ABSTRACT: Background/Objectives: The aim was to provide a comprehensive, systematic review on the Lateral Extra-articular Tenodesis (LET) methods used in anterior cruciate ligament (ACL) reconstruction in the light of recent data. Methods: To identify all of the essential studies that reported relevant data concerning primary outcomes: indications for surgery, surgical technique, graft type, fixation method, and tibial fixation location, an extensive search of the major and significant electronic databases (PubMed, Cochrane Central, ScienceDirect, Web of Science, Embase) was performed by three independent authors. A systematic investigation was conducted in November 2023, with no limits regarding the year of publication. After the database search, three independent reviewers screened all the papers, which followed strictly the inclusion and exclusion criteria, identifying a title, abstract, and full text concerning LET, surgical technique, femoral attachment, tibial attachment, graft type, fixation method, knee angle during fixation, and graft tension at fixation in ACL reconstruction. A systematic review of the collected literature was carried out according to the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Study quality was assessed using the Cochrane Risk of Bias Tool. Results: Of the 35 papers reviewed, seven surgical techniques of LET differing in the way the procedure was performed were separated. The majority of papers were from Italy (n = 11), USA (n = 3), France (n = 3), and Canada (n = 3). The number of total participants across all studies was 6253. The majority of studies (17 papers) used the Lemaire modified procedure, and 10 papers used the MacIntosh technique modified by the Coker-Arnold approach. Most of the papers mentioned fixation location on the lateral distal part of the femur including six articles referring directly to lateral femoral epicondyle. Most authors (25 papers) defined tibial attachment as Gerdy's tubercle. The most common graft was the iliotibial band and fixation method was sutures. The types of fixation in the surgical techniques of the collected papers were Sutures, Staples, Anchor, Interference screw, K-wire, Bioabsorbable Screw and Titanium Screw with a serrated polyethylene washer. Conclusions: Despite variability in technique, the Lemaire-modified procedure emerged as the preferred approach for Lateral Extra-articular Tenodesis, suggesting a general consensus around its reliability and reproducibility in clinical practice. The frequent use of the iliotibial band as graft material reflects its accessibility and suitability for reinforcing anterolateral stability. Similarly, the consistent use of sutures and fixation at Gerdy's tubercle may indicate a favorable balance between technical ease and biomechanical strength. The variability in femoral fixation points-either at the lateral femoral condyle or epicondyle-highlights the ongoing debate or surgeon preference, underscoring the need for further comparative studies to establish optimal fixation strategy. Collectively, these patterns may help guide surgical decision-making, particularly when tailoring procedures to individual patient anatomy or surgical expertise.
