Could Extra-Articular Tenodesis Be The Future Of ACL Reconstruction Surgery?

Extra-Articular Tenodesis, What Is It?

Surgery continues to evolve in all areas of medicine. The goal is always the same—better results, greater accuracy, and safer outcomes. ACL reconstruction is no exception. Surgeons are constantly improving techniques, outcomes, and patient selection for this procedure.

ACL reconstruction is widely used to treat damage inside the knee joint. It targets the torn anterior cruciate ligament (ACL) and aims to restore stability. However, an ACL injury often affects more than just the ligament. Other parts of the knee—like the anterolateral capsule—can also suffer damage. Ignoring these can leave the knee unstable, even after a successful ACL graft.

Extra-articular tenodesis is a surgical technique that addresses this issue. It focuses on repairing structures outside the knee joint. In some cases, adding tenodesis improves knee stability, especially for people who twist or pivot regularly during sport or daily life.

One common associated injury is a Segond fracture. This happens when the anterolateral capsule pulls away from the bone. It’s frequently seen in people with ACL tears. Research links this fracture to increased rotational looseness in the knee. (Claes et al., 2013, Journal of Anatomy)

It Sounds Logical…

If both inside and outside structures are damaged, fixing only one part may not be enough. The logic is simple—and supported by research:

• One study found that adding a tenodesis reduced tibial rotation. It also lowered the stress on the ACL graft by around 40%.
• Surgeons believe this may be helpful in revision ACL surgeries. These are done when someone re-injures their ACL after the first surgery.

Anatomical Studies

Researchers are still learning about how the side structures of the knee work. One study identified the anterolateral ligament (ALL). This ligament runs from the thigh bone (lateral femoral condyle) to the shin bone (anterolateral tibia).

In knees with a torn ACL, the ALL can stretch over time. This may add to knee looseness. Repairing or reinforcing this ligament during surgery may help. It can reduce instability and improve function. That’s why some believe tenodesis may become more common in ACL treatment.

Extra-Articular Tenodesis and ACL Reconstruction Surgery

One challenge for surgeons is knowing who needs tenodesis. Traditional ACL surgery works well for many. But some people need more support—especially those who experience rotational instability even after a graft.

Right now, it’s hard to measure that type of instability. MRI scans and physical exams don’t always give clear answers. As a result, doctors often base decisions on injury history, physical tests, and how the patient responds to movement.

Some surgeons recommend tenodesis for revision ACL surgeries. This is especially the case when the reason for graft failure isn’t obvious. While not routine yet, tenodesis may become more common as research grows and assessment tools improve.

Content for this blog was taken and adapted from the “Medical Observer” article titled “Not all knee surgeries are the same”.

Disclaimer: This blog is for educational purposes only and is not a substitute for medical advice. Sydney Physio Clinic does not endorse specific treatments or procedures. For advice about Extra-Articular Tenodesis or ACL surgery, speak to your physiotherapist, orthopaedic surgeon, GP, or another qualified health professional.

Further references: Claes S, Vereecke E, Maes M, Victor J, Verdonk P, Bellemans J. (2013). Anatomy of the anterolateral ligament of the knee. Journal of Anatomy, 223(4), 321–328.