Extra-articular techniques in anterior cruciate ligament reconstruction

Abstract

This annotation considers the place of extra-articular reconstruction in the treatment of anterior cruciate ligament (ACL) deficiency. Extra-articular reconstruction has been employed over the last century to address ACL deficiency. However, the technique has not gained favour, primarily due to residual instability and the subsequent development of degenerative changes in the lateral compartment of the knee. Thus intra-articular reconstruction has become the technique of choice. However, intra-articular reconstruction does not restore normal knee kinematics. Some authors have recommended extra-articular reconstruction in conjunction with an intra-articular technique. The anatomy and biomechanics of the anterolateral structures of the knee remain largely undetermined. Further studies to establish the structure and function of the anterolateral structures may lead to more anatomical extra-articular reconstruction techniques that supplement intra-articular reconstruction. This might reduce residual pivot shift after an intra-articular reconstruction and thus improve the post-operative kinematics of the knee.

Does Combined Intra- and Extraarticular ACL Reconstruction Improve Function and Stability? A Meta-analysis

“…In addition, most extraarticular procedures described in the included trials are nonanatomic. As knowledge of the anterolateral compartment anatomy of the knee evolves, repair techniques of specific structures and more anatomic extraarticular reconstruction techniques may be developed, which may improve results and minimize donor site morbidity [12].…”

“…Some ACL injuries may be more complex than previously believed, and a combination of central and peripheral structures appear to be involved in the pathoanatomy of pivot shift injury. Previous studies also have shown that the addition of an extraarticular lateral restraint can decrease rotational instability, as assessed by the pivot shift test [12,13,24]. Understanding the improved Lachman test results among patients who underwent combined ACL reconstruction is less straightforward.…”

“…Because some ACL injuries result in damage to central and peripheral structures leading to complex rotatory instability [5,22], the addition of a lateral extraarticular procedure to intraarticular ACL reconstruction may stabilize rotational knee laxity and decrease graft forces [12,24].…”

The evolution of ACL reconstruction over the last fifty years

“…If at first, this anterolateral reconstruction gave quite good results, we soon noticed a clinical deterioration in outcome. This evolution was later confirmed by Dodds [19] who, in 2011, wrote: the technique (extra-articular reconstruction) has not gained favor due to the residual instability and the subsequent development of degenerative changes.…”

Anterior cruciate ligament reconstruction best practice: A review of graft choice

“…The surgical technique used during ACL reconstruction varies widely not only from country to country but even within departments of the same hospital. Different techniques include arthroscopic vs open surgery, intra vs extra-articular reconstruction, femoral tunnel placement, number of graft strands, single vs double bundle and fixation method [16][17][18][19][20] . This heterogeneity of techniques makes comparison of graft choice difficult.…”