Optimizing Drilling Orientation for the ALL Femoral Tunnel During Anterolateral Augmentation Procedures For Minimizing Collision With the ACL Tunnel Created Using Modified Transtibial Technique.

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.

In combined anterior cruciate ligament (ACL) and anterolateral ligament (ALL) reconstruction, there is a risk of collision between the femoral tunnels of the ACL and ALL. To identify (1) the optimal knee flexion angle when creating the femoral tunnel for ACL reconstruction using the transportal technique and (2) the optimal orientation of the ALL femoral tunnel to minimize collisions between the tunnels. Controlled laboratory study. Computed tomography scans from 10 participants were used to create 3-dimensional (3D) models. A 3D-reconstructed knee model at 90°of flexion was virtually further flexed to 5 different angles (100°-140°; 10° interval). Relationship between the ACL femoral tunnel created at 5 different flexion angles using transportal technique and ALL femoral tunnel created with 25 orientations (5 axial × 5 coronal) were analyzed. The minimal distance between tunnels was measured, and collisions between tunnels were investigated. The characteristics of each tunnel including tunnel length and wall breakage were also assessed. An ACL femoral tunnel created at a knee flexion angle of 140° inevitably overlaps with ALL femoral tunnels in all orientations. Considering tunnel length and posterior wall blowout, knee flexion angles from 120° to 130° were considered suitable for ACL femoral tunnel drilling. The optimal ALL drill orientations to minimize collision between the tunnels were identified as axial 20° to coronal 0°, axial 30° to coronal 0°, and axial 30° to coronal 10°, demonstrating no collision between tunnels when the ACL femoral tunnel was created at a knee flexion of 120° to 130°. A knee flexion angle within the range of 120° to 130° in ACL femoral tunnel drilling and ALL drill orientations of axial 20° to coronal 0°, axial 30° to coronal 0°, and axial 30° to coronal 10° can be recommended as optimal conditions for creating tunnels while minimizing intertunnel collision in combined ACL and ALL reconstruction. This study provides practical guidelines for surgeons by identifying a safe range of knee flexion angles for ACL femoral tunnel creation using the transportal technique and optimal ALL femoral tunnel orientations. Applying these results may improve tunnel integrity, and enhance the success of combined ligament reconstructions.

Clinical results of combined anterior cruciate ligament (ACL) and anterolateral ligament (ALL) reconstruction have demonstrated a significant reduction in ACL graft rupture rates and improved rates of return to sports compared with isolated ACL reconstruction1. This finding is supported by laboratory studies that have demonstrated that combined ACL reconstruction and lateral extra-articular tenodesis procedures protect the ACL graft by load-sharing with it and by more reliably restoring normal knee kinematics compared with isolated ACL reconstruction. The ACL graft is formed from a tripled semitendinosus tendon and a single strand of gracilis tendon. The femoral tunnel is drilled to provide an anatomic location intra-articularly and to exit the femur just posterior and proximal to the lateral epicondyle. The additional length of gracilis therefore exits the femoral tunnel at the anatomic origin of the ALL and is then routed (under the iliotibial band [ITB]) through a tibial tunnel, and back to the femoral origin, to reconstruct the ALL. Many different types of nonanatomic lateral extra-articular tenodesis procedures have been reported. The most frequently performed were the Lemaire and MacIntosh procedures; however, these, and others, were widely abandoned after poor results were reported in the 1980s. ALL reconstruction differs from other lateral extra-articular tenodesis-type procedures because the procedure is anatomically based and can be percutaneously performed. Nonanatomic procedures (typically with a strand of ITB passed under the lateral collateral ligament [LCL]) have been reported to be associated with overconstraint, early arthritis, and an increased risk of infection2-5. In contrast, ALL reconstruction has been shown to restore normal knee kinematics and to avoid overconstraint when correctly fixed in full extension and neutral rotation6. The main concern with any type of lateral extra-articular tenodesis is based on historical reports of poor outcomes2,3. However, a recent study has demonstrated that combined ACL and ALL reconstruction is associated with a reoperation rate that is comparable with the rate seen after isolated ACL reconstruction, and it has a very low rate of complications7. This makes a compelling argument for anatomic ALL and ACL reconstruction being the procedure of choice when considering an extra-articular procedure. This is further supported by the fact that, even though previous studies have demonstrated a trend toward reduced ACL graft rupture with nonanatomic lateral extra-articular tenodesis procedures, they have not shown a significant improvement in outcomes8. Combined ACL and ALL reconstruction is currently the only type of lateral extra-articular procedure that has been demonstrated to significantly reduce the risk of ACL graft rupture and improve the rate of return to sports1.

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.

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

Poster 351: Relation Between Femoral Anterior Cruciate Ligament Tunnel Orientation and Anterolateral Ligament Tunnel Collision in a 3D-CT Model

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.

Background: Lateral extra-articular tenodesis (LET) is being increasingly added to primary and revision anterior cruciate ligament (ACL) reconstruction to address residual anterolateral rotatory instability. However, currently there is a lack of knowledge on how close the femoral tunnels are when combining these procedures. Purpose/Hypotheses: To assess the risk of tunnel convergence in combined ACL and LET procedures using 2 different surgical techniques (Lemaire and MacIntosh). It was hypothesized that the risk of tunnel convergence would be greater when using the more distally located Lemaire position. The authors further hypothesized that tunnel proximity would be influenced by knee size. Study Design: Controlled laboratory study. Methods: Ten fresh-frozen cadaveric knees were used for this study. In each specimen, an anatomic ACL femoral tunnel and 2 LET tunnels were drilled using the Lemaire and MacIntosh positions, respectively. After knee dissection, minimal distances between each ACL and LET tunnel were directly measured on the lateral femoral cortex. Furthermore, computed tomography scans were obtained to measure intertunnel convergence and lateral femoral condyle (LFC) width. On the basis of the average LFC width, knees were divided into large and small knees to determine a relationship between knee size and tunnel convergence. Results: Convergence of ACL and LET tunnels occurred in 7 of 10 cases (70%) using the Lemaire attachment position. All tunnel collisions occurred directly on the lateral femoral cortex, while intertunnel (intramedullary) conflicts were not observed. Collisions emerged in both small (n = 4) and large (n = 3) knees. Critical tunnel convergence did not occur using the MacIntosh position. The mean minimal distance between the LET and ACL tunnel using the Lemaire and MacIntosh positions was 3.1 ± 4.6 mm and 9.8 ± 5.4 mm, respectively. Conclusion: Tunnel convergence was more frequently observed in combined ACL and LET reconstruction using the Lemaire technique, independent of the knee size. LET femoral tunnel positioning according to the MacIntosh reconstruction was not associated with tunnel collision. Clinical Relevance: These findings help to raise the awareness for the risk of tunnel convergence in combined ACL and LET procedures. Surgeons may contemplate adjustments on the ACL femoral tunnel drilling technique or fixation device when applying an additional Lemaire procedure. However, in the absence of clinical outcome studies comparing different LET techniques, it remains unclear which technique is superior in a clinical setting.

To assess the risk of femoral tunnel convergence in combined anterior cruciate ligament (ACL) and anterolateral ligament (ALL) reconstructions. The hypothesis was that a more proximal and anterior orientation of the ALL femoral tunnel should reduce the risk of convergence with the ACL femoral tunnel. 15 fresh-frozen cadaver knees were examined. An anatomic ACL femoral tunnel was drilled arthroscopically in each specimen and ALL tunnels were made in two directions: (1) 0° coronal angulation and 20° axial angulation, (2) 30° coronal angulation and 30° axial angulation. Computed tomography scans were performed to investigate tunnel convergence and to measure the minimal distance between tunnels, tunnel length and the LFC width. Tunnel convergence occurred in 20 of 30 cases (67%). Convergence was significantly reduced when tunnels were drilled at 30° coronal and 30° axial angulation (p < 0.05). The mean length of the ALL tunnel was 15.9mm [95% CI (13.6; 18.1)] and was independent of ALL tunnel angulation. The mean minimal distance between the ALL and ACL tunnel was 3.1mm [95% CI (2.1; 4.1)]. The odds ratio for tunnel convergence was 3.5 for small LFC, relative to large LFC (n.s.) CONCLUSION: A high risk of tunnel convergence was observed when performing combined ACL and ALL reconstructions. The clinical relevance of this work is that the occurrence of tunnel conflicts can be reduced by aiming the ALL tunnel in a more proximal and anterior direction. Surgeons should be aware of this, since tunnel convergence could jeopardize the ACL reconstruction and fixation.

Concomitant anterior cruciate ligament (ACL) and anterolateral ligament (ALL) reconstruction has been reported as an effective technique for providing rotational control of the knee. However, the intraoperative risk of collision with an ACL tunnel during the drilling for the femoral ALL tunnel has been described. The purpose of this study was to investigate the various femoral drilling procedures to avoid tunnel collisions during combined double-bundle ACL and ALL reconstruction. Nine cadaveric knees were used in this study. ACL drilling was performed through the anteromedial portal to footprints of the posterolateral bundle at 120° (PL120) and 135° (PL135) knee flexion and the anteromedial bundle at 120° (AM120) and 135° (AM135) knee flexion. ALL drilling was performed at 0° (Cor0-ALL) and 30° (Cor30-ALL) coronal angles using a Kirschner wire (K-wire). The distance between the ALL footprint and ACL K-wire outlets, axial angles of ALL K-wires colliding with ACL K-wires, and distances from the ALL footprint to the collision point were measured. From these values, the safe zone, defined as the range of axial angles in which no collisions or penetrations occurred, was identified by simulation of tunnels utilized for reconstruction grafts in each drilling procedure. The point-to-point distance from the ALL footprint to the K-wire outlet was significantly greater in the AM120 than the AM135 (13.5 ± 3.1, 10.8 ± 3.2 mm; p = 0.048) and in the PL135 than the PL120 (18.3 ± 5.5, 16.1 ± 6.5 mm; p = 0.005) conditions, respectively. During an ACL drilling combination of PL135/AM120, a safe zone of > 45° in Cor30-ALL was identified. With a narrow safe zone during the PL135/AM120 combination only, the risk of femoral tunnel collisions in combined double-bundle ACL and ALL reconstruction is high. AM drilling at 120° and PL drilling at > 135° knee flexion, combined with ALL drilling at 30° coronal angle and > 45° axial angle, may reduce this risk.

To (1) evaluate the optimal drill orientation of the anterolateral ligament (ALL) femoral tunnel to minimize collision with the anterior cruciate ligament (ACL) femoral tunnel during anatomical ACL reconstruction according to the need for far-cortex drilling and (2) investigate the geometric factors that affect tunnel collision secondary to drill orientation of the ALL femoral tunnel. A three-dimensional femoral model of patients who underwent anatomical single-bundle ACL reconstruction between 2015 and 2016 was constructed, and the geometric factors were evaluated. Virtual ALL femoral tunnels were created to simulate 45 drilling conditions. For each condition, whether the virtual ALL femoral tunnel and its trajectory violated the femoral cortex and the minimum distance between tunnels was investigated. Thirty-nine subjects were included. Overall violation rates of the femoral cortex by the ALL tunnels and its trajectories were 11.1% (195 of 1755 conditions) and 40.7% (714 of 1755 conditions), respectively. A drilling angle of axial 0° and coronal -40° showed the longest minimum distance between tunnels without femoral cortex violation by the ALL tunnel (6.3 ± 4.0mm; collision rate 2.6% [1 of 39 subjects]). With simultaneous consideration of the ALL tunnel's trajectory representing far-cortex drilling, a drill angle of axial 40° and coronal 10° showed the longest minimum distance between tunnels without femoral cortex violation (0.6 ± 3.9mm; collision rate 38.5% [15 of 39 subjects]). For surgical techniques requiring far-cortex drilling, regression analyses were performed on geometric factors that could affect tunnel collision, which revealed that the sagittal inclination angle of the ACL and the distance between the ACL femoral tunnel's outlet and ALL's femoral attachment were associated with tunnel collision. The optimal drill orientations of the ALL femoral tunnel to minimize collision with the ACL femoral tunnel were axial 0° and coronal -40° for surgical techniques not requiring far-cortex drilling and axial 40° and coronal 10° for techniques requiring far-cortex drilling. For techniques requiring far-cortex drilling, additional adjustment for orientation of the ACL femoral tunnel is required to reduce the risk of tunnel collision. Therefore, an individualized surgical strategy should be applied according to the graft fixation method of the ALL femoral tunnel.

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.

There are several techniques for the combined reconstruction of the anterior cruciate ligament (ACL) and the anterolateral ligament (ALL), but none have shown superiority. This study aims to present a surgical technique that theoretically reduces some of the risks reported in these procedures. The main indications for the ALL reconstruction include chronic ACL injuries, revision ACL reconstruction, acute ACL injuries in patients with high-grade pivot-shift (grades 2 or 3), patients involved in pivoting sports, and generalized ligament hyperlaxity or knee hyperextension. Hamstring tendon autografts are used for the ACL and ALL reconstruction; a common femoral ACL and ALL tunnel is made outside-in, making a short socket. A continuous looped hamstring tendon autograft attached to one button is used. The ACL is fixed with an adjustable-loop button. Through small incisions, the tibial fixation of both grafts is performed with bioabsorbable screws. We present a 19-year-old professional soccer player with an acute ACL tear, with no associated meniscal or chondral lesions. Owing to his young age and high-risk sports practice, a combined ACL and ALL reconstruction was performed. The combined ACL and ALL reconstruction with a single femoral tunnel using the hamstrings tendons graft is a well-established procedure for ACL augmentation, reducing failure rates for certain risk groups, with excellent outcomes reported. The use of an adjustable-loop button on the femur is a viable option for this kind of reconstruction with postoperative stability comparable to the interference screw, classically used for this kind of reconstruction. This technique has some advantages, such as the use of a short outside-in femoral socket, thus theoretically improving healing. In addition, this lowers the risk of lateral collateral ligament injury, and since the ileotibial band graft is not used, the risk of injuring the lateral inferior genicular vessels and the peroneal nerve is theoretically reduced. Besides, using an adjustable-loop cortical button in the femur can theoretically reduce potential complications such as screw migration, soft-tissue impingement, femoral-site pain, and implant removal. Finally, the reconstruction is done with small incisions, improving the aesthetic result and postoperative pain. Considering all the aforementioned factors, this technique theoretically offers some benefits. 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.

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.