Abstract
Background:
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.
Indications:
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.
Technique Description:
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.
Results:
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.
Discussion/Conclusion:
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.
Patient Consent Disclosure Statement:
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.
Keywords: anterior cruciate ligament reconstruction, anterolateral ligament reconstruction, suspensory fixation, surgical technique
Graphical Abstract.
This is a visual representation of the abstract.
Video Transcript
Background: The anterolateral ligament (ALL) has been well established as a structure in the anterolateral capsular region of the knee. Combined reconstructions of the ALL resulted in a lower re-rupture rate than isolated anterior cruciate ligament (ACL) reconstructions in at-risk populations. Patients who underwent the associated ALL reconstruction presented lower failure rates of the meniscal repair.1-5
In patients with chronic ACL tears, the combined ALL reconstructions lead to better functional outcomes and less objective instability on physical exams. The main indications for the ALL reconstruction include a grade 2 or 3 pivot shift, generalized ligament hyperlaxity or knee hyperextension, young patients intending to return to pivoting sports, chronic ACL lesions, and revision surgery.6-10
The patient presented is a 19-year-old professional soccer player who suffered trauma to the left knee 2 weeks before surgery, progressing with immediate joint pain and effusion, and became unable to return to sport activity.
On physical exam, he had a full range of motion, a grade 2 Lachman and pivot shift tests, a negative varus and valgus stress tests, a negative posterior drawer test. On magnetic resonance imaging (MRI), he had a complete ACL tear, with no associated meniscal or chondral lesions. Due to his young age and high-risk sports practice, we indicated the combined ACL and ALL reconstruction using an adjustable-loop fixation device.
Conventional arthroscopic portals are performed, and the treatment of any chondral or meniscal injuries is carried out. Then, the lateral wall of the intercondylar notch is prepared, and the anatomical point of the ACL is marked on it.
Landmarks of the ALL are identified, posterior and proximal to the lateral epicondyle and at the midpoint between Gerdy's tubercle and the head of the fibula, about 0.5 cm of the joint line.
The outside-in guide is positioned at the anatomical point of the ACL on the inner wall of the lateral femoral condyle, and at the ALL-anatomical point on the outer wall. Then, the guide pin of the retrograde drilling device is inserted into the femur. A guide wire is positioned at the ALL-tibial point and is passed toward a point distal to the ACL tunnel on the anteromedial surface of the tibia.
The position of the ALL tunnels is checked. The tape shows proper functioning of the ALL, tight in extension and loose in flexion. If the position is suitable, the cutting blade is flipped to the previously measured diameter of the ACL graft, and a femoral socket of 25 mm is performed. A suture retriever is inserted into the joint through the drill sleeve. Next, the tibial tunnel is performed as usual, with the exit point in the footprint of the native ACL.
The suture retriever is then pulled to the tibial tunnel to guide the passage of the graft. The graft is prepared with a 3-strand semitendinosus tendon and a single-strand gracilis tendon, resulting in a quadruple ACL graft. The remaining portion of the gracilis is used for ALL reconstruction.
The adjustable-loop fixation device is prepared on the ACL portion of the graft. The adjustable-loop button is passed from the tibia toward the femur, together with the ALL graft. Once the button is flipped on the lateral cortex of the femur, the tensioning sutures are slowly pulled to advance the graft into the femoral socket. A shuttle suture is passed deep to the iliotibial band, and the ALL graft is passed to the tibial incision and then pulled into the ALL-tibial tunnel. After pretensioning the graft, tibial fixation of the ACL is performed in 20° of flexion, and a posterior drawer force is applied to the tibia.
Then, ALL fixation is performed on the tibial tunnel with an interference screw at full extension and neutral rotation. That is the final physical exam, with satisfactory joint stability and no remaining pivot-shift.
Advantages: The technique presented is done with an autograft. A socket is made in the femur, instead of a full tunnel. The tunnel in the femoral cortex has a small area, protecting the femoral insertion of the lateral collateral ligament.4-6 Combined ACL and ALL reconstruction is not associated with a higher risk of adverse outcomes.
As potential complications, we can cite loss of extension, graft rupture, postoperative hematoma on the posteromedial region of the thigh, associated with the hamstrings harvesting, deep infection, cyclops lesion, hardware complications requiring removal, or chronic pain.4-9
Rehab protocol: The association with the ALL reconstruction does not interfere with the ACL rehabilitation protocol. After surgery, ice and compression are indicated to control pain and swelling.
Free range of motion of the knee is allowed, and patients can walk with partial weight bearing and progress as tolerated. The return to sports activity happens around 4 months for nonpivoting sports, 6 months for pivoting noncontact sports, and 9 months for pivoting and contact sports.
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 fixation device 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.
Footnotes
Submitted August 23, 2023; accepted November 17, 2023.
One or more of the authors has declared the following potential conflict of interest or source of funding: G.A.J.Q. is a consultant for Johnson & Johnson and Stryker. P.A.S.R. is a consultant for Arthrex. C.P.H. is a consultant for Johnson & Johnson, Conmed, and Smith and Nephew. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.
ORCID iD: Ruben Dario Arias Perez 
https://orcid.org/0000-0001-8963-9238
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