Combined ACL and Anterolateral Ligament Reconstruction.

Is the anterolateral ligament the smoking gun to explain rotational knee laxity or just vaporware?

Background:Graft rupture rate, return to sport and persistent rotational instability remain a concern postoperatively following anterior cruciate ligament (ACL) reconstruction. The anterolateral ligament (ALL) has recently been shown to act as a lateral knee stabilizer that helps improve rotational stability. To improve functional and clinical outcomes, a combined ACL reconstruction with an associated ALL reconstruction has been proposed.Purpose:The main purpose of this study was to evaluate the clinical outcomes of the combined ACL and ALL reconstruction.Methods:A literature search in PubMed was performed and papers reporting on clinical outcomes after combined ACL and ALL reconstruction were identified. The inclusion criteria was a minimum 2-year follow-up.Results:Five studies were included in the review. The overall graft failure rate in patients with ACL and ALL reconstruction was <3% at 2 years minimum after surgery. Comparison analysis in a high-risk population demonstrated that the graft failure rate in combined ACL and ALL reconstruction was 2.5 times lower than with isolated bone-patella tendon-bone graft and 3.1 times lower than with isolated hamstring graft. The medial meniscal repair failure rate was also 2 times lower in the combined ACL and ALL reconstruction group compared with isolated ACL reconstruction. Return to sport and functional outcomes did not show any significant difference between the groups. The rate of reoperations was not increased in patients with combined ACL and ALL reconstruction.Conclusions:Overall, combined ACL and ALL reconstruction provides promising results that may improve graft rupture rates and meniscal repair failure rates, while maintaining excellent functional outcomes.

Background: Early clinical results of anterolateral ligament (ALL) reconstruction are promising, but concerns exist due to high rates of complications after other types of lateral extra-articular tenodesis. The rate of surgery after combined anterior cruciate ligament (ACL) and ALL reconstruction is not known. Purpose: To determine the rate of reoperation after combined ACL and ALL reconstruction. Study Design: Case series; Level of evidence, 4. Methods: A retrospective analysis of prospectively collected data from the Scientific ACL Network International (SANTI) Study Group database was performed to include all patients who had undergone combined ACL and ALL reconstruction between January 2012 and June 2014. At the end of the study period, all patients were contacted by telephone, and the operative notes of those who stated that they had undergone reoperation were reviewed to determine the type and rates of the subsequent procedures performed. Descriptive data were analyzed for the entire patient cohort. Results: The study population comprised 548 quadruple hamstring graft (4HT)+ALL reconstructions. The mean age (±SD) was 24.3 ± 7.9 years (range, 11.9-55.7 years), and 70.3% of subjects were male. The mean duration of follow-up was 35.5 ± 8.0 months (range, 24-54 months). Seventy-two patients (13.1%) underwent ipsilateral reoperation. This comprised a total of 77 procedures. Graft revision occurred in 14 knees (2.6%) at a mean of 18.3 months (±7.4 months) after the index procedure. There were 63 reoperations for ipsilateral, non–graft rupture–related indications (meniscus, n = 30; arthrofibrosis, n = 22; removal of hardware, n = 4; deep infection, n = 3; arthroscopic lavage without infection, n = 4). The only specific complications related to the ALL procedure (n = 3) were all related to femoral hardware that required removal. In both univariate and multivariate analyses, only the presence of a medial meniscal lesion at the index procedure was significantly associated with ipsilateral reoperation (odds ratio, 2.58; 95% CI, 1.43-4.76; P = .002). Conclusion: The reoperation rate after combined ACL and ALL reconstruction in this series is broadly comparable to the reoperation rate after isolated ACL reconstruction as reported in previous studies. In addition, the high rates of knee stiffness and reoperation reported in historical series of nonanatomic, lateral extra-articular tenodesis were not observed in the current series.

To compare the outcomes of anterior cruciate ligament (ACL) reconstruction with those of combined ACL and anterolateral ligament (ALL) reconstruction in ACL-deficient knees. The objective of this study wasto improve knowledge regarding the treatment of ACL-deficient knees with combined ACL and ALL reconstruction. Combined ACL and ALL reconstruction has been hypothesized to result in better clinical and functional outcomes than isolated ACL reconstruction (ACLR). One-hundred and seven adult male athletes with ACL tears and high-grade pivot shifts were randomized into two groups. Those in group A (n = 54) underwent ACLR, while those in group B (n = 53) underwent combined ACL and ALL reconstruction. The median age was 26 (18-40) and 24 (18-33) years in groups A and B, respectively, and the median follow-up was 60 (55-65) months. Physical examination findings, instrumented knee laxity tested using a KT-1000 arthrometer, and International Knee Documentation Committee Scale (IKDC) scores were used to evaluate the outcomes. One-hundred and two patients were available for follow-up: 52 in group A and 50 in group B. Postoperatively, the pivot shift was normal in 43 (82.7%) and 48 (96%) patients in groups A and B, respectively (p < 0.001). The median instrumented knee laxity was 2.5 ± 0.7 (1.2-6.1) mm in patients in group A and 1.2 ± 0.7 (1.2-3.2) mm in patients in group B (p < 0.001). Additionally, 44 (84.6%) patients in group A had normal IKDC scores and 3 (5.8%) had nearly normal scores, while 48 (96.0%) patients in group B had normal IKDC scores and 2 (4%) had nearly normal scores (p < 0.001). Combined ACL and ALL reconstruction, compared with isolated ACLR resulted in favourable clinical and functional outcomes, as demonstrated by decreased rotational instability and instrumented knee laxity, a lower graft rupture rate and better postoperative IKDC scores. 1.

The purpose of the current randomized clinical trial (RCT) was to evaluate the clinical outcomes of combined anterior cruciate ligament (ACL) and anterolateral ligament (ALL) reconstruction and to compare them with those of isolated ACL reconstruction. The hypothesis was that combined ACL and ALL reconstruction will result in superior clinical outcomes in terms of the rotational stability of the knee. This prospective RCT included 57 patients (44 men and 13 women, mean age = 31 ± 7.1 years) who underwent ACL reconstruction either isolated (Group I: 25 patients) or combined with ALL reconstruction (Group II: 32 patients). The evaluation of the patients was done preoperatively and postoperatively at 6 weeks, 12 weeks, 6 months, and 12 months including a clinical examination (Lachman's test, Pivot shift's test, and Rolimeter differential anterior laxity), an objective clinical scores (objective: the International Knee Documentation Committee [IKDC] score) and a subjective clinical scores (subjective: IKDC's score, Lysholm's score, and Tegner's activity score). Postoperative complications of all the patients were recorded. There was a significant difference between the study groups at all follow-up intervals when evaluating the postoperative pivot shift test (p < 0.05) with a superior rotational stability in the group of combined ACL and ALL reconstruction. At the final follow-up evaluation, 36% of the patients from Group I and 6.2% in Group II had a grade I positive pivot shift test (p < 0.05). There was a statistically significant difference between the two groups regarding the number of patients with a grade A IKDC objective score (p < 0.05) at the 6- and 12-month follow-up intervals (p = 0.007). There was a significant difference concerning the IKDC subjective score between the two study groups in favor of the combined ACL and ALL reconstruction group at 12 months postoperatively (p = 0.048). Combined ACL and ALL reconstruction technique was demonstrated to be effective in obtaining a superior control of the rotational knee instability and to improve the clinical objective and subjective outcomes when compared with isolated ACL reconstruction in sports patients with high-grade pivoting shifts.

Objectives:The aim of this study was to report long term comparative clinical outcomesof isolated Anterior Cruciate Ligament (ACL) reconstruction versus combinedACL and Anterolateral Ligament (ALL) reconstruction in a matched pairanalysis.Methods:A retrospective analysis of prospectively collected data was undertaken.Patients who underwent combined ACL and ALL reconstruction were matched 1:1to patients who had undergone isolated ACL reconstruction using a propensityscore. Matching was based upon age, BMI, side to side laxity difference,duration of time between injury and surgery, type of sports participation(e.g pivoting, contact), presence of concomitant meniscal injuries and theirtreatment. At the end of the study period all patients completed Lysholm,Tegner, IKDC and KOOS scores, and underwent telephone interview and medicalnotes review to determine whether they had experienced any complications orre-operations after the index procedure. Kaplan-Meier analysis was used todetermine survivorship with respect to graft rupture rates in each groupResults:90 patients who underwent combined ACL and ALL reconstruction were matched to90 patients who underwent isolated ACL reconstruction. The mean duration offollow up was 108.09±9.43 months (range 97-182). The combined ACLR and ALLRgroup had significant lower graft rupture rate (3.5%) than the isolated ACLRgroup (16%) (OR=5.306 ; CI =1.46-19.19 ; p=0.007) (Fig 1). There was nosignificant difference between groups with respect to non-graft rupturerelated reoperation rates (secondary meniscectomy, cyclops excision,arthroscopic lavage for infection or hemarthrosis). Contralateral ACLrupture rates were comparable between combined ACL and ALL reconstruction(16.27%) and isolated ACL reconstruction (19.5%) groups. The KOOS score wassignificantly higher in the combined group with respect to subdomains ofpain (p=0.007) and quality of life (p=0.007). There was no significantdifference in other KOOS domains, Tegner, Lysholm, or IKDCConclusions:This study reports the first long-term results of combined ACL and ALLreconstruction. The results demonstrate a significantly lower graft failurerate when compared to isolated ACL reconstruction in a matched pair serieswith a minimum follow-up of 9 years.

Background:Tunnel collision during ligament surgery may impact graft integrity and fixation, potentially influencing surgical outcomes. Identifying the optimal anterolateral ligament (ALL) femoral tunnel orientation is therefore important to improve the overall success of combined anterior cruciate ligament (ACL) reconstruction (ACLR) and ALL reconstruction (ALLR).Purpose:To investigate whether the orientation of the ALL femoral tunnel in combined ACLR and ALLR affects the risk of femoral tunnel collision and subsequent clinical outcomes.Study Design:Cohort study; Level of evidence, 3.Methods:Medical records of patients who underwent combined ACLR and ALLR from 2018 to 2022 were reviewed, and those with at least 2 years of follow-up were evaluated. Patients were classified based on the orientation of the ALL femoral tunnel as targeted at the time of surgery, with tunnels created at 30° axial and 30° coronal (Group P) or 0° axial and −40° coronal (Group D). Between-group comparisons were conducted for radiological parameters—including the characteristics of the ACL and ALL femoral tunnels, tunnel collision rates, minimal distance between the tunnels (MDBT), and collision volumes—assessed using 3-dimensional knee models from postoperative computed tomography scans. In addition, functional scores, knee laxity, and intraoperative data were analyzed.Results:A total of 64 patients were included. Group D exhibited a significantly lower tunnel collision rate compared with group P (68.8% and 6.3% in groups P and D, respectively; P < .001), along with a larger MDBT (–5.5 ± 2.5 mm and 3.7 ± 4 mm in groups P and D, respectively; P < .001) and a smaller collision volume (92.2 ± 89.5 mm3 and 1.2 ± 3.5 mm3, respectively; P < .001). No significant differences were observed between groups in functional scores or knee laxity at the final follow-up. However, the surgical time for cases without combined meniscal procedures was significantly longer in group P (P = .025). Additional comparative analysis newly categorized by tunnel collision also revealed no differences regarding the surgical outcomes; however, surgical time was significantly longer in cases where tunnel collision occurred (P < .001 for both the overall cohort and cases without combined meniscal procedures).Conclusion:Distally directed drilling for the ALL femoral tunnel reduced the risk of tunnel collision in combined ACL and ALL procedures without compromising clinical outcomes. Although the tunnel collision itself did not affect surgical outcomes, distal drilling significantly reduced surgical time by minimizing collision risk, thereby optimizing the surgical process.

Objectives: This study aimed to perform matched comparisons of the surgical outcomes of combined anterior cruciate ligament (ACL) and anterolateral ligament (ALL) reconstruction with those of isolated ACL reconstruction, in which allografts were used for the ACL. Methods: Patients who underwent anatomical ACL reconstruction with or without additional ALL reconstruction between 2017 and 2023 and had a minimum follow-up of 2 years were included and grouped according to whether an additional ALL reconstruction was performed. The cohorts were statistically adjusted using an inverse probability of treatment weighting (IPTW) to control for potential confounders related to surgical indication, including age, activity level, sex, rotational knee laxity, and preoperative osteoarthritic grade. Between-group comparisons were conducted for baseline characteristics, clinical outcomes, knee laxity, and radiologic parameters. Results: Fifty-nine patients were included (Group 1: 39 isolated ACL reconstructions; Group 2: 20 combined ACL and ALL reconstructions). Before IPTW adjustment, a significant difference was observed in the preoperative pivot-shift test (p = 0.008), which was no longer significant after weighting. Postoperative functional outcomes and knee stability were comparable between groups; however, the incidence of surgical failure was significantly lower in Group 2 both before and after IPTW adjustment (p = 0.044 and p = 0.049, respectively). Regarding radiologic parameters, the signal-to-noise quotient of the ACL graft was also significantly lower in Group 2, both before and after IPTW adjustment (p = 0.046 and p = 0.038, respectively). Conclusions: In ACL reconstruction using allografts, the addition of ALL reconstruction resulted in more favorable clinical and radiologic outcomes-particularly a lower incidence of surgical failure and greater postoperative graft maturity-compared with isolated ACL reconstruction.

Background: Despite numerous technical descriptions of anterolateral procedures, knowledge is limited regarding the effect of knee flexion angle during graft fixation. Purpose: To determine the effect of knee flexion angle during graft fixation on tibiofemoral joint kinematics for a modified Lemaire tenodesis or an anterolateral ligament (ALL) complex reconstruction combined with anterior cruciate ligament (ACL) reconstruction. Study Design: Controlled laboratory study. Methods: Twelve cadaveric knees were mounted in a test rig with kinematics recorded from 0° to 90° flexion. Loads applied to the tibia were 90-N anterior translation, 5-N·m internal tibial rotation, and combined 90-N anterior force and 5-N·m internal rotation. Intact, ACL-deficient, and combined ACL plus anterolateral-deficient states were tested, and then ACL reconstruction was performed and testing was repeated. Thereafter, modified Lemaire tenodeses and ALL procedures with graft fixation at 0°, 30°, and 60° of knee flexion and 20-N graft tension were performed combined with the ACL reconstruction, and repeat testing was performed throughout. Repeated-measures analysis of variance and Bonferroni-adjusted t tests were used for statistical analysis. Results: In combined ACL and anterolateral deficiency, isolated ACL reconstruction left residual laxity for both anterior translation and internal rotation. Anterior translation was restored for all combinations of ACL and anterolateral procedures. The combined ACL reconstruction and ALL procedure restored intact knee kinematics when the graft was fixed in full extension, but when the graft was fixed in 30° and 60°, the combined procedure left residual laxity in internal rotation (P = .043). The combined ACL reconstruction and modified Lemaire procedure restored internal rotation regardless of knee flexion angle at graft fixation. When the combined ACL reconstruction and lateral procedure states were compared with the ACL-only reconstructed state, a significant reduction in internal rotation laxity was seen with the modified Lemaire tenodesis but not with the ALL procedure. Conclusion: In a knee with combined ACL and anterolateral ligament injuries, the modified Lemaire tenodesis combined with ACL reconstruction restored normal laxities at all angles of flexion for graft fixation (0°, 30°, or 60°), with 20 N of tension. The combined ACL and ALL procedure restored intact knee kinematics when tensioned in full extension. Clinical Relevance: In combined anterolateral procedure plus intra-articular ACL reconstruction, the knee flexion angle is important when fixing the graft. A modified Lemaire procedure restored intact knee laxities when fixation was performed at 0°, 30°, or 60° of flexion. The ALL procedure restored normal laxities only when fixation occurred in full extension.

ObjectivesThis study aims to compare the outcomes of isolated anterior cruciate ligament (ACL) reconstruction and combined anterolateral ligament (ALL) suture tape augmentation (STA) and ACL reconstruction after a minimum follow-up of two years.Patients and methodsThis retrospective study included 63 patients (36 males, 27 females; mean age 27.8±4.0; range, 19 to 35 years) who had unilateral ACL injury and participated in pivoting sports and were randomly assigned to undergo either isolated ACL reconstruction (Group 1, n=33) or combined ACL reconstruction and ALL STA (Group 2, n=30) between January 2015 and February 2018. The presence of an associated meniscal injury, chondral pathology, contralateral ACL rupture, and residual pivot shift; subjective and objective International Knee Documentation Committee scores; Cincinnati and Lysholm functional scores; KT-1000 measurements; and graft rupture rate were evaluated.ResultsPatients were followed for a minimum of two years. The groups did not differ with respect to age, sex, side, time from injury to surgery, postoperative follow-up time, ACL graft size, contralateral ACL rupture, graft size, partial meniscectomy, chondral pathology or preoperative physical examination results. A total of 9.1% of the patients in Group 1 and 0% of those in Group 2 presented postoperative positive pivot shift (p=0.357). The graft failure rate was 6.06% (n=2) in Group 1 and 0% in Group 2 (p=0.270). In the final evaluation, compared with Group 1, Group 2 showed better anteroposterior clinical stability, as evaluated by KT-1000 arthrometry (p=0.006). Although better results were observed in Group 2, the clinical evaluation results for postoperative function did not differ significantly between groups.ConclusionCombined ALL STA and ACL reconstruction was found to be effective in improving subjective and objective outcomes. Nevertheless, these findings were not significantly superior to those of isolated ACL reconstruction with hamstring grafts, except for the side-to-side differential anterior laxity testing results.

Combining an anterior cruciate ligament (ACL) reconstruction with an anterolateral ligament (ALL) reconstruction results in significant advantages including reduced graft rupture rates, a lower risk of reoperation for secondary meniscectomy, improved knee stability, and higher rates of return to preinjury levels of sport. The previously reported indications for combined ACL and ALL reconstruction are as follows: ACL reconstruction revision; high-grade pivot shift test; long-term ACL rupture; young patients; pivoting activities; concomitant medial meniscus repair, and, specifically, regarding the ALL repair, it must be an acute surgery (within 15 days from injury). Several modern techniques have been described to repair and reconstruct the ALL. This technical note details a number of these techniques performed by the Scientific Anterior Cruciate Ligament Network International (SANTI) Study Group. First, we describe a combined ACL reconstruction and double-bundle ALL reconstruction using hamstring autograft. Secondly, we describe a single-bundle ALL reconstruction using gracilis autograft. Thirdly, we describe an ALL reconstruction technique using a knotless soft anchor, which provides shallow fixation and prevents tunnel convergence. Finally, we describe a technique for ALL repair. Several techniques have been described to repair and reconstruct the ALL, all offering significant advantages over an isolated ACL reconstruction. The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

To evaluate the results of combined anterior cruciate ligament (ACL) and anterolateral ligament (ALL) reconstruction in patients with chronic ACL injury. It was hypothesized that patients who underwent combined ACL and ALL reconstruction would exhibit less residual laxity and better clinical outcomes. Two groups of patients were evaluated and compared retrospectively. Both groups consisted only of patients with chronic (more than 12months) ACL injuries. Patients in group 1 underwent anatomical intra-articular reconstruction of the ACL and patients in group 2 underwent anatomic intra-articular ACL reconstruction combined with ALL reconstruction. The presence of associated meniscal injury, the subjective International Knee Documentation Committee (IKDC) and Lysholm functional outcome scores in the postoperative period, KT-1000 evaluation, the presence of residual pivot shift and graft rupture rate were evaluated. One hundred and one patients who underwent reconstruction of chronic ACL injuries were evaluated. The median follow-up was 26 (24-29)months for group 1 and 25 (24-28)months for group 2. There were no significant differences between groups regarding gender, age, duration of injury until reconstruction, follow-up time or presence of associated meniscal injuries in the preoperative period. Regarding functional outcome scores, patients in group 2 presented better results on both the IKDC (p = 0.0013) and the Lysholm (p < 0.0001) evaluations. In addition, patients in group 2 had better KT-1000 evaluation (p = 0.048) and a lower pivot shift rate at physical examination, presenting only 9.1% positivity versus 35.3% in the isolated ACL reconstruction (p = 0.011). Regarding re-ruptures, group 1 presented 5 (7.3%) cases, and group 2 presented no cases. The combined ACL and ALL reconstruction in patients with chronic ACL injury is an effective and safety solution and leads to good functional outcomes with no increase in complication rate. The clinical relevance of this finding is the possibility to indicate this type of procedure when patients present with more than 12months after injury for surgery. Level III.

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Combined Revision of Anterior Cruciate Ligament and Lateral Extra-Articular Procedure Using Rectus Femoris Autologous Graft

Research on surgical strategies to minimize tunnel collisions in combined anterior cruciate ligament (ACL) reconstruction (ACLR) using the modified transtibial technique (MTT) and anterolateral augmentation is limited, unlike with independent tunnel drilling techniques. To analyze the optimal drill orientations for the anterolateral ligament (ALL) femoral tunnel to minimize tunnel collisions and reduce damage to surrounding structures during combined ACLR with MTT and anterolateral augmentation procedures, accounting for far-cortex drilling (FCD) of the ALL femoral tunnel required for graft fixation. Descriptive laboratory study. Three-dimensional reconstructed femoral models of patients who underwent ACLR with MTT between 2015 and 2018 were used. Geometric factors of femoral models were analyzed, and virtual ALL femoral tunnels were simulated to evaluate 45 drilling combinations. To assess potential damage to surrounding structures associated with ALL femoral tunnel drilling, femoral cortical violation caused by the ALL femoral tunnel itself was assessed under each drilling condition, whereas tunnel trajectories were analyzed to classify drilling conditions according to FCD. In addition, the minimum distance between the ACL and ALL femoral tunnels (MDBT) and the tunnel collision rate were evaluated. A total of 27 patients were analyzed. In scenarios where FCD was not required for ALL graft femoral fixation, the optimal drill orientation for the ALL femoral tunnel was within the range of coronal -40° to -20°, eliminating cortex violation and tunnel collisions (mean MDBT, 9 ± 4.1 mm; collision rate 0%). When FCD was required for ALL graft femoral fixation, the optimal drill orientation was axial 40° and coronal 10°, resulting in the longest MDBT without the risk of femoral cortex violation (MDBT, 4.9 ± 3.5 mm; collision rate, 7.4%). During the combined surgeries for ACLR using MTT and anterolateral augmentation procedures, the optimal drill orientation of the ALL femoral tunnel was within the range of coronal -40° to -20° for techniques not requiring FCD and axial 40° and coronal 10° for those requiring FCD. This study provides practical surgical guidance for optimizing ALL femoral tunnel orientation during combined ACLR using MTT and anterolateral augmentation. By accounting for whether FCD is required for ALL graft femoral fixation, the findings may help surgeons minimize tunnel collision and reduce the risk of femoral cortical violation, thereby potentially decreasing procedure-related complications.