Combined ACL and Peripheral Instability: The Western Experience

  • Stefano Zaffagnini
  • Alberto Grassi
  • Tommaso Roberti di Sarsina
  • Tommaso Bonanzinga
  • Giulio Maria Marcheggiani Muccioli
  • Maurilio Marcacci


In this chapter we analyze our experience concerning ACL lesion with an associated peripheral instability, as peripheral structures are getting more and more attention. We know that combined damage of the ACL and the posterolateral structures of the knee have been associated to Chronic anterior cruciate ligament laxity, in particular rotational laxity associated with a severe pivot-shift test (PST). Posterolateral structures, that may not have been yet directly identified, probably act as secondary restraints to the PST, supplementing the primary restraint role of the ACL in anteroposterior laxity, with emphasis on rotatory laxity and internal rotation. The persistence of this rotatory laxity has been reported even after cases of uneventful ACL reconstruction, suggesting that a single-bundle intra-articular reconstruction could not be sufficient to completely restore rotational knee stability in certain patients (Tashman et al, Am J Sports Med 32(4):975–983, 2004). The rationale behind extra-articular plasty is therefore to create a restraint in internal tibial rotation, and that’s why we adopted in our Institute since 1993 Marcacci’s technique with good results and good graft survivorship. Authors who favour the supplementary extra-articular plasty to standard ACL reconstruction, report the reduction of the PST and lateral tibial translation, however the introduction of evidence-based inclusion criteria for any similar technique as a primary or a revision option,is difficult and remains sporadical and empirically-based.


Tibial Tunnel Pivot Shift Test Rotatory Laxity Internal Tibial Rotation Lateral Femoral Cortex 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Bull AMJ, Amis AA (1998) The pivot-shift phenomenon: a clinical and biomechanical perspective. Knee 5(5):141–158CrossRefGoogle Scholar
  2. 2.
    Norwood LA Jr, Andrews JR, Meisterling RC et al (1979) Acute anterolateral rotatory instability of the knee. J Bone Joint Surg Am 61(5):704–709PubMedGoogle Scholar
  3. 3.
    Campos JC, Chung CB, Lektrakul N et al (2001) Pathogenesis of the Segond fracture: anatomic and MR imaging evidence of an iliotibial tract or anterior oblique band avulsion. Radiology 219(2):381–386PubMedCrossRefGoogle Scholar
  4. 4.
    Tashiro Y, Okazaki K, Miura H et al (2009) Quantitative assessment of rotatory instability after anterior cruciate ligament reconstruction. Am J Sports Med 37(5):909–916PubMedCrossRefGoogle Scholar
  5. 5.
    Delzell PB, Schils JP, Recht MP (1996) Subtle fractures about the knee: innocuous-appearing yet indicative of significant internal derangement. AJR Am J Roentgenol 167(3):699–703PubMedCrossRefGoogle Scholar
  6. 6.
    Dodds AL, Gupte CM, Neyret P et al (2011) Extra-articular techniques in anterior cruciate ligament reconstruction: a literature review. J Bone Joint Surg Br 93(11):1440–1448PubMedCrossRefGoogle Scholar
  7. 7.
    Tashman S, Collon D, Anderson K (2004) Abnormal rotational knee motion during running after anterior cruciate ligament reconstruction. Am J Sports Med 32(4):975–983PubMedCrossRefGoogle Scholar
  8. 8.
    Marcacci M, Zaffagnini S, Marcheggiani Muccioli GM et al (2011) Arthroscopic intra- and extra-articular anterior cruciate ligament reconstruction with gracilis and semitendinosus tendons: a review. Curr Rev Musculoskelet Med 4(2):73–77PubMedCentralPubMedCrossRefGoogle Scholar
  9. 9.
    Zaffagnini S, Signorelli C, Lopomo N et al (2012) Anatomic double-bundle and over-the-top single-bundle with additional extra-articular tenodesis: an in vivo quantitative assessment of knee laxity in two different ACL reconstructions. Knee Surg Sports Traumatol Arthrosc 20(1):153–159PubMedCrossRefGoogle Scholar
  10. 10.
    Dejour D, Vasconcelos W, Bonin N (2013) Comparative study between mono-bundle bone-patellar tendon-bone, double-bundle hamstring and mono-bundle bone-patellar tendon-bone combined with a modified Lemaire extra-articular procedure in anterior cruciate ligament reconstruction. Int Orthop 37:193–199PubMedCentralPubMedCrossRefGoogle Scholar
  11. 11.
    Marcacci M, Zaffagnini S, Giordano G et al (2009) Anterior cruciate ligament reconstruction associated with extra-articular tenodesis: A prospective clinical and radiographic evaluation with 10- to 13-year follow-up. Am J Sports Med 37(4):707–714PubMedCrossRefGoogle Scholar
  12. 12.
    Bignozzi S, Zaffagnini S, Lopomo N et al (2009) Does a lateral plasty control coupled translation during antero-posterior stress in single-bundle ACL reconstruction? An in vivo study. Knee Surg Sports Traumatol Arthrosc 17(1):65–70PubMedCrossRefGoogle Scholar
  13. 13.
    Buda R, Ruffilli A, Di Caprio F (2013) Allograft salvage procedure in multiple-revision anterior cruciate ligament reconstruction. Am J Sports Med 41(2):402–410PubMedCrossRefGoogle Scholar
  14. 14.
    Trojani C, Beaufils P, Burdin G (2012) Revision ACL reconstruction: influence of a lateral tenodesis. Knee Surg Sports Traumatol Arthrosc 20(8):1565–1570PubMedCrossRefGoogle Scholar
  15. 15.
    Krackow KA, Brooks RL (1983) Optimization of knee ligament position for lateral extraarticular reconstruction. Am J Sports Med 11(5):293–302PubMedCrossRefGoogle Scholar
  16. 16.
    Zaffagnini S, Klos TV, Bignozzi S (2010) Computer-assisted anterior cruciate ligament reconstruction: an evidence-based approach of the first 15 years. Arthroscopy 26(4):546–554PubMedCrossRefGoogle Scholar
  17. 17.
    Colombet PD (2011) Navigated intra-articular ACL reconstruction with additional extra-articular tenodesis using the same hamstring graft. Knee Surg Sports Traumatol Arthrosc 19(3):384–389PubMedCrossRefGoogle Scholar
  18. 18.
    Engebretsen L, Lew WD, Lewis JL et al (1990) The effect of an iliotibial tenodesis on intraarticular graft forces and knee joint motion. Am J Sports Med 18(2):169–176PubMedCrossRefGoogle Scholar
  19. 19.
    Roth JH, Kennedy JC, Lockstadt H et al (1987) Intra-articular reconstruction of the anterior cruciate ligament with and without extra-articular supplementation by transfer of the biceps femoris tendon. J Bone Joint Surg Am 69(2):275–278PubMedGoogle Scholar
  20. 20.
    Strum GM, Fox JM, Ferkel RD et al (1989) Intraarticular versus intraarticular and extraarticular reconstruction for chronic anterior cruciate ligament instability. Clin Orthop Relat Res 245:188–198PubMedGoogle Scholar
  21. 21.
    Acquitter Y, Hulet C, Locker B et al (2003) Patellar tendon-bone autograft reconstruction of the anterior cruciate ligament for advanced-stage chronic anterior laxity: is an extra-articular plasty necessary? A prospective randomized study of 100 patients with five year follow-up. Rev Chir Orthop Reparatrice Appar Mot 89(5):413–422PubMedGoogle Scholar
  22. 22.
    Giraud B, Besse JL, Cladiere F et al (2006) Intra-articular reconstruction of the anterior cruciate ligament with and without extra-articular supplementation by quadricipital tendon plasty: seven-year follow-up. Rev Chir Orthop Reparatrice Appar Mot 92(8):788–797PubMedCrossRefGoogle Scholar
  23. 23.
    Lerat JL, Chotel F, Besse JL et al (1998) The results after 10–16 years of the treatment of chronic anterior laxity of the knee using reconstruction of the anterior cruciate ligament with a patellar tendon graft combined with an external extra-articular reconstruction. Rev Chir Orthop Reparatrice Appar Mot 84(8):712–727PubMedGoogle Scholar
  24. 24.
    Zaffagnini S, Marcacci M, Lo Presti M et al (2006) Prospective and randomized evaluation of ACL reconstruction with three techniques: a clinical and radiographic evaluation at 5 years follow-up. Knee Surg Sports Traumatol Arthrosc 14(11):1060–1069PubMedCrossRefGoogle Scholar
  25. 25.
    Monaco E, Labianca L, Conteduca F et al (2007) Double bundle or single bundle plus extraarticular tenodesis in ACL reconstruction? A CAOS study. Knee Surg Sports Traumatol Arthrosc 15(10):1168–1174PubMedCrossRefGoogle Scholar

Copyright information

© Springer Verlag Italia 2014

Authors and Affiliations

  • Stefano Zaffagnini
    • 1
  • Alberto Grassi
    • 1
  • Tommaso Roberti di Sarsina
    • 1
  • Tommaso Bonanzinga
    • 1
  • Giulio Maria Marcheggiani Muccioli
    • 1
  • Maurilio Marcacci
    • 1
  1. 1.Clinica Ortopedica e Traumatologica II, Laboratorio di Biomeccanica ed Innovazione TecnologicaIstituto Ortopedico RizzoliBolognaItaly

Personalised recommendations