Editorial Commentary: This Is the Way: Extra-Articular Augmentation Is an Essential Consideration in Contemporary Anterior Cruciate Ligament Surgery

Abstract

Since the rediscovery of the anterolateral ligament, extra-articular augmentation (EA) has evolved from controversial to an essential consideration in contemporary anterior cruciate ligament reconstruction surgery. Anterolateral ligament (ALL) reconstruction and lateral extra-articular tenodesis are 2 common methods. Indications among early adopters pioneering anterolateral ligament reconstruction at anterior cruciate ligament surgery included revision anterior cruciate ligament (ACL) case, chronic ACL tear, high-grade pivot shift, and patients with hyperlax, hypermobile knees. Newer indications include young patient age, pivoting sport/high-demand/high-risk athlete, and concurrent medial meniscus repair. Questions remain regarding best practices as indications continue to evolve regarding technique, graft choice, angle/position of reconstruction fixation, and whether EA should be reconstructed routinely. This fast-moving surgical evolution serves as a reminder of 2 key concepts; first, that anterior cruciate ligament tears occur more fundamentally in the setting of anterolateral rotatory instability, in which concurrent soft tissue injuries are common, and, second, that even our best "anatomic" reconstructions do not fully recapitulate the native ACL, both of which give impetus to reconstructing the ALL.

Editorial Commentary: Anterior Cruciate Ligament Reconstruction Alone Is Not Sufficient in Anterolateral Complex Injury: Extra-Articular Augmentation (Lateral Extra-Articular Tenodesis [LET] or Anterolateral Ligament [ALL] Reconstruction) Allows Surgeons to Indicate Tight (LET) or Just Right (ALL) on a Case-by-Case Basis

“…I believe EA has become an essential consideration in contemporary ACL surgery. 1 While indications continue to develop, a key question now facing knee surgeons is which EA procedure to perform. Getgood et al's STABILITY trial makes a case for a modified Lemaire LET to reduce the risk of recurrent ACL tear or persistent rotatory laxity following hamstring autograft ACL reconstruction (ACLR).…”

Combined ACL and anterolateral ligament reconstruction: time to pivot and shift the focus?

“…This term is often subjective, varying between studies and ultimately, in our opinion, matching a high percentage of young and active patients who seek ACL injury treatment. It is concerning if concomitant lateral extra‐articular reconstruction or repair procedures becomes the new standard augmentation for most ACL reconstruction cases [25]. Indications for the inclusion of a lateral extra‐articular procedure remains a contentious debate in the research community [10], particularly regarding how much its addition truly adds to the restoration of normal knee kinematics and which patient population benefits from it.…”