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. 2025 Feb 5;14(5):103456.
doi: 10.1016/j.eats.2025.103456. eCollection 2025 May.

Anterior Cruciate Ligament Reconstruction and Double Extra-Articular Reinforcement

Pedro Baches Jorge  1 , Mariana Belaunde Toledo  1 , Juliano Mangini Dias Malpaga  1 , Camilo Partezani Helito  2 , Sérgio Marinho de Gusmão Canuto  3 , Vitor Barion Castro de Padua  4 , Diego Escudeiro De Oliveira  1
Affiliations

Anterior Cruciate Ligament Reconstruction and Double Extra-Articular Reinforcement

Pedro Baches Jorge et al. Arthrosc Tech. .

Abstract

This study describes a technique for double extra-articular reinforcement associated with anterior cruciate ligament (ACL) reconstruction for patients with both internal and external rotational instability, using reinforcements from the hamstrings and the anterior half of the peroneus longus muscle. The technique involves using 2 reinforcements: one for anterolateral stabilization and the other for anteromedial stabilization. The procedure follows a detailed algorithm for diagnosing rotational instability through physical examination under anesthesia. This approach offers a solution for complex ACL injuries involving bidirectional rotational instability, aiming to optimize knee stability and reduce failure rates in ACL reconstruction.

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Conflict of interest statement

All authors (P.B.J., M.B.T., J.M.D.M., C.P.H., S.M.d.G.C., V.B.C.d.P., D.E.D.O.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Figures

Fig 1
Fig 1
Decision-making algorithm for determining which patients with anterior cruciate ligament (ACL) injuries are candidates for extra-articular reinforcement. (ADER, anterior drawer in external rotation; ALL, anterolateral ligament; AOL, anterior oblique ligament).
Fig 2
Fig 2
Patient in supine position; left ankle. Posterolateral region of the fibula. The incision is made in a distal-to-proximal direction, starting 3 cm proximal to the most distal point of the lateral malleolus.
Fig 3
Fig 3
Patient in supine position; left ankle. Posterolateral region of the fibula. The peroneus longus is identified and isolated with hemostatic forceps (mosquito or Kelly) after distinguishing it from the peroneus brevis.
Fig 4
Fig 4
Patient in supine position; left ankle. Posterolateral region of the fibula. The anterior half is repaired with No. 1-0 VICRYL thread (Fig 5) and removed to its proximal insertion with a tenotome, up to approximately 5 cm from the fibular head.
Fig 5
Fig 5
A guidewire is passed through the femur, starting at the medial epicondyle anterior portion, in the anterior direction.
See this image and copyright information in PMC

References

    1. Jorge P.B., Guglielmetti L.G.B., Helito C.P., et al. A new algorithm for extra-articular reinforcement in ACL injury based on rotational instability. Video J Sports Med. 2024;4 - PMC - PubMed
    1. Jorge P.B., Escudeiro D., Severino N.R., et al. Positioning of the femoral tunnel in anterior cruciate ligament reconstruction: functional anatomical reconstruction. BMJ Open Sport Exerc Med. 2018;4 - PMC - PubMed
    1. Jorge P.B., Horita M.M., de Oliveira E.Silva M., et al. Anterior cruciate and anterior oblique ligament reconstruction using hamstrings and peroneus longus' anterior half grafts. Arthrosc Tech. 2023;12:e861–e866. - PMC - PubMed
    1. Flagg K.Y., Karavatas S.G., Thompson S., Jr., et al. Current criteria for return to play after anterior cruciate ligament reconstruction: An evidence-based literature review. Ann Transl Med. 2019;7(suppl 7) - PMC - PubMed
    1. Ueki H., Nakagawa Y., Ohara T., et al. Risk factors for residual pivot shift after anterior cruciate ligament reconstruction: Data from the MAKS group. Knee Surg Sports Traumatol Arthrosc. 2018;26:3724–3730. - PubMed

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