AANA Lab Course 913 - Advanced Knee Course-Lateral Extra-articular Procedures_ When or Ever Should They be Used with an ACLR (with Technique Options) Faculty Lecture

Lateral Extra-articular Procedures_ When or Ever Should They be Used with an ACLR (with Technique Options) Faculty Lecture_ Andrew G. Geeslin, MD

Back to course

Pdf Summary

This presentation by Dr. Andrew Geeslin focuses on the role of lateral extra-articular procedures (LET), particularly in conjunction with anterior cruciate ligament reconstruction (ACLR), emphasizing the anatomy, biomechanics, surgical techniques, and clinical relevance of the knee's anterolateral complex (ALC).<br /><br />The renewed interest in the ALC is due to its components—the iliotibial band (ITB) with Kaplan fibers, the anterolateral ligament (ALL), and the capsulo-osseous layer (COL)—which contribute to controlling internal rotation and knee stability. Imaging techniques such as T1-weighted and fluid-sensitive MRI help visualize these structures and their injury patterns.<br /><br />Biomechanical studies, including those by Getgood et al., demonstrate that native ALC structures restrain internal rotation, and reconstructive LET procedures reduce internal rotation and ACL graft forces, potentially improving stability. Various LET techniques, including Modified Andrews and Lemaire, involve harvesting a strip of the ITB, careful identification of surrounding anatomy such as the fibular collateral ligament (FCL), and fixation typically at 30 degrees of knee flexion.<br /><br />Clinically, a significant 624-patient multicenter randomized controlled trial (STABILITY trial) compared ACLR alone versus ACLR combined with LET in high-risk young patients. Results showed a reduction in pivot shift occurrences (40% to 25%) and graft ruptures (11% to 4%) with the addition of LET, suggesting improved rotational stability and graft survival.<br /><br />Despite some controversies and ongoing debate about the exact anatomy and nomenclature of the ALC components, growing clinical evidence and consensus meetings (e.g., the 2017 ALC Consensus) support the use of LET in selected patients undergoing ACLR. However, further studies examining mid- and long-term outcomes are necessary to solidify these findings.<br /><br />In summary, understanding the ALC's anatomy and biomechanics enhances surgical approaches to knee stability, with LET procedures offering promising adjuncts to ACLR in reducing graft failure and improving rotational control in high-risk individuals.

Keywords

Lateral Extra-Articular Procedures

Anterior Cruciate Ligament Reconstruction

Anterolateral Complex

Iliotibial Band

Anterolateral Ligament

Capsulo-Osseous Layer

Knee Stability

Biomechanical Studies

STABILITY Trial

Rotational Control