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MacIntosh technique. 28 (ACL, anterior cruciate ligament; FCL, fibular collateral ligament; IT, iliotibial; PCL, posterior cruciate ligament.)
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Context 1
... 28 A strip of iliotibial band was detached proximally and passed deep to the FCL, through an osteoperiosteal tunnel posterior to the FCL femoral attachment. The graft was then looped through the lateral intermuscular septum and sutured back onto itself at the Gerdy tubercle with the knee flexed to 90 and held in external rotation (Fig 3). 1978 ...
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... However, the clinical implications of this finding can be challenging to ascribe with certainty because tightness of the grafts can result in either laxity, rupture, or altered tibiofemoral contact mechanics, the latter of which has been proposed to lead to osteoarthritis over time. 12 In a recent systematic review of biomechanical studies of lateral extra-articular tenodesis (LET) procedures, Slette et al 12 reported that in the ACL-deficient knee, LET procedures overconstrained the knee and restricted internal tibial rotation when compared with the native state. In addition, LET procedures were reported to significantly reduce intra-articular graft forces during anterior tibial loading. ...
... However, the clinical implications of this finding can be challenging to ascribe with certainty because tightness of the grafts can result in either laxity, rupture, or altered tibiofemoral contact mechanics, the latter of which has been proposed to lead to osteoarthritis over time. 12 In a recent systematic review of biomechanical studies of lateral extra-articular tenodesis (LET) procedures, Slette et al 12 reported that in the ACL-deficient knee, LET procedures overconstrained the knee and restricted internal tibial rotation when compared with the native state. In addition, LET procedures were reported to significantly reduce intra-articular graft forces during anterior tibial loading. ...
This chapter presents a case scenario of a 15‐year‐old woman who comes to orthopedic specialists’ office for pain and effusion in her right knee after sustaining an injury while playing basketball four days ago. Intra‐articular reconstruction has become the technique of choice to address anterior cruciate ligament (ACL) deficiency. A simple intra‐articular procedure combined with an extra‐articular augmentation may achieve better clinical results, while also diminishing failure rates. Preliminary results from an ongoing clinical trials are supportive for lateral extra‐articular tenodesis (LET) when used as an augmented intra‐articular ACL reconstruction in a targeted group of high‐risk patients. Renewed interest in LET is based on its important role in biomechanical stability. Nevertheless, over‐constraint has also been linked to osteoarthritis. Biomechanical studies suggest that traditional lateral tenodeses are most efficient in restoring native knee kinematics in combined ACL and anterolateral injured knees. The chapter provides recommendations for implementing evidence‐based practice in the clinical setting.
A subset of patients have residual rotational laxity following anterior cruciate ligament reconstruction (ACLR) despite the evolution of ACLR techniques. In recent years, there has been increased interest in addressing residual laxity because it is associated with poor outcomes after ACLR. There is an expanding body of knowledge on the anatomy and biomechanics of the anterolateral soft tissue restraints in regard to their rotational control of the knee and this has reignited an interest in extra-articular reconstruction techniques for augmenting ACLR. Reconstruction techniques currently used can be broadly categorized as either lateral extra-articular tenodesis or anterolateral ligament reconstruction. In this review, we discuss the relevant anatomy, biomechanics, and rationale behind the indications and technique of our current extra-articular augmentation procedure.
Purpose of Review
In the setting of rotatory knee instability following anterior cruciate ligament (ACL) reconstruction, there has been a resurgence of interest in knee’s anterolateral complex (ALC). Reconstruction or augmentation of the ALC with procedures such as a lateral extra-articular tenodesis (LET) has been proposed to reduce rotatory knee instability in conjunction with ACL reconstruction. The current review investigates the recent literature surrounding the role of the ALC in preventing rotatory knee instability.
Recent Findings
The knee’s anterolateral complex (ALC) is a complex structure composed of the superficial and deep portions of the iliotibial band, the capsulo-osseous layer, and the anterolateral capsule. Distally, these various layers merge to form a single functional unit which imparts stability to the lateral knee. While the iliotibial band and the capsule-osseous layer have been shown to be primary restraints to rotatory motion after ACL injury, the biomechanical role of the anterolateral capsule remains unclear. Biomechanical studies have shown that the anterolateral capsule and the anterolateral thickening of this capsule act as a sheet of fibrous tissue which does not resist motion around the knee as other longitudinally oriented ligaments do.
Summary
Augmentation of the ALC, with LET, has been performed globally for over 30 years. This procedure can decrease rotatory knee instability, but long-term studies have found little difference in patient-reported outcomes, osteoarthritis, or ACL reconstruction failure with the addition of LET. Further research is needed to clarify indications for the clinical use of ALC-based procedures.
