Does Adding LEAP to ACL Reconstruction Reduce Graft Failure? A Systematic Review and Meta-Analysis of Comparative Studies with Minimum Two-Year Follow-Up

Background: Anterior cruciate ligament (ACL) reconstruction (ACLR) is the gold-standard treatment for ACL rupture; however, graft failure remains a significant concern, particularly in young, active, or high-risk patients. The addition of a Lateral Extra-Articular Procedure (LEAP) has been proposed to enhance rotational stability and reduce the risk of graft rupture. This systematic review and meta-analysis aimed to determine whether adding LEAP to primary ACLR reduces graft failure rates compared to isolated ACLR, with a minimum follow-up of two years. Methods: A comprehensive literature search was conducted across PubMed, Scopus, Embase and Cochrane Library databases in accordance with PRISMA guidelines. Eighteen comparative studies with a minimum 24-month follow-up were included, encompassing 7336 patients (3857 undergoing isolated ACLR and 3479 undergoing ACLR with LEAP). The primary outcome was graft failure rate. Data were analyzed using the Mantel–Haenszel method with a fixed-effects model to calculate pooled risk ratios (RR) and 95% confidence intervals (CI). Results: Pooled analysis demonstrated a significant increase in graft rupture risk in the ACLR-alone group compared to ACLR + LEAP (RR 2.72; 95% CI: 2.23–3.32; p < 0.00001), with negligible heterogeneity (I² = 0%). LEAP was particularly beneficial in high-risk populations such as young athletes and individuals with high-grade pivot shift or ligamentous laxity. Secondary outcomes showed improved rotational stability and comparable patient-reported outcomes and complication rates between groups. Conclusions: ACLR alone presents a higher risk of graft failure in comparison with the ALCR + LEAP technique. Furthermore, the addition of LEAP to ACLR improves rotational stability without increasing complications. LEAP should be selectively considered in patients with high-risk profiles or persistent intraoperative instability. These findings support the incorporation of LEAP as a valuable adjunct in modern ACL reconstruction strategies.