcomes: a systematic review

The purpose of this study was to investigate the effects of lateral extraarticular procedures (LEAPs) combined with anterior cruciate ligament reconstruction (ACLR) on graft healing quality and clinical outcomes compared with isolated ACLR. We systematically searched databases for clinical studies comparing ACLR combined with LEAPs versus isolated ACLR reporting graft signal-to-noise quotient (SNQ) or clinical outcomes. Data on SNQ, Lysholm, International Knee Documentation Committee (IKDC), and Tegner scores; Howell and Ge classifications; and complications were extracted. Methodological quality and results were analyzed descriptively. Nine studies (one level II, eight level III) were included. SNQ outcomes varied by follow-up duration and LEAP type. Nine studies assessed graft maturation using the SNQ at 6–24 months postoperatively. Most demonstrated significantly lower SNQ values following ACLR combined with LEAPs compared with isolated ACLR, whereas others reported no significant between-group differences, reflecting heterogeneity in reference standards, graft sources, and measurement protocols. Regarding bone tunnel changes, one study showed lower femoral but higher tibial tunnel widening in the combined group, whereas another found comparable tibial tunnel widening. Postoperative Lysholm, IKDC, and Tegner scores were comparable, as were Howell and Ge classifications. Return-to-sports rates and complications did not differ significantly. ACLR combined with LEAPs may confer potential benefits in graft healing quality, but available evidence is limited by nonrandomized study designs and substantial heterogeneity. No significant differences in clinical functional scores were observed, and long-term benefits await validation through high-quality randomized controlled trials. PROSPERO 2026 CRD420261309163. Level III, systematic review of II and III studies.