With renewed interest in the lateral soft tissue envelope anatomy, there is also a rise in the popularity of extra-articular anterolateral procedures. There is reasonable laboratory-based evidence for additional benefit of such procedures, but clinical data are not sufficient to judge outcome in the long term for better or worse. Furthermore, the decision-making process to decide when to add an extra-articular procedure is lacking; there are no clinical tests or investigations to guide the clinician. This article presents an overview of the literature and reflections from the authors on the subject.