{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,13]],"date-time":"2026-09-13T04:05:27Z","timestamp":1789272327631,"version":"build-2803163510"},"reference-count":47,"publisher":"Wiley","license":[{"start":{"date-parts":[[2026,9,12]],"date-time":"2026-09-12T00:00:00Z","timestamp":1789171200000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"},{"start":{"date-parts":[[2026,9,12]],"date-time":"2026-09-12T00:00:00Z","timestamp":1789171200000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"content-domain":{"domain":["arthroscopyjournals.onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Arthroscopy"],"abstract":"<jats:sec>\n                    <jats:title>Purpose<\/jats:title>\n                    <jats:p>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\u2010articular procedure (LEAP).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>Forty panel members were included. In Round 1, the panel addressed 18 open\u2010ended questions on ALLR or LEAP in ACL surgery, followed by 8 semi\u2010open\u2010ended 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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Unanimous consensus supports LEAP or ALLR for high\u2010grade 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\u2010risk 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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>This Delphi Expert Consensus has established that high\u2010grade pivot shift, revision surgery, and participation in high\u2010risk 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\u2010deficient or low\u2010demand 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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Level of Evidence<\/jats:title>\n                    <jats:p>Level V, expert opinion.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1002\/arj.70532","type":"journal-article","created":{"date-parts":[[2026,9,13]],"date-time":"2026-09-13T03:11:40Z","timestamp":1789269100000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Delphi Expert Consensus Identifies Revision Surgery, High\u2010Grade Pivot Shift, and High\u2010Risk Athletes in Pivoting Sports as Indications for Anterolateral Ligament Reconstruction or Lateral Extra\u2010articular Procedures in Anterior Cruciate Ligament Reconstruction"],"prefix":"10.1002","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-1991-8682","authenticated-orcid":false,"given":"Erik","family":"Hohmann","sequence":"first","affiliation":[{"name":"Medical School Faculty of Health Sciences University of Pretoria  Pretoria South Africa"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5085-6446","authenticated-orcid":false,"given":"Andreas","family":"Imhoff","sequence":"additional","affiliation":[{"name":"Sports Orthopaedics, Orthopaedics and Traumatology Department of Orthopaedic Sports Medicine Technical University Hospital Rechts der Isar  Munich Germany"},{"name":"Orthopedic Sports Program ADAM Vital Hospital AlGarhood Dubai  UAE"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0466-3122","authenticated-orcid":false,"given":"Nicholas P. J.","family":"Perry","sequence":"additional","affiliation":[{"name":"Naval Medical Center San Diego   San Diego U.S.A."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"name":"Delphi Panel","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2026,9,12]]},"reference":[{"key":"e_1_2_10_2_1","doi-asserted-by":"crossref","first-page":"764","DOI":"10.1007\/s00167-020-06002-8","article-title":"Antero\u2010lateral ligament reconstruction improves knee stability alongside anterior cruciate ligament reconstruction","volume":"29","author":"Hurley ET","year":"2021","journal-title":"Knee Surg Sports Traumatol Arthrosc."},{"key":"e_1_2_10_3_1","doi-asserted-by":"crossref","first-page":"629","DOI":"10.1177\/0363546503261722","article-title":"Relationships between objective assessment of ligament stability and subjective assessment of symptoms and function after anterior cruciate ligament reconstruction","volume":"32","author":"Kocher MS","year":"2004","journal-title":"Am J Sports Med."},{"key":"e_1_2_10_4_1","doi-asserted-by":"crossref","first-page":"758","DOI":"10.1016\/j.arthro.2022.11.032","article-title":"Combined lateral extra\u2010articular tenodesis or combined anterolateral ligament reconstruction and anterior cruciate ligament reconstruction improves outcomes compared to isolated reconstruction for anterior cruciate ligament tear: A network meta\u2010analysis of randomized controlled trials","volume":"39","author":"Park YB","year":"2023","journal-title":"Arthroscopy."},{"key":"e_1_2_10_5_1","doi-asserted-by":"crossref","first-page":"232596712412309","DOI":"10.1177\/23259671241230967","article-title":"Factors Associated with residual pivot shift after ACL reconstruction: A quantitative evaluation of the pivot\u2010shift test preoperatively and at minimum 12\u2010month follow\u2010up","volume":"12","author":"Kawanishi Y","year":"2024","journal-title":"Orthop J Sports Med."},{"key":"e_1_2_10_6_1","doi-asserted-by":"crossref","first-page":"1209","DOI":"10.1177\/0363546515625282","article-title":"The involvement of the anterolateral ligament in rotational control of the knee","volume":"44","author":"Sonnery\u2010Cottet B","year":"2016","journal-title":"Am J Sports Med."},{"key":"e_1_2_10_7_1","doi-asserted-by":"crossref","first-page":"3153","DOI":"10.1016\/j.arthro.2024.10.029","article-title":"The knee anterolateral ligament is present in 82% of North Americans and 65% of Europeans but only in 46% of Asian studies: A systematic review of frequency and anatomy","volume":"41","author":"Hohmann E","year":"2025","journal-title":"Arthroscopy."},{"key":"e_1_2_10_8_1","doi-asserted-by":"crossref","first-page":"1352","DOI":"10.1177\/0363546518759053","article-title":"Anterolateral knee extra\u2010articular stabilizers: A robotic sectioning study of the anterolateral ligament and distal iliotibial band Kaplan fibers","volume":"46","author":"Geeslin AG","year":"2018","journal-title":"Am J Sports Med."},{"key":"e_1_2_10_9_1","doi-asserted-by":"crossref","first-page":"345","DOI":"10.1177\/0363546515614312","article-title":"The role of the anterolateral structures and the ACL in controlling laxity of the intact and ACL\u2010deficient knee","volume":"44","author":"Kittl C","year":"2016","journal-title":"Am J Sports Med."},{"key":"e_1_2_10_10_1","doi-asserted-by":"crossref","first-page":"632","DOI":"10.1016\/j.arthro.2023.05.005","article-title":"The iliotibial band is the main secondary stabilizer for anterolateral rotatory instability and both a Lemaire tenodesis and anterolateral ligament reconstruction can restore native knee kinematics in the anterior cruciate ligament reconstructed knee: A systematic review of biomechanical cadaveric studies","volume":"40","author":"van der Wal WA","year":"2024","journal-title":"Arthroscopy."},{"key":"e_1_2_10_11_1","doi-asserted-by":"crossref","first-page":"4882","DOI":"10.1016\/j.arthro.2025.04.043","article-title":"The anterolateral ligament complex has limited impact on anterior tibial translation or internal rotational stability in anterior cruciate ligament\u2010deficient and anterior cruciate ligament\u2010reconstructed knees. 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