Background: Currently, there is no consensus on objective measures to determine when augmentation of ACL reconstruction (ACLR) with a lateral extra-articular tenodesis (LET) is indicated. Understanding this is critical to maximize the likelihood of a positive outcome following surgery. The purpose of this study was to determine the appropriate indications from the literature for LET augmentation to ACLR. Methods: A systematic review of the literature was performed using PRISMA guidelines. The following databases were searched: PubMed, EMBASE, Web of Science and Cochrane from 2000-present. Inclusion criteria: participants must include male and/or female patients of any age that underwent LET in addition to ACL reconstruction, studies must report ≥1 indication for LET, and for observational and RCT study designs, the number of patients with/prevalence of indications must be reported. Publications must be reported in English, peer reviewed, and originated in the US or countries offering the same procedures, protocol, and outcome reporting. Exclusion criteria: publications that are not peer-reviewed journal articles (conference abstracts, dissertations, study protocols, commentaries), as well as systematic reviews and meta-analyses. Results: 463 studies were identified in a preliminary search with 23 chosen for review using the inclusion criteria. Eight studies used a modified Lemaire technique, 7 used a MacIntosh modified by Arnold-Coker and 8 used other techniques to perform the LET. A total of 2,125 patients (approximately 47% male) received LET augmented with an ACLR procedure. The indications, along with prevalence used in the studies, were as follows: positive pivot shift test (n=19, 82.6%), need for revision ACLR (n=12, 52.2%), ligamentous laxity (n=11, 47.8%), sport participation (n=11, 47.8%), age less than 25 years old (n=8, 34.8%), high risk of graft failure (n=5, 21.7%), and positive Lachman sign (n=4, 17.4%). Conclusion: Data from included studies suggests that regardless of technique/gender, positive pivot shift test (≥grade 2) is an objective measurement used to indicate LET in addition to ACLR. Needing revision ACLR was also mentioned significantly more in the literature, suggesting objective measurements of graft failure could be used to indicate this procedure. This data should be considered when determining the appropriate indication for augmenting ACLR with LET.

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