Extra-articular Augmentation of Anterior Cruciate Ligament Reconstruction: The Monoloop Procedure

Surgical intervention aimed at limiting translation and pivot in the anterior cruciate ligament-injured knee has evolved over time, and there is ongoing debate as to the optimal technique to apply. While arthroscopic intra-articular surgery is the current mainstay of treatment, historical literature suggests that optimal surgical restoration of knee stability in some cases needs simultaneous consideration of potentially unrecognized concomitant injury to structures at the periphery of the knee joint. Of specific concern is the role of capsular or ligamentous structures on the lateral side of the knee. It has been repeatedly postulated that a combined intra-articular ACL reconstruction with extra-articular augmentation on the lateral side may be of benefit for some patients. While we also apply both single and double-bundle intra-articular ACL reconstruction techniques alone in many cases, surgeons at our institution have also applied extra-articular augmentation in select patients for over 30 years. We continue to believe it has a role to play in optimizing the outcome in many patients presenting with the primary finding of a ruptured ACL. In particular, we use this extra-articular augmentation in patients participating in activities with a high level of cutting or pivoting, patients with hyperlaxity or a pronounced pivot shift, and all cases of revision ACL reconstruction. Herein we describe our technique and rationale for a combined intra-articular ACL reconstruction with an extra-articular procedure we refer to as the monoloop technique.