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ACL Reconstruction – Your surgeon should be considering adding an Extra-Articular Procedure

To decrease reinjury rates and increase return to sport rate – a new paradigm requires consideration of the anterolateral corner of the knee.

At the 2019 ISAKOS meeting of international knee surgeons in Cancun, Mexico, the clear viewpoint has been the anterolateral corner of the knee is also injured in many patients. There is no dispute. Doing a procedure to rectify it reduces the forces on the ACL reconstruction, and a higher proportion of patients return to high level sport. The remaining questions are “who” and “how”. Studies are continuing on both subjects.

With respect to which patients – there is no doubt that patients with a very high grade pivot shift should be fixed, and most revision procedures. There is no doubt that adolescents should probably have them too, as their re-rupture rate has been very disappointing. Other groups requiring serious consideration are those with a high tibia slope, and those with a meniscal tear that needs to be protected, and perhaps others returning to high stress sports.

A difficulty with anterior cruciate reconstruction has been that not every athlete gets back to sport, not every knee feels completely stable. Surgeons argue whether an AnteroLateral Ligament reconstruction, or an Ellison procedure is the most effective. Many of the old procedures were done “too tight” and arthritis seemed to progress as a result of the over constraint. Current studies though seem to infer ALL reconstructions without excessive tension are reducing the rate of damage to the lateral meniscus.

extraarticular
An XR of a patient with an ACL reconstruction and an Ellison procedure. Many screws and fixation tools now are not visible on plain XR.
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