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Despite technologic advances in the surgical technique for anterior cruciate ligament (ACL) reconstruction, some patients continue to have rotational instability postoperatively. Recently, authors have reported the anatomic and functional characteristics of the anterolateral ligament (ALL), a structure that originates near the lateral epicondyle on the femur and inserts on the tibia between the Gerdy tubercle and the fibular head. Recent biomechanical studies have shown the ALL is an important stabilizer against anterolateral tibial rotation, and its reconstruction has shown excellent initial clinical results. Several techniques have been developed to try to anatomically address this structure in the setting of an ACL reconstruction. This article details a simple anatomic technique to reconstruct the ACL and the ALL of the knee using hamstring tendon autograft and maintaining the semitendinosus insertion.
Technique Video
See video under supplementary data.
Anterior cruciate ligament (ACL) injury is among the most common orthopaedic injuries.
Despite technologic advances in the surgical technique for ACL reconstruction, some patients continue to have rotational instability postoperatively, decreasing the return-to-sport rate.
Failures can occur because of improper tunnel positioning, problems with patient rehabilitation, or non-optimal incorporation of the graft used for reconstruction.
Recently, authors have reported the anatomic and functional characteristics of the anterolateral ligament (ALL), describing a structure that originates near the lateral epicondyle on the femur and inserts on the lateral meniscus and broadly in a fanlike attachment on the tibia between the Gerdy tubercle and the fibular head.
Although its function remains controversial, recent biomechanical studies have shown it is an important stabilizer against anterolateral tibial rotation and its reconstruction has shown excellent initial clinical results.
The lead author (B.S-C.) has developed a simple anatomic technique to reconstruct the ACL and the ALL of the knee using hamstring tendons and keeping the semitendinosus inserted to preserve tendon vascularization (Video 1, Table 1).
Table 1Surgical Steps, Pearls, and Pitfalls of Combined ACL-ALL Reconstruction
Surgical Step
Pearls
Pitfalls
ALL tibial drilling
Widening of the bone tunnels allows easier passage of the graft. Drilling 1 cm distal to the joint line allows for an adequate bone tunnel to be made.
If drilling is performed too distal or too close together, the development of the bone tunnels can be hindered.
Verification of ALL isometry
Suture placed through the tibial tunnels and then placed proximal and posterior to the lateral epicondyle provides a physiological non-isometry of the ALL graft (tight in extension, loose in flexion).
Placement of the femoral tunnel distal and/or anterior to the lateral epicondyle could potentially limit range of motion.
Graft harvest and preparation
Using a tripled semitendinosus and a single gracilis provides a graft typically between 8 and 10 mm.
When harvesting the semitendinosus tendon, to preserve the tibial insertion, the surgeon should use a right-angled clamp to retract the tendon and cut the 2 expansions before using the stripper.
Drilling of femoral ACL-ALL tunnel
Drilling is performed in an outside-in manner. The drill guide is placed at the femoral origin of the ACL and externally placed at the femoral ALL isometric point.
The surgeon should palpate posteriorly to the femoral guide before drilling to ensure adequate placement for the bone tunnel.
Drilling of tibial ACL tunnel
Use of a 55° tibial guide allows for adequate tunnel length and position.
The surgeon should carefully retract the intact hamstring tendon grafts to avoid iatrogenic injury.
Fixation of ACL graft
Fixation of the ACL graft at 30° allows for appropriate tension.
The surgeon should use caution when performing fixation with the femoral screw to avoid iatrogenic damage to the ALL graft.
Fixation of ALL graft
Fixating the ALL in the anterior tibial tunnel and also again proximally allows for 2 points of fixation. This is performed in full extension and neutral rotation.
If the ALL graft is secured in non-neutral rotation, a gait disturbance or over-constraint may be possible.
ACL, anterior cruciate ligament; ALL, anterolateral ligament.
The patient is placed supine on an operative table in the standard arthroscopy position with a lateral post just proximal to the knee, at the level of the padded tourniquet, and a foot roll to prevent the hip from externally rotating and to keep the knee flexion at 90°. In this way, the knee can be moved freely through the full range of motion.
Bony Landmarks
Three bony landmarks are marked before application of the povidone-iodine–coated cutaneous drape, namely the head of the fibula, the Gerdy tubercle, and the lateral epicondyle (Fig 1).
Fig 1As shown in a right knee (lateral view), 3 stab incisions (blue ovals) are positioned in relation to the 3 bony landmarks for combined anterior cruciate ligament and anterolateral ligament reconstruction. One is placed on the femoral side, slightly proximal and posterior to the lateral epicondyle (LE). Two tibial stab incisions are subsequently positioned 8 mm below the joint line between the Gerdy tubercle (GT) and fibula head (FH).
Two stab incisions, separated by roughly 2 cm, are made approximately 1 cm distal to the joint line between the Gerdy tubercle and the fibular head. One stab incision is made slightly posterior and proximal to the lateral epicondyle on the femur (Fig 1). A 4.5-mm drill bit is then used to create a bony tunnel on the tibia, and the entrances to the tunnels are widened to ease passage of the graft. The 2 tunnels are connected in a subcortical manner using a right-angled clamp. A suture (No. 2 Ethibond; Ethicon, Somerville, NJ) is then passed in a retroverted fashion to create a loop and ease graft passage (Fig 2).
Fig 2(A) As shown in a right knee (lateral view), 2 convergent bony tunnels are created through the tibial stab incision with a 4.5-mm drill. (B) The 2 tunnels are connected with a right-angled clamp. (C) A No. 2 suture is then passed in a retroverted fashion to create a loop for further anterolateral ligament graft passage.
The Ethibond suture, once looped on itself, is clamped with a hemostat slightly posterior and proximal to the lateral epicondyle at the area previously incised. The knee is then taken through the range of motion to ensure a non-isometry of the ALL graft that is tight in extension and slack in flexion.
Graft Harvest and Preparation
The semitendinosus and gracilis are harvested using an open-ended tendon stripper (Pigtail Hamstring Tendon Stripper; Arthrex, Naples, FL). The attachment sites for both tendons are initially maintained. The gracilis is then whip-stitched using a FiberLoop suture (Arthrex). The semitendinosus is measured from its insertion and marked using a skin marker at 4 cm and 10 cm for a female patient and at 5 cm and 11 cm for a male patient. The gracilis is then incised from the base of its insertion and subsequently sutured onto the semitendinosus, beginning at the proximal mark and finishing at the distal mark, using multiple No. 1 Ethibond sutures (Ethicon). A No. 2 FiberWire (Arthrex) is placed on the semitendinosus at the distal mark, and the graft is folded onto itself and tagged with No. 1 Ethibond sutures at the proximal mark. The graft is then tripled over itself and tagged with No. 1 Ethibond sutures to tubularize the graft. This thus creates an ACL graft that is 3 parts semitendinosus and 1 part gracilis (Fig 3). The ALL graft is then the continuation of the gracilis distal to the ACL graft. The graft is measured for appropriate sizing.
Fig 3Graft preparation for combined anterior cruciate ligament–anterolateral ligament reconstruction in a right knee. The harvested graft is composed of a tripled-over semitendinosus (ST) and a single strand of gracilis by first incising the gracilis (A), incorporating a doubled-over ST and gracilis (B), and then completing the graft preparation with the insertion of the ST still intact (C).
The femoral ACL tunnel (outside-in jig; Arthrex) is established with arthroscopic assistance by an outside-in approach. The drill guide is placed intra-articularly at the femoral origin of the ACL. The drill guide is then placed on the lateral femoral cortex at the appropriate point marked for optimal ALL isometry. A guidewire is placed in an outside-in manner, from the ALL isometric point on the lateral epicondyle to the femoral origin of the ACL (Fig 4A). Once the guidewire is placed, subsequent drilling of the appropriate ACL size is performed.
Fig 4(A) Outside-in femoral tunnel shown in a right knee (lateral view). The guide is introduced through the anteromedial portal. The tip of the guide is hooked at the proximal notch outlet with the guide target oriented toward the anterior cruciate ligament femoral insertion on the lateral wall of the lateral femoral condyle. The guide sleeve is pushed onto the lateral femoral cortex through the femoral stab incision to position a drill pin for femoral tunnel drilling. (B) The target of the tibial guide is placed onto the tibial anterior cruciate ligament remnant, as shown in a right knee (lateral view). The tibial guide sleeve is then pushed onto the tibial anteromedial cortex through the graft harvest incision to position a drill pin. Sequential reaming is performed, using first a 6-mm reamer followed by an incremental drill diameter.
Drilling of the tibial ACL tunnel is performed in an ACL remnant–sparing manner. The tibial guide is placed at 55° and taken from the external cortex into the ACL insertion (Fig 4B). Sequential reaming is performed, using first a 6-mm reamer followed by the previously measured ACL size reamer.
Graft Passage
A TigerStick (Arthrex) is placed into the femoral tunnel and taken transtibially out the tibial tunnel. The suture is used to shuttle the ACL-ALL graft transtibially into and then out of the femoral tunnel.
Fixation of ACL Graft
An interference screw, measuring the same size as the ACL graft, is placed into the tibial tunnel using a nitinol guidewire. With the knee at 30° of flexion, the femoral interference screw, measuring the same size as the ACL graft, is placed into the femoral tunnel using a nitinol guidewire (Fig 5).
Fig 5Anterior cruciate ligament graft fixation (right knee, lateral view). (A) Tibial graft fixation with an interference screw. The graft is tensioned during interference screw insertion by pulling on the gracilis strand on the femoral side. (B) Femoral anterior cruciate ligament graft fixation with an interference screw. The gracilis strand emerging from the femoral stab incision is pulled toward the ground to pull down the iliotibial band split; the screw is then advanced through the stab incision. The knee is extended at 20° of flexion for fixation.
By use of an arthroscopic grasper, the suture connected to the gracilis is shuttled to the posterior bone tunnel deep to the iliotibial band. This is subsequently shuttled through the tibial bone tunnel using the previously passed suture. The arthroscopic grasper is then passed deep to the iliotibial band, and the gracilis graft is brought back proximally once again out the proximal incision. A 5.5-mm interference screw is placed into the anterior bone tunnel with the knee in full extension, leading to automatic neutral rotation, while tension is maintained on the graft. Proximally, the sutures holding the ACL graft are then circled around the ALL graft and tied once again in full extension and neutral rotation (Fig 6). Excess suture and graft is incised, and the knee is taken through the range of motion.
Fig 6(A) Passage of the anterolateral ligament (ALL) graft for combined anterior cruciate ligament (ACL)–ALL reconstruction in a right knee. After fixation of the ACL graft on the femur, the sutured gracilis graft goes beneath the iliotibial band to the posterior tibial hole; then the sutured graft is passed through the tibial bone tunnels and back proximally under the iliotibial band and out the lateral femoral tunnel incision, as shown in a lateral view (B) and frontal view (C) of a right knee in the supine position. (ST, semitendinosus.)
A routine ACL rehabilitation program is instituted, entailing full weight bearing after the procedure, without a brace, and progressive range-of-motion exercises. Early rehabilitation is focused on obtaining full extension and quadriceps activation. A gradual return to sports activities is allowed starting at 4 months for non-pivoting sports, at 6 months for pivoting non-contact sports, and at 8 to 9 months for pivoting collision sports.
Discussion
The described technique offers the main advantage of providing adequate anterior and anterolateral control of knee instability without using more graft tissue than a regular ACL reconstruction, adding just percutaneous incisions to the tibia for the ALL tunnel and keeping the semitendinosus attached for better graft vascularization. Extra-articular reconstructions are increasing in popularity again because of the rediscovery of the ALL.
Previous nonanatomic extra-articular techniques, despite having good rotational control, used to place excessive pressure on the lateral compartment and resulted in limited range of motion, degenerative arthritis, and poor clinical results.
The significant difference in this technique compared with previously published extra-articular lateral tenodesis is positioning of the ALL femoral tunnel and securing the graft in full extension and neutral rotation.
Recent studies have concluded that there might be a biomechanical advantage to placing the graft origin posterior and proximal to the lateral epicondyle.
When the graft is placed using the described landmarks, fixation should be performed in full extension. This leads to a graft that is tight in extension and slack in flexion. Fixation in flexion would lead to loss of extension and is not recommended. Respecting this guideline is essential to having an adequate postoperative rehabilitation and return to sports. Our current indications include the presence of a pivot shift on examination, a pivoting or high-demand athlete, revision ACL situations, a Segond fracture, the presence of the lateral notch sign, age younger than 20 years, or the presence of a chronic ACL injury. Despite the early promise in our results and expanding indications, the indications in the literature are still widely debated.
Possible risks of this technique include anterolateral tibial fracture or tunnel collision if the tunnels are not performed properly and iliotibial band irritation due to the small access for femoral screw insertion. One limitation would be a gracilis graft that is not long enough for extra-articular reconstruction, although we have never experienced this issue (Table 2). Clinical and radiologic studies are being conducted to show the long-term effectiveness of this technique, and a series should be presented as soon as we have sufficient cases with an adequate minimum follow-up period.
Table 2Advantages, Indication, Contraindications, Tips, and Risks of Combined ACL-ALL Reconstruction
Advantages
The technique provides anatomic reconstruction of the ACL and the ALL with minor morbidity.
Indication
Presence of pivot shift on examination
Pivoting or high-demand athlete
Revision ACL reconstruction
Segond fracture
Presence of lateral notch sign
Age <20 yr
Chronic ACL injury
Contraindications
Gracilis of insufficient size
Performance of this technique without treatment of known causes of ACL failure
Lack of knowledge about extra-articular procedures and ALL anatomy
Tips
Harvest the semitendinosus carefully to avoid detachment.
Only remove the gracilis attachment after harvesting it.
Measure the graft length right after harvesting it.
Place the surgeon's index finger on the lateral epicondyle, and perform the skin incision proximal and posterior to it.
Use small drills (preference for 4.5 mm) to establish the tibial tunnel.
Avoid leaving the femoral screw protruding on the femur.
Pass the ALL graft under the iliotibial band.
Risks
A protruding screw can irritate the iliotibial band.
Care should be taken when drilling the tibial tunnel to avoid an anterolateral plateau fracture or tunnel collision.
Patients can have lateral discomfort for up to 3 mo because of the iliotibial tract incision, although this is infrequent.
ACL, anterior cruciate ligament; ALL, anterolateral ligament.
The surgical technique for combined anterior cruciate ligament and anterolateral ligament reconstruction is shown in a right knee in the supine position.
References
Frank R.M.
Verma N.N.
Graft selection in revision ACL reconstruction.
in: Bach Jr., B.R. Provencher M.T. ACL surgery: How to get it right the first time and what to do if it fails. SLACK,
Thorofare, NJ2010: 217-229
The authors report the following potential conflict of interest or source of funding: B.S.-C. receives support from Arthrex (consultant). J.-M.F. receives support from Arthrex (consultant). M.T. receives support from Arthrex (consultant).
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