Clinical Results of Lateral Extra-Articular Tenodesis

Abstract

In the anterior cruciate ligament (ACL) deficient knee, excellent outcomes are achieved in many patients with an isolated, intra-articular ACL reconstruction. Some patients, however, have ongoing instability or suffer graft rupture. Failure after ACL reconstruction is multifactorial, but residual anterolateral rotatory laxity is 1 potential contributing factor. Lateral extra-articular procedures are a heterogenous group of operations that were initially described as isolated treatments for the ACL deficient knee, and subsequently used in combination with intra-articular reconstructions. Initial observational studies were encouraging, however, comparative studies were less flattering and lead to a general abandonment of these procedures. With improved understanding of the anatomy and biomechanics of the anterolateral capsuloligamentous complex there has been a renewed interest in these procedures. Recent systematic reviews suggest efficacy of these procedures in improving rotational control, though data showing improved patient reported outcomes or reduced graft rupture rates are lacking. Preliminary results from ongoing clinical trials are supportive for lateral extra-articular tenodesis when used as an augment to modern, intra-articular ACL reconstructions in targeted, high-risk patients.

Keywords: ACL reconstruction; anterolateral rotatory instability; lateral extra-articular tenodesis.

FIGURE 1

Macintosh 1. Lateral extra-articular reconstruction with a strip of iliotibial band passed through the intermuscular septum and under the lateral collateral. Reproduced from McCulloch et al.

FIGURE 2

Ellison procedure. A “dynamic” lateral reconstruction where the iliotibial band was passed under the lateral collateral ligament, but was left intact proximally so that the tensor fascia muscle could help stabilize the knee during activity. Reproduced from McCulloch et al.

FIGURE 3

MacIntosh over the top. Iliotibial band is detached proximally and passed over the top of the femur and through an intra-articular tunnel in the tibia. Reproduced from McCulloch et al.

FIGURE 4

Marcacci procedure. Anterior cruciate ligament reconstruction with hamstring tendons plus extra-articular plasty. A, anteroposterior view; B, lateral view. Reproduced from Marcacci et al.