Minimally invasive extra-articular anterolateral reinforcement: a new technique

Degenerative changes that occur after anterior cruciate ligament (ACL) reconstruction most often are due to poor rotary control with the use of usually 1-bundle intra-articular techniques. For this reason, double-bundle procedures were developed; however, they must be evaluated. The other solution designed to improve rotational stability, which was initiated by MacIntosh in the 1980s, involves extra-articular lateral reinforcement during intra-articular ACL reconstruction. This surgical combination is invasive because of the need for long grafts from the extensor apparatus or the fascia lata, and because anterolateral anatomic stabilizing structures must be dissected. In response to these criticisms, our technique uses the semitendinosus for the usual intra-articular reconstruction procedure and the gracilis in an effort to enhance the original minimally invasive procedure by performing an extra-articular lateral reinforcement procedure. The gracilis is folded to create a free 10-cm-long graft. Interference screws inside bone tunnels are used for femoral and tibial fixation of the graft. The site of fixation adheres to the best isometric principles of Krackow and Draganish. Drilling of the tunnels, insertion of the graft, and its fixation with interference screws are performed through two 1.5-cm-long incisions. Between them, the graft application is completed through Blount dissection under the fascia lata through the distal incision with a pincer.