A standard prep and drape of the lower extremity is made. The operative tourniquet is placed around the thigh, but not inflated. Local anesthesia can be used. Standard antero-lateral, antero-medial, and proximal-lateral arthroscopic portals are utilized. An arthroscopic examination is conducted to identify and address any concomitant injuries. The infrapatellar surface is carefully explored. If the patella exhibits a lateral tilt, lateral subluxation or chondral damage, findings consistent with patellofemoral pain, a lateral release is initiated.

Figure 1

To initiate the lateral release, a scalpel is introduced through the proximal lateral portal with the scope in the distal lateral portal. The blade is introduced under direct arthroscopic visualization (Fig 1). Following this, an insulated-tip cautery probe is introduced through the proximal-lateral portal.

Figure 2

The release of the lateral retinaculum is accomplished by first hooking the intended tissue with the curved cautery probe tip, applying current, cutting through the tissue, and then advancing the probe distally (Fig 2). The release continues until approximately two-thirds of the lateral retinaculum is divided. The use of the cautery probe helps maintain hemostasis throughout the procedure.

The scope is then switched to the proximal lateral portal, through which the distal portion of the lateral retinacular release is now visualized. The scalpel is re-introduced through the distal lateral portal to approximate the area of the previous completion of the lateral retinacular release. Through this, the insulated-tip cautery is again introduced, the release is continued distally to the lateral border to the patellar ligament. The release is complete when it is possible to rotate the lateral border of the patella to 90 degrees.

The knee is irrigated thoroughly \and evacuated of all debris. The portal are closed with Steri-Strips. Sterile dressing and Ace wrap are applied along with a compressive cold therapy cuff. The procedure is accomplished in an outpatient setting, with the patient typically returning home later that same day.

Specifically, the lateral structures may be compromised in chronic and acute ligament disruption, resulting in severe rotary instability. In such instances, the secondary restrains may be so damaged and the rotary instability so severe that an isolated ligament reconstruction using any graft source may fail. This is especially true in those patients where prior lateral reconstructions may have affected the lateral structures. If severe antero-lateral rotary instability is diagnosed, we have found that an extra-articular anterolateral reconstruction (ALR) should be performed in conjunction with the primary ligament reconstruction. Antero-lateral instability is most commonly associated with ACL disruption.

Additionally, in cases of PCL disruption the postero-lateral structures of the knee may be damages. In these cases where postero-lateral instability is identified a postero-lateral reconstruction (PLR) is performed in conjunction with a primary PCL reconstruction. There are cases, often following knee dislocation where both the PCl and ACL is torn, when both an antero-lateral and postero-lateral reconstruction is needed. We feel that the failure to recognize such instabilities (antero-lateral; postero-lateral; combined) and to perform the appropriate extra-articular reconstruction is an under-recognized cause of ligament reconstruction failure.

The Physical Exam

Physical Exam

A compromise of the lateral structures is suspected in those patients who have had a prior lateral side procedure, a knee dislocation, or a prior ACL reconstruction procedure that has failed. It is also highly suspected following a PCL tear.

The internal and external rotation (Fig 1) dial tests can be used to assist in the diagnoses of severe lateral rotary instability . The point is that the greater the degree of lateral rotary instability and the more evidence supporting a compromise of the lateral supporting structure, the more likely it is that an “isolated” intra-articular ligament reconstruction will fail.

Therefore, the greater the evidence of severe instability and the greater the evidence of compromise of the lateral structures, the more likely it is that the surgeon should add a lateral stabilizing procedure to the intra-articular procedure.

When torn the ACL does not heal well on its own. Early attempts to repair the ligament by sewing it back together were not successful. Current techniques remove the torn ACL and replace it using a substitute tissue. ACL reconstruction can be accomplished using a variety of tissue sources. This includes tissues that are taken from you, termed autografts, and tissues taken from cadaveric donors (allografts).

In our practice we perform approximately 150 ACL reconstructions each year. Specific tissues that can be used include:

• Patellar Tendon (Auto / Allograft)
• Hamstring Tendon (Autograft)
• Achilles Tendon (Allograft)

The surgical technique varies slightly depending on the type of graft used. Choose one of the graft types to learn more about that specific technique.