An in vitro study of an intraarticular and extraarticular reconstruction in the anterior cruciate ligament deficient knee

Abstract

The biomechanical effectiveness of an extraarticular ACL reconstruction, an intraarticular ACL reconstruction, and the combination of these on both anterior stability and internal rotational stability of the ACL deficient knee was investigated in six cadaver knees. The extraarticular reconstruction consisted of the Müller anterolateral femorotibial ligament iliotibial band tenodesis, and the intraarticular reconstruction used the middle third of the patellar tendon in the manner of Clancy. The extraarticular reconstruction was found to overconstrain internal tibial rotation of the ACL excised knee between 30 degrees and 90 degrees (P less than 0.05). While the isolated extraarticular reconstruction did not return normal anterior stability to the ACL deficient knee (P less than 0.05), it did significantly reduce the anterior laxity of the ACL deficient knee between 30 degrees and 90 degrees of knee flexion (P less than 0.05). For the combined reconstruction, the intraarticular procedure was performed and then only enough tension was applied to the extraarticular reconstruction to take up slack in the tenodesis without shifting the rotatory position of the tibia from that produced by the intraarticular procedure alone. Neither the intraarticular reconstruction nor the combined procedure resulted in any significant shifts from normal (P less than 0.05) in the rotatory position of the unloaded tibia; during loading neither resulted in rotational displacements significantly different from normal; and both of these procedures reduced the increased anterior laxity of the ACL deficient knee to a level not statistically different from normal. Because the extraarticular reconstruction shared the load when performed with the intraarticular reconstruction as part of a combined procedure, we concluded that it would be useful as an adjunctive procedure in appropriate clinical situations.

Biomechanical Results of Lateral Extra-articular Tenodesis Procedures of the Knee: A Systematic Review

“…Application of the inclusion and exclusion criteria yielded 10 full-text articles for inclusion in the review. [16][17][18][19][20][21][22][23][24][25] …”

“…Graft force, strain, and/or length change patterns were reported in 6 studies. [18][19][20][21][22][23] Graft Force and Graft Strain. Engebretsen et al 20 compared the total graft force experienced by the ACL reconstruction when a modified Andrews iliotibial band tenodesis was added both before and after an intra-articular ACL reconstruction.…”

“…In a subsequent study, Draganich et al 18 analyzed force patterns using 3 surgical techniques: isolated extraarticular reconstruction (Müller), isolated intra-articular reconstruction, and a combined extra-articular and intra-articular reconstruction. Force patterns for the extra-articular reconstruction technique were obtained from the previous study by Draganich et al 19 In the combined reconstruction, the strain exhibited by the tenodesis during a 50-N anteriorly applied force was not significantly different (P > .05) from the strain shown when the extra-articular reconstruction was performed alone.…”

Combined Intra-articular and Extra-articular Reconstruction in Anterior Cruciate Ligament–Deficient Knee: 25 Years Later

“…The risk of late OA and varus deformity due to an overtightening of the lateral compartment is a crucial concern on combined reconstruction as suggested by some authors since the 1980s, 12,22 when most surgeons used bone patellar tendon bone as the graft of choice and postoperative immobilization. On the basis of the results of the present study, this theory should be refuted because a trend toward fewer radiologic signs of OA was detected in patients where an extra-articular reconstruction was added.…”

Arthroscopic intra- and extra-articular anterior cruciate ligament reconstruction with gracilis and semitendinosus tendons: a review

“…In fact almost all authors, with the exception of Ferretti et al (that prefer a modified MacIntosh procedure for the extra-articular reinforcement), perform a lateral tenodesis fixing the graft behind the femoral lateral collateral ligament insertion. This point corresponds to the optimal isometric position, as defined by Krackow et al [16] and Draganich et al [17,18].…”