Editorial Commentary: Lateral Extra-articular Reconstructions With Anterior Cruciate Ligament Surgery: Are These Operative Procedures Supported by In Vitro Biomechanical Studies?

There remains controversy on the role of a concurrent lateral extra-articular procedure with anterior cruciate ligament (ACL) reconstruction. Previous biomechanical studies often are historical and inconclusive. Studies show the anterolateral ligament and iliotibial band are secondary restraints and, when injured in conjunction with the ACL, produce gross (Grade 3) pivot-shift subluxations. Recent robotic studies show a well-placed bone-patellar tendon-bone reconstruction does restore time-zero kinematics with a negative pivot-shift. Accordingly, a lateral extra-articular procedure does not provide any further resistance to the pivot-shift. Extra-articular reconstructions may produce a modest unloading of an ACL graft and reduce a few degrees of abnormal internal rotation at high flexion angles but at the expense of overconstraining the knee joint. The conclusion appears warranted at this time that biomechanical studies do not support the routine addition of anterolateral ligament or iliotibial band tenodesis procedures with ACL reconstructions. These procedures may, however, still play a role in select ACL chronic or revision knees with gross anterior subluxations.