Editorial Commentary: This Is the Way: Extra-Articular Augmentation Is an Essential Consideration in Contemporary Anterior Cruciate Ligament Surgery

Since the rediscovery of the anterolateral ligament, extra-articular augmentation (EA) has evolved from controversial to an essential consideration in contemporary anterior cruciate ligament reconstruction surgery. Anterolateral ligament (ALL) reconstruction and lateral extra-articular tenodesis are 2 common methods. Indications among early adopters pioneering anterolateral ligament reconstruction at anterior cruciate ligament surgery included revision anterior cruciate ligament (ACL) case, chronic ACL tear, high-grade pivot shift, and patients with hyperlax, hypermobile knees. Newer indications include young patient age, pivoting sport/high-demand/high-risk athlete, and concurrent medial meniscus repair. Questions remain regarding best practices as indications continue to evolve regarding technique, graft choice, angle/position of reconstruction fixation, and whether EA should be reconstructed routinely. This fast-moving surgical evolution serves as a reminder of 2 key concepts; first, that anterior cruciate ligament tears occur more fundamentally in the setting of anterolateral rotatory instability, in which concurrent soft tissue injuries are common, and, second, that even our best “anatomic” reconstructions do not fully recapitulate the native ACL, both of which give impetus to reconstructing the ALL.