Abstract
Persistent rotational instability, reported in 15–35% of isolated anterior cruciate ligament (ACL) reconstruction remains a significant cause of graft failure and impaired return to sports. This has led to an increased interest in supplementing ACL reconstruction with anterolateral ligament (ALL) reconstruction to address residual rotational laxity. ALL reconstruction may better restore rotational stability compared to traditional lateral extra-articular procedures. The patient is positioned supine with the knee flexed at 90°, and standard landmarks are identified. Semitendinosus and gracilis tendons are harvested via a small incision. A quadrupled semitendinosus graft reconstructs the ACL, while the gracilis tendon reconstructs the ALL. Femoral tunnels for ACL and ALL reconstruction share a common anatomical entry point proximal and posterior to the lateral epicondyle. Tibial tunnels for the ALL are created below Gerdy’s tubercle. Graft fixation is achieved with a suture disc on both femoral and tibial sides, ensuring physiological tension in extension. Patients begin immediate weight-bearing and range-of-motion exercises within controlled limits. A progressive rehabilitation protocol facilitates return to sports, allowing pivoting activities after six months. Combined ACL and ALL reconstruction using autologous hamstring grafts offers a reproducible surgical option for addressing rotational knee instability. Anatomical graft placement and minimally invasive techniques may offer the potential for improved clinical outcomes, decreased graft failure rates, and enhanced patient return to pre-injury activity levels.
Keywords: Anterior cruciate ligament, Anterolateral ligament, Rotational instability, Hamstring autograft, Ligament reconstruction
Introduction
Persistent rotational instability after anterior cruciate ligament (ACL) reconstruction is a concern among surgeons with an incidence reported between 15 and 35% especially with younger and physically active patients [1]. This has led surgeons to explore supplementary procedures, among which anterolateral ligament (ALL) reconstruction has recently regained significant interest. Several surgical techniques have been described to reconstruct the ALL, ranging from non-anatomic lateral extra-articular tenodesis (LET) using the iliotibial band (ITB) to contemporary near-anatomic ALL reconstructions using hamstring tendon autografts, each carrying its own advantages and potential drawbacks [2–4].
This surgical technique paper describes a combined ACL and ALL reconstruction approach, aiming to provide reliable rotational stability, reduce graft rupture risk, and facilitate a safe return to pivoting sports. The described technique uses an autologous gracilis graft for ALL reconstruction in conjunction with a quadrupled semitendinosus graft for ACL reconstruction, reflecting current understanding of knee anatomy and biomechanics.
This technique is typically indicated in cases of high-grade pivot shift, generalized ligamentous laxity or recurvatum, revision ACL surgery, or participation in pivoting/contact sports—scenarios associated with a higher risk of residual rotational instability after isolated ACL reconstruction. The technique is supported by preliminary 6-month post-operative functional and clinical data in this article.
Methodology
Patient Positioning
The patient is positioned supine on a standard operative table with the knee flexed at 90 degrees. A knee tourniquet is applied at the thigh level. A lateral post is placed at the level of the tourniquet to prevent hip abduction during surgery, and a foot roll is used to maintain knee flexion throughout the procedure. Following aseptic preparation and draping, bony landmarks—including the patella, tibial tubercle, Gerdy's tubercle, fibular head, lateral epicondyle, and joint lines—are marked with a sterile marker pen (Fig. 1).
Fig. 1.
Positioning of the right knee as seen anteriorly (A) and laterally (B) with bony landmarks marked on the skin (LE-lateral epicondyle; F-fibular head; JL-joint line; GT-Gerdy’s tubercle; T-Tibial tuberosity). The skin incisions are marked with lines (1,2,3). The femoral incision (1) is placed just proximal and posterior to the lateral epicondyle. There are 2 tibial incisions, which are placed anteriorly at Gerdy’s tubercle (2) and posteriorly at the midway between Gerdy’s tubercle and fibular head (3) each of which is 1 cm below the joint line
Graft Harvest and Preparation
A 3 cm vertical incision is made parallel to the tibial tubercle over the anteromedial aspect of the proximal tibia to harvest the semitendinosus (ST) and gracilis (G) tendons. Both grafts are detached from their tibial attachments. The ST tendon is quadrupled for anterior cruciate ligament (ACL) reconstruction and prepared with No. 2 FibreWire at the femoral end and at the tibial end (Fig. 2). The G tendon is utilized for anterolateral ligament (ALL) reconstruction; one end is prepared with No. 2 FibreWire sutures, and the other end is fixed to the prepared femoral end of the ST tendon using No. 1 Vicryl sutures (Fig. 3).
Fig. 2.
Both ends of a double-folded semitendinosus graft prepared by Krakow sutures using No.5 FibreWire. The two-fold graft is then folded over itself to make it quadrupled and fixed at the femoral end with No.5 FibreWire
Fig. 3.
Gracilis graft attached at the tip of the femoral side ACL graft with No.1 Vicryl sutures for ALL reconstruction
ALL Tibial Tunnel
Two stab incisions are made on the tibia: one over Gerdy's tubercle, 1 cm below the joint line, and another 2 cm posterior to it. An additional stab incision is made on the femur, proximal and posterior to the lateral epicondyle. A 2 mm guide pin is inserted through both tibial stab incisions (Fig. 4), followed by reaming with a 4.5 mm cannulated reamer. The tunnels are connected using a transosseous tunnel connector (Fig. 5), and a No. 2 FibreWire suture is passed through to create a loop for graft passage.
Fig. 4.
ALL tibial tunnel preparation showing two guide pins; an anterior guide pin at Gerdy’s tubercle and a second guide pin midway between Gerdy’s tubercle and fibular head. The guide pins are inserted in a convergent fashion, 1 cm below the joint line. Two convergent bony tunnels are then drilled with the help of 4.5 drill bit over the guide pins on the tibia
Fig. 5.
A ALL tibial tunnel connected with a transosseous tunnel connector from posterior to anterior direction. Avoid forceful insertion of the tunnel connector to prevent bone bridge breakage. B Transosseous Tunnel Connector
ALL and ACL Femoral Tunnel
The femoral tunnels for ACL and ALL are prepared using an outside-in technique with an ACL femoral tunnel jig (Sironix). The exit point of the ACL femoral tunnel and the entry point of the ALL femoral tunnel coincide at a location proximal and posterior to the lateral epicondyle. A 2 mm guidewire is placed in an outside-in manner, followed by sequential reaming up to the pre-measured size of the ACL femoral graft (Fig. 6).
Fig. 6.
A, B showing placement of the outside in the ACL femoral tunnel jig. The guide is introduced through the anterolateral portal and placed at the femoral footprint of the ACL at the medial aspect of the lateral epicondyle. C Arthroscopic view of the jig placement on the femoral condyle. The guide sleeve is then placed on the lateral femoral cortex through the skin incision after properly identifying the correct location of the pin entry, which is proximal and posterior to the lateral epicondyle. D Arthroscopic view of the tunnel position indicated by the guide pin, E ACL femoral tunnel outside in jig (Sironix)
ACL Tibial Tunnel
The ACL tibial tunnel is prepared using a standard technique with an ACL tip aimer jig (Sironix) set at a 55-degree angle, preserving remnants. Sequential reaming is performed up to the pre-measured size of the ACL graft.
Graft Passage
A wire loop is passed through the femoral ACL-ALL tunnel and retrieved via the ACL tibial tunnel. The ACL-ALL graft is then passed from the tibia to the femur with the aid of the wire loop, allowing the ALL graft to exit through the femoral ACL tunnel (Fig. 7). The femoral ACL graft is fixed with a suture disc on the femoral surface with the knee in 20 degrees of flexion, and the ALL graft exits through the suture disc. The ACL graft is then fixed with a suture disc on the tibial surface with the knee in complete extension and while maintaining the posterior drawer. Subsequently, the ALL graft is passed beneath the iliotibial band from the femur to the tibia. On the tibial side, it is directed from posterior to anterior using the previously placed wire loop, then passed back from the tibia to the femur beneath the iliotibial band (Fig. 8), and fixed alongside the FibreWire of the ACL graft over the suture disc with the knee in full extension (Fig. 9). Excess sutures and graft material are trimmed, and closure is performed in layers, starting with the iliotibial band, followed by the subcutaneous layer. Postoperative radiograph confirms adequate tunnel placement and suture disc fixation of the graft at the tibial and femoral end (Fig. 10).
Fig. 7.
A Passage of ACL and ALL graft through the tibial and femoral ACL tunnels, B Arthroscopic view of the ACL and ALL graft
Fig. 8.
A–C Diagrammatic representation, A Femoral ACL graft fixed with suture disc on the femoral surface under the iliotibial band and the ALL graft exits through the suture disc, B Gracilis graft goes from beneath the iliotibial band to the posterior ALL tibial tunnel and out from the anterior tunnel, C Graft passed back proximally under the iliotibial band and fixed alongside the ACL graft over the suture disc, D ACL graft fixed with suture disc with ALL graft exiting the suture disc, E ALL graft positioned exteriorly from posterior to anterior tunnel to depict how it will be passed from underneath
Fig. 9.
Shows a simplified schematic passage of the combined ACL & ALL graft starting from tibia to femur and final fixation of the combined ACL & ALL graft at the femoral and tibial site with suture disc
Fig. 10.
Post-operative radiograph showing fixation of the ACL graft with suture discs at the femoral and the tibial tunnels as well as the tunnels for graft passage of ACL and ALL reconstruction
Postoperative Course
Postoperatively, a knee brace is applied, and the patient is encouraged to begin partial to full weight-bearing ambulation based on pain tolerance, starting the day after surgery. Knee range of motion from 0 to 90 degrees is permitted for the first two weeks. After two weeks, the knee brace is removed, and the patient is allowed to walk with a hinged knee cap and achieve a full range of motion. Quadriceps and hamstring strengthening exercises commence after four weeks. Gradual return to non-pivoting sports is advised after four months, pivoting non-contact sports after six months, and contact sports after one year. [5]
Discussion
The technique is supported by preliminary 6-month post-operative functional and clinical data in this article. A preliminary 6-month data of 45 patients with an average age of 28.76 ± 7.24 years (16–44 years) with an average follow-up duration of 19.87 ± 5.41 months (7–27 months) shows improved functional and clinical outcomes at the end of 6 months. The ACL Return to Sport after Injury (ACL-RSI) survey was 21.14 ± 4.92 before surgery and improved to 83.22 ± 4.54 at 6 months after surgery; Tegner Lysholm Knee Scoring Scale improved from 32 ± 5.45 pre-operatively to 89.11 ± 4.30 at 6 months after surgery. The mean Subjective Knee Value (SKV) Score was 33 ± 5.05 before surgery and 89.44 ± 4.42 at 6 months after surgery. The International Knee Documentation Committee (IKDC) Subjective Knee Evaluation was 41.18 ± 5.12 before surgery and 89.33 ± 3.47 at 6 months post-operatively. The Knee injury and Osteoarthritis Outcome Score (KOOS) also showed improvement from 47.29 ± 4.29 before surgery to 89.22 ± 4.39 at the end of 6 months post-operative period, suggesting a positive outcome with our technique. (Table 1).
Table 1.
Clinical Outcomes of combined ACL with ALL reconstruction with pre-operative and 6 months after surgery
| Clinical scores | Combined ACL + ALL Reconstruction (n = 45) | |
|---|---|---|
| Pre-operative scores | 6-months post-operative scores | |
| ACL-RSI | 21.14 ± 4.93 (20–50) | 83.22 ± 4.54 (70–90) |
| Lysholm | 31 ± 5.45 (30–61) | 89.11 ± 4.30 (80–95) |
| SKV | 33 ± 5.05 (30–50) | 89.44 ± 4.42 (80–95) |
| IKDC Subjective | 41.18 ± 5.12 (30–50) | 89.33 ± 3.47 (85–95) |
| KOOS | 47.29 ± 4.29 (40–60) | 89.22 ± 4.39 (80–95) |
These results are comparable to a study by Sonnery-Cottet et al. [6], which demonstrated that a combined ACL and ALL reconstruction can be an effective procedure without specific complications at a minimum follow-up of 2 years.
Lateral extra-articular tenodesis (LET) procedures, particularly those involving the iliotibial band (ITB), have historically been popular due to their technical simplicity and ability to control rotational instability. Marcacci et al. [7] showed satisfactory functional outcomes with ITB-based LET, but acknowledged limitations related to its non-anatomic design. Such non-anatomic positioning risks altering normal knee biomechanics and potentially causing joint over-constraint or early lateral compartment degeneration, especially with prolonged follow-up [8]. Additionally, while technically less demanding and associated with minimal donor site morbidity, ITB-based LET techniques generally do not replicate native ALL anatomy, potentially limiting their effectiveness in precisely controlling internal rotation [9]. Compared to our described technique, ITB-based LET lacks the anatomical fidelity provided by gracilis graft-based reconstruction, which aims to more closely replicate physiological knee biomechanics, thus potentially offering more favourable long-term functional outcomes and joint preservation.
Recognizing the limitations of LET, recent techniques have increasingly emphasized anatomical reconstruction of the ALL using hamstring tendon grafts. Sonnery-Cottet et al. [10] described a percutaneous ALL reconstruction method using a gracilis autograft, anchored anatomically at femoral and tibial insertions. This minimally invasive approach reduces surgical morbidity, allows anear anatomical replication of the native ligament, and has shown promising clinical outcomes in reducing graft failure rates when performed alongside ACL reconstruction [11, 12]. However, despite its advantages, gracilis autograft-based reconstruction requires precise anatomical knowledge and meticulous surgical technique to ensure correct tunnel placement. Incorrect femoral tunnel placement may result in non-isometric graft tensioning, either compromising knee stability or causing restricted motion postoperatively [13]. Our described technique similarly utilizes a gracilis graft; however, it emphasizes precise tunnel positioning and verification of graft tension throughout knee flexion–extension, mitigating these concerns by carefully replicating the native ligament's biomechanical behaviour. Furthermore, clinical evidence suggests that combined ACL and ALL reconstructions significantly reduce graft rupture incidence and improve rates of return-to-sport activities compared to isolated ACL reconstruction [11]. Nonetheless, these combined techniques require careful planning to avoid tunnel convergence or intersection, presenting increased surgical complexity compared to isolated ACL reconstruction.
It is also important to recognize that while the anterolateral ligament (ALL) contributes significantly to rotational control between 0° and 30° of flexion, the Kaplan fibres of the iliotibial band assume a more dominant role in mid-range flexion angles between 30° and 90°. Recent imaging and cadaveric studies have shown that both structures are often co-injured, especially in cases of high-grade pivot shift [14, 15]. Isolated reconstruction of the ALL may therefore inadequately address residual laxity if the Kaplan fibres are disrupted. In such scenarios, supplementary procedures such as distal Kaplan fibre tenodesis have been described to effectively enhance rotational control across the flexion arc [16, 17].
One critical factor affecting ALL reconstruction outcomes, irrespective of graft choice, is the precise anatomical placement of femoral and tibial tunnels. Biomechanical analyses confirm that the optimal femoral attachment for ALL reconstruction is proximal and posterior to the lateral epicondyle to closely mimic native ligament behavior [13]. This specific anatomical positioning ensures appropriate tensioning through knee motion, providing physiological rotational stability without risking joint over-constraint. Our surgical technique explicitly adopts this femoral positioning strategy, emphasizing careful anatomical landmark identification to replicate these favourable biomechanical characteristics.
Lastly, some authors have utilized other autograft sources, such as isolated semitendinosus or synthetic grafts. While synthetic graft options eliminate donor site morbidity and harvesting time, they have historically raised concerns regarding biocompatibility, increased stiffness, and risk of graft rupture over time, making their usage relatively limited [2]. Similarly, isolated semitendinosus grafts have shown biomechanical feasibility but may not always provide sufficient graft diameter or length for combined ACL and ALL reconstruction without extensive graft manipulation, potentially compromising graft integrity or tension [18]. Our described technique addresses these concerns by utilizing separate gracilis and quadrupled semitendinosus grafts, ensuring sufficient graft strength, length, and diameter to reliably reconstruct both ACL and ALL without extensive manipulation.
There is a concern for an increased incidence of lateral compartment osteoarthritis with ALL reconstruction. However, Shatrov et al. [19] concluded that ACLR + ALLR did not increase the risk of osteoarthritis in the lateral tibiofemoral compartment of the knee at a mean follow-up of 104 months compared to isolated ACL reconstruction.
While the technique offers biomechanical advantages, it has limitations, including a steeper learning curve, longer operative time, and the need for precise tunnel placement to avoid convergence (Table 2). These factors may limit its use in less experienced hands or resource-limited settings, where simpler LET procedures may be preferred. Patient-reported outcome measures, such as IKDC, KOOS, and Tegner scores, are key indicators of functional success. While prior studies support the role of combined ACL and ALL reconstruction in reducing failure rates [11], our group is conducting a follow-up study to report clinical and PROM-based outcomes using this technique.
Table 2.
Surgical Steps, Pearls and Pitfalls of Combined ACL-ALL Reconstruction
| Surgical step | Pearls and pitfalls |
|---|---|
| ALL Tibial Tunnel Drilling | There may be chances of both tunnel collision or bone bridge breakage between two tunnels. However, one can avoid it by drilling both the tunnels at least 1 cm apart |
| ACL-ALL Femoral Tunnel drilling | Combined ACL –ALL femoral tunnel should be at proximal and posterior to lateral epicondyle. However, surgeon should confirm entry by just palpating the lateral epicondyle. Drilling is performed in an outside-in manner |
| Fixation of ALL graft | The ALL graft is fixed with the knee in full extension in our technique which keeps the graft taut in extension and lax in flexion. Fixation in flexion would lead to a loss of extension and is not recommended with our technique |
In conclusion, various ALL reconstruction methods present distinct surgical characteristics, biomechanical implications, and clinical outcomes. Contemporary evidence favours anatomically accurate reconstruction techniques, particularly those using gracilis or combined hamstring tendon grafts, due to their potential for improved rotational stability, reduced graft rupture rates, and enhanced return-to-sport outcomes. Our described combined ACL and ALL reconstruction method leverages these insights, explicitly addressing potential challenges through precise anatomical reconstruction and careful graft management, placing it among the current reconstructive approaches with potential biomechanical and clinical advantages.
Declarations
Conflict of interest
On behalf of all authors, the corresponding author states that there is no conflict of interest.
Ethical Standard
The study was approved by the Institutional Ethics Committee.
Informed Consent
Informed written consent was obtained from all patients for participation and publication of clinical details and images.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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