Introduction. A high-grade pivot in an ACL deficient patient suggests of rotational instability along with antero-posterior instability. Persistent anterolateral rotary instability as measured by pivot-shift test is associated with worse functional outcomes in patients who have undergone ACL reconstruction surgery. In cases with high propensity for rotational instability, ACL reconstruction along with lateral extra-articular tenodesis (LET) can be a good option to provide rotational stability to the knee and prevent failure of the reconstructed ACL ligament.

Methods. In this study, 70 patients with ACL tear along with high grade pivot shift were operated with Arthroscopic ACL reconstruction and LET between November 2016 to December 2018 with a minimum follow-up of 2 years. 63 male and 7 female patients were analysed. The mean age in the study is 28.8±7.5 years. The mean duration between injury and surgery is 15.8±9.3 months.
Diagnostic arthroscopy is done first and intra-articular pathologies are addressed first (ACL tear, meniscus tear). ITB band is harvested with 8mm width and 10 cm length and its insertion to the Gerdy`s tubercle is preserved. The graft is passed under the Fibular Collateral Ligament (FCL) and fixed to femur at the distal ridge of the Kaplan`s fibres with the knee in neutral rotation and 20 degrees flexion.

Results. All the patients were kept at regular followup and the knees were examined clinically at 6 months, 1 year and 2 years interval. No patient had a positive pivot shift at final follow-up. The mean Lysholm score improved from 46.6±11.0 in the pre-operative period to 94.0±4.2 at final follow-up. 63 patients were able to return to their previous activity level out of the 70 patients operated.

Conclusions. Simultaneous intra- and extra- articular stabilization in revision and high pivot shift patients provides saggital plane and rotational stability to the knee and thus improving post-operative recovery and function.