The rationale for adding a lateral extra-articular tenodesis to ACL reconstruction is to better control rotational instability, but long-term trade-offs are important. This randomized study followed patients for many years after bone-patellar tendon-bone ACL reconstruction performed with or without an extra-articular lateral tenodesis. The long follow-up is valuable because early gains in stability must be balanced against later graft survival, patient-reported outcomes and the development of osteoarthritis. The study found that the addition of LET can influence knee stability and long-term structural outcomes without automatically translating into large differences in every patient-reported measure. These data complement more contemporary high-risk ACL trials by showing why the decision should be based on patient profile and surgical indication rather than technique preference alone. A surgeon considering LET should therefore integrate pivot-shift grade, sport, laxity, previous reconstruction history, meniscal status and alignment. The evidence also underscores the importance of counselling: improved rotational control does not guarantee a completely different long-term experience, and rehabilitation remains central. For selected high-risk patients, LET can be a useful adjunct, but it should sit inside a broader strategy of biological graft choice, anatomic reconstruction and return-to-sport planning.