Anterior Cruciate Ligament Reconstruction With or Without Lateral Extra-articular Tenodesis: A Systematic Review and Meta-analysis of Comparative Outcomes From Randomized Controlled Trials

Background: Clinical outcomes continue to be a concern after anterior cruciate ligament reconstruction (ACLR). Lateral extra-articular tenodesis (LET) has reemerged as an adjunct procedure for enhancing knee function; however, its overall clinical effectiveness remains controversial. Hypothesis: The addition of LET to primary ACLR would result in superior clinical, functional, and patient-reported outcomes as compared with isolated ACLR. Study Design: Systematic review and meta-analysis; Level of evidence, 1. Methods: This study was conducted according to the PRISMA 2020 guidelines (Preferred Reporting Items for Systematic Reviews and Meta-analyses) and registered in PROSPERO. Multiple databases were searched from 1995 to October 2025. Ten high-quality randomized controlled trials comparing ACLR with and without LET were included in the final meta-analysis. The outcomes assessed included graft failure, rotational and anterior knee stability, functional scores, patient-reported outcomes, and return-to-sport rates. Random effects models were used, and heterogeneity was evaluated. Results: When compared with isolated ACLR, ACLR augmented with LET demonstrated significantly lower graft failure rates (odds ratio [OR], −1.19; 95% CI, −1.73 to −0.65; P < .001) and improved rotational stability, as evidenced by superior pivot-shift outcomes (OR, −0.81; 95% CI, −1.11 to −0.52; P < .001). Significant improvements were also observed in Lysholm scores (OR, 1.98; 95% CI, 0.19-3.77; P = .030) and International Knee Documentation Committee (IKDC) subjective scores (OR, 1.65; 95% CI, 0.24-3.05; P = .22). No statistically significant differences were identified between the groups in KT-1000 measurements, Lachman test results, IKDC objective scores, Knee injury and Osteoarthritis Outcome Score subscales, Tegner activity scores, or return-to-sport rates. Heterogeneity was low across most outcomes ( I 2 = 0%), except for the Tegner scale ( I 2 = 83.12%). Conclusion: The addition of LET to primary ACLR was associated with significantly improved graft survival (log OR, −1.19; 95% CI, −1.73 to −0.65; P < .001); enhanced rotational stability as demonstrated by improved pivot-shift outcomes (log OR, −0.81; 95% CI, −1.11 to −0.52; P < .001); and better patient-reported knee function, including Lysholm scores (mean difference, 1.98; 95% CI, 0.19-3.77; P = .030) and IKDC subjective scores (mean difference, 1.65; 95% CI, 0.24-3.05; P = .22). However, no significant benefits were observed in anterior laxity or return-to-sport rates.