Combined ACL and anterolateral ligament reconstruction

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Saithna, A ORCID: https://orcid.org/0000-0002-2408-5307, Thaunat, M, Delaloye, JR, Ouanezar, H, Fayard, JM and Sonnery-Cottet, B, 2018. Combined ACL and anterolateral ligament reconstruction. JBJS Essential Surgical Techniques, 8 (1): e2. ISSN 2160-2204

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Official URL: http://doi.org/10.2106/JBJS.ST.17.00045

Abstract

Background: Clinical results of combined anterior cruciate ligament (ACL) and anterolateral ligament (ALL) reconstruction demonstrate a significant reduction in ACL graft rupture rates and improved return to sport when compared to isolated ACL reconstruction (ACLR). This is supported by laboratory studies which demonstrate that combined ACLR and lateral extra-articular tenodesis (LET) procedures protect the ACL graft by load sharing with it and also by more reliably restoring normal knee kinematics, when compared to isolated ACLR.

Description: The ACL graft is formed from a tripled semitendinosus tendon and a single strand of gracilis. The femoral tunnel is drilled to provide an anatomic location intra-articularly and 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) through a tibial tunnel, and back to the femoral origin, to reconstruct the ALL.

Alternatives: A large number of different types of non- anatomic LET have been reported. The most frequently performed were the Lemaire and MacIntosh procedures but these, and others, were widely abandoned after reports of poor results in the 1980’s.

Rationale: ALL reconstruction differs from other lateral extra-articular tenodesis type procedures by virtue of the fact that the procedure is anatomically based and can be percutaneously performed. Nonanatomical procedures (typically with a strand of ITB passed under the LCL) are associated with reports of overconstraint, early arthritis and an increased risk of infection. In contrast, ALLR has been shown to restore normal knee kinematics and avoid overconstraint, when correctly fixed in full extension and neutral rotation. The main concern with any type of LET is based on historical reports of poor outcomes. However, contemporary study demonstrates that combined ACL and ALLR is associated with a re-operation rate that is comparable to the rate seen after isolated ACLR, and a very low rate of complications. This makes a compelling argument for anatomic ALL+ACLR being considered as 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 to reduced ACL graft rupture with non anatomic LETs they have not shown a statistically significant improvement in outcomes. Combined ACL and ALLR is currently the only type of lateral extra- articular procedure that has been demonstrated to significantly reduce ACL graft rupture risk and improve return to sport.

Item Type:	Journal article
Publication Title:	JBJS Essential Surgical Techniques
Creators:	Saithna, A., Thaunat, M., Delaloye, J.R., Ouanezar, H., Fayard, J.M. and Sonnery-Cottet, B.
Publisher:	Journal of Bone and Joint Surgery
Date:	2018
Volume:	8
Number:	1
ISSN:	2160-2204
Identifiers:	Number Type 10.2106/JBJS.ST.17.00045 DOI 30233974 PubMed ID
Divisions:	Schools > School of Science and Technology
Record created by:	Linda Sullivan
Date Added:	07 Nov 2018 16:29
Last Modified:	17 Sep 2019 14:35
URI:	https://irep.ntu.ac.uk/id/eprint/34870