Mr Guy, on behalf of BASK (British Association for Surgery of the Knee), presented at the annual national meeting for Orthopaedics in 2024. This presentation was on the use of lateral extra-articular procedures that aim to reduce the risk of tearing the anterior cruciate ligament (ACL) graft. Historically, when you were an elite athlete in the late 1970’s, the technical skills and equipment were not available to allow surgeons to anatomically reconstruct an anterior cruciate ligament. Elite athletes would get a ‘MacIntosh’ procedure (1976) which is a ‘non-anatomical’ sling of tissue on the outside of the knee that aims to reduce the amount of rotation (internal rotation of the shin bone relative to the thigh bone). This would allow athletes and weekend warriors to go back to sport by mimicking part of the the role of the absent ACL. It was by no means perfect but was the best treatment at the time.
With the advent of better equipment and surgical techniques in the mid 80’s the role of the ‘anatomical’ ACL reconstruction took over from the ‘MacIntosh’. Largely as a result of a sports meeting in America in 1986 (Snowmass Convention) the lateral extra-articular procedures were abandoned but a few centres in Europe kept performing them and keeping data. Despite this use of the anatomical ACL reconstruction we still see re-rupture rates of 20% in some groups of patients and so perhaps ACL reconstruction was not as good as we thought it was? Perhaps we need to think hard about these hight risk group and think about ACL graft type (hamstrings / quads tendon / patella tendon) and also about reinforcing the knee with lateral extra-articular procedures.
In essence its easy to think of a lateral extra-articular procedure as like another ACL but on the outside of your knee. Recent studies from a prospective trial and lots of data from retrospective database studies have shown that the addition of a lateral extra-articular procedure significantly reduces the risk of an ACL graft tearing. Some people have high risk factors due to the sport they play, their sex (see other articles in this blog section), the level they play at, their age and how ‘hyper mobile’ they are. Also, we know when people injure their ACL in the knee also injure and stretch out some of the strong tissues on the lateral side of their knee. This lateral tissue is not addressed with modern ACL techniques but is with the historical procedures! Hence to reduce the risks of people tearing their ACL graft, some people may well need both procedures performing. An ACL in the knee and an ACL outside the knee!
The area is evolving with more studies due to come out over the next 12 months looking at different ACL graft types. Mr Guy has been performing the extra-articular procedures since 2013 from reviewing elite athlete data and visitations to European centres of excellence in sports knee surgery.