ISAKOS: 2019 Congress in Cancun, Mexico

2019 ISAKOS Biennial Congress ePoster #715


ACL Reconstruction with and without an Additional Extra-Articular Anterolateral Reconstruction by the Monoloop Technique: A Retrospective Comparing Study

Peter Bollars, MD, Hasselt BELGIUM
Jasper De Geyter, MD BELGIUM
Sebastiaan Kellens, MD, Leuven BELGIUM
Jan Mievis, MD, St. Truiden BELGIUM

St. Trudo Hospital, St. Truiden, Limburg, BELGIUM

FDA Status Cleared


This study illustrates this importance as well as the great success of the EAR by Monoloop in preventing re ruptures and the contribution to a higher fraction of return to sport athletes.



Post-traumatic anterior cruciate ligament (ACL) ruptures are frequently seen injuries. Intra-articular ACL reconstructions are well-known surgical treatment options with overall high rates of success and satisfaction. Nevertheless, the postoperative rate of graft ruptures is 6-7% and can be as high as 16-18% in patients participating in pivoting sports. Postoperative persistent rotatory instability is possible after an ACL reconstruction and can cause remaining problems and re-ruptures. Nowadays there is increasing interest for the anterolateral ligament (ALL) as a contributor to this anterolateral rotatory stability together with the ACL. To counter the rotatory instability, an extra-articular reconstruction (EAR) of the anterolateral structures was designed by Coker-Arnold (Monoloop technique).
Objectives/Purpose: We conducted a retrospective study concerning the impact of the Monoloop in addition to intra-articular ACL reconstruction on the rate of complications , return to sports, return to competition and return to work. Moreover, we tried to identify predictive parameters to predict the need of an EAR.


Out of 216 ACL reconstructions in the St Trudo hospital who underwent an ACL reconstruction between the 1st of January 2013 and the 30th of June 2016, 163 patients were included in this retrospective study. In one group there were 57 patients (35%) treated with an additional EAR, another group only underwent an intra-articular ACL reconstruction without EAR (n = 106 ; 65%). Patient records were retrospectively reviewed for pre- and postoperative characteristics. In June 2017 all patients were contacted in order to retrieve further information, providing a minimal follow-up of 1 year.


Fourteen re-ruptures (9%) were recorded with mean follow up of 25.8 (12 – 44.3 months). Nine (69%) occurred in high demanding patients executing high risk sports. The re-rupture rate in the ACL only group is significantly higher with a rate of 11% compared to the ACL + EAR group (4%) (p= 0.0497).We noticed a higher fraction returning to their pre-injury sport activity type (67% vs 57%) (p = 0.262) as well as a shorter work incapability (3.1 months vs 4.4 months) (p = 0.6425) in the ACL + EAR group compared to the ACL only group. However, these study results show a longer mean time to return to sport activity (7.8 months vs 7.5 months) (p = 0,8204) as well as to return to pre-injury competition level (9.8 months vs 8.4 months) (p = 0.1165) in the ACL + EAR group.


This study illustrates this importance as well as the great success of the EAR by Monoloop in preventing re ruptures and the contribution to a higher fraction of return to sport athletes. After this study, we developed the St Trudo Protocol for ACL injuries : Patients, intra-operative tested under general anaesthesia, with a positive pivot shift phenomenon and with the ambition to return to a pivoting sport underwent an ACL with EAR . We are convinced that the protocol we use is a good guidance in the decision making of which patients can be treated only with an ACL repair and which of them needs an extra-articular repair.