Skip to main content
SpringerLink
Log in

Anterolateral ligament reconstruction improves the clinical and functional outcomes of anterior cruciate ligament reconstruction in athletes

  • KNEE
  • Published:
Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

A Correction to this article was published on 20 August 2020

This article has been updated

Abstract

Purpose

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 was to 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).

Methods

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.

Results

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).

Conclusion

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.

Level of evidence

1.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

Change history

References

  1. Ayeni OR, Chahal M, Tran MN, Sprague S (2012) Pivot shift as an outcome measure for ACL reconstruction: a systematic review. Knee Surg Sports Traumatol Arthrosc 20:767–777

    PubMed  Google Scholar 

  2. Bell KM, Rahnemai-Azar AA, Irarrazaval S et al (2018) In situ force in the anterior cruciate ligament, the lateral collateral ligament, and the anterolateral capsule complex during a simulated pivot shift test. J Orthop Res 36(3):847–853

    PubMed  Google Scholar 

  3. Chouliaras V, Ristanis S, Moraiti C, Tzimas V, Stergiou N, Georgoulis AD (2009) Anterior cruciate ligament reconstruction with a quadrupled hamstrings tendon autograft does not restore tibial rotation to normative levels during landing from a jump and subsequent pivoting. J Sports Med Phys Fitness 49:64–70

    CAS  PubMed  Google Scholar 

  4. Claes S, Vereecke E, Maes M, Victor J, Verdonk P, Bellemans J (2013) Anatomy of the anterolateral ligament of the knee. J Anat 223:321–328

    PubMed  PubMed Central  Google Scholar 

  5. Claes S, Luyckx T, Vereecke E, Bellemans J (2014) The Segond fracture: a bony injury of the anterolateral ligament of the knee. Arthroscopy 30(11):1475–1482

    PubMed  Google Scholar 

  6. Claes S, Bartholomeeusen S, Bellemans J (2014) High prevalence of anterolateral ligament abnormalities in magnetic resonance images of anterior cruciate ligament-injured knees. Acta Orthop Belg 80(1):45–49

    PubMed  Google Scholar 

  7. Collins NJ, Misra D, Felson DT, Crossley KM, Roos EM (2011) Measures of knee function: International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form, Knee Injury and Osteoarthritis Outcome Score (KOOS), Knee Injury and Osteoarthritis Outcome Score Physical Function Short Form (KOOS-PS), Knee Outcome Survey Activities of Daily Living Scale (KOS-ADL), Lysholm Knee Scoring Scale, Oxford Knee Score (OKS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Activity Rating Scale (ARS), and Tegner Activity Score (TAS). Arthritis Care Res (Hoboken) 63(Suppl 11):S208–228

    Google Scholar 

  8. Daggett M, Ockuly AC, Cullen M, Busch K, Lutz C, Imbert P, Sonnery-Cottet B (2016) Femoral origin of the anterolateral ligament: an anatomic analysis. Arthroscopy 32(5):835–841

    PubMed  Google Scholar 

  9. Devitt B, Bell S, Ardern C, Ardern CL et al (2017) The role of lateral extra-articular tenodesis in primary anterior cruciate ligament reconstruction: a systematic review with meta-analysis and best-evidence synthesis. Orthop J Sports Med 5(10):2325967117731767

    PubMed  PubMed Central  Google Scholar 

  10. Ferretti A, Monaco E, Fabbri M, Maestri B, De Carli A (2017) Prevalence and classification of injuries of anterolateral complex in acute anterior cruciate ligament tears. Arthroscopy 33(1):147–154

    PubMed  Google Scholar 

  11. FU FH, Brown CH Jr, Shelbourne KD, Prodromos C et al (2018) The anterior cruciate ligament: reconstruction and basic science E-book, 2nd edition, chapter 67, P 116.

  12. Geeslin AG, Chahla J, Moatshe G et al (2018) Anterolateral knee extra-articular stabilizers: a robotic sectioning study of the anterolateral ligament and distal Iliotibial Band Kaplan Fibers. Am J Sports Med 46(6):1352–1361

    PubMed  Google Scholar 

  13. Helito CP, Bonadio MB, Soares TQ, da Mota e Albuquerque RF, Natalino RJ, Pécora JR, Camanho GL, Demange MK (2016) The meniscal insertion of the knee anterolateral ligament. Surg Radiol Anat 38(2):223–228

    PubMed  Google Scholar 

  14. Helito CP, Camargo DB, Sobrado MF, Bonadio MB, Giglio PN, Pécora JR, Camanho GL, Demange MK (2018) Combined reconstruction of the anterolateral ligament in chronic ACL injuries leads to better clinical outcomes than isolated ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 26(12):3652–3659

    PubMed  Google Scholar 

  15. Hettrich CM, Dunn WR, Reinke EK et al (2013) The rate of subsequent surgery and predictors after anterior cruciate ligament reconstruction: two- and 6-year follow-up results from a multicenter cohort. Am J Sports Med 41(7):1534–1540

    PubMed  PubMed Central  Google Scholar 

  16. Huang W, Zhang Y, Yao Z, Ma L (2016) Clinical examination of anterior cruciate ligament rupture: a systematic review and meta-analysis. Acta Orthop Traumatol Turc 50(1):22–31

    PubMed  Google Scholar 

  17. Ibrahim SA, Shohdy EM, Marwan Y et al (2017) Anatomic reconstruction of the anterior cruciate ligament of the knee with or without reconstruction of the anterolateral ligament: a randomized clinical trial. Am J Sports Med 45(7):1558–1566

    PubMed  Google Scholar 

  18. Ibrahim SAR, Hamido F, Al Misfer AK, Mahgoob A, Ghafar SA, Alhran H (2009) Anterior cruciate ligament reconstruction using autologous hamstring double bundle graft compared with single bundle procedures. J Bone Joint Surg Br 91(10):1310–1315

    CAS  PubMed  Google Scholar 

  19. Jakob RP, Staubli HU, Deland JT (1987) Grading the pivot shift, objective tests with implications for treatment. J Bone Joint Surg 69-B:69–294

    Google Scholar 

  20. Jonsson T, Althoff B, Peterson L, Renström P (1982) Clinical diagnosis of ruptures of the anterior cruciate ligament: a comparative study of the Lachman test and the anterior drawer sign. Am J Sports Med 10:100–102

    CAS  PubMed  Google Scholar 

  21. Junkin DM Jr (2009) Knee ligament injuries. Orthopaedic knowledge update: sports medicine, 4th edn. American Academy of Orthopaedic Surgeons, Rosemont, pp 135–146

    Google Scholar 

  22. Katakura M, Koga H, Nakamura K, Sekiya I, Muneta T (2017) Effects of different femoral tunnel positions on tension changes in anterolateral ligament reconstruction. Knee Surg Sports Traumatol Arthroc 25(4):1272–1278

    Google Scholar 

  23. Kennedy MI, Claes S, Fuso FA, Williams BT, Goldsmith MT, Turnbull TL, Wijdicks CA, LaPrade RF (2015) The anterolateral ligament: an anatomic, radiographic, and biomechanical analysis. Am J Sports Med 43:1606–1615

    PubMed  Google Scholar 

  24. Kittl C, El-Daou H, Athwal KK, Gupte CM, Weiler A, Williams A, Amis AA (2016) The role of the anterolateral structures and the ACL in controlling laxity of the intact and ACL-deficient knee. Am J Sports Med 44(2):345–354

    PubMed  Google Scholar 

  25. Kraeutler MJ, Welton KL, Chahla J, LaPrade RF, McCarty EC (2018) Current concepts of the anterolateral ligament of the knee: anatomy, biomechanics, and reconstruction. Am J Sports Med 46(5):1235–1242

    PubMed  Google Scholar 

  26. Lee DW, Kim JG, Cho SI, Kim DH (2019) Clinical outcomes of isolated revision anterior crucite ligament reconstruction or in combination with anatomic anterolateral ligament reconstruction. Am J Sports Med 47(2):324–333

    PubMed  Google Scholar 

  27. Meredick RB, Vance KJ, Appleby D, Lubowitz JH (2008) Outcome of single-bundle versus double-bundle reconstruction of the anterior cruciate ligament: a meta-analysis. Am J Sports Med 36(7):1414–1421

    PubMed  Google Scholar 

  28. Nielsen ET, Olesen KS, Raedt S, Jørgensen B et al (2018) Influence of the anterolateral ligament on knee laxity: a biomechanical cadaveric study measuring knee kinematics in 6 degrees of freedom using dynamic radiostereometric analysis. Orthop J Sports Med 6(8):2325967118789699

    PubMed  PubMed Central  Google Scholar 

  29. Nitri M, Rasmussen MT, Williams BT, Moulton SG, Cruz RS, Dornan GJ, Goldsmith MT, LaPrade RF (2016) An in vitro robotic assessment of the anterolateral ligament, part 2: anterolateral ligament reconstruction combined with anterior cruciate ligament reconstruction. Am J Sports Med 44(3):593–601

    PubMed  Google Scholar 

  30. Parsons EM, Gee AO, Spiekerman C, Cavanagh PR (2015) The biomechanical function of the anterolateral ligament of the knee. Am J Sports Med 43:669–674

    PubMed  PubMed Central  Google Scholar 

  31. Paschos NK, Howell SM (2017) Anterior cruciate ligament reconstruction: principles of treatment. EFORT Open Rev 1(11):398–408

    PubMed  Google Scholar 

  32. Pugh L, Mascarenhas R, Arneja S, Chin PY, Leith JM (2009) Current concepts in instrumented knee-laxity testing. Am J Sports Med 37:199–210

    PubMed  Google Scholar 

  33. Ristanis S, Stergiou N, Patras K, Tsepis E, Moraiti C, Georgoulis AD (2006) Follow-up evaluation 2 years after ACL reconstruction with bone-patellar tendon-bone graft shows that excessive tibial rotation persists. Clin J Sport Med 16:111–116

    PubMed  Google Scholar 

  34. Ristanis S, Stergiou N, Patras K, Vasiliadis HS, Giakas G, Georgoulis AD (2005) Excessive tibial rotation during high-demand activities is not restored by anterior cruciate ligament reconstruction. Arthroscopy 21:1323–1329

    PubMed  Google Scholar 

  35. Scholten RJ, Opstelten W, van der Plas CG, Bijl D, Deville WL, Bouter LM (2003) Accuracy of physical diagnostic tests for assessing ruptures of the anterior cruciate ligament: a meta-analysis. J Fam Pract 52(9):689–694

    PubMed  Google Scholar 

  36. Smith JO, Yasen SK, Lord B, Wilson AJ (2015) Combined anterolateral ligament and anatomic anterior cruciate ligament reconstruction of the knee. Knee Surg Sports Traumatol Arthrosc 23:3151–3156

    PubMed  Google Scholar 

  37. Sonnery-Cottet B, Saithna A, Cavalier M, Kajetanek C, Temponi EF, Daggett M, Helito CP, Thaunat M (2017) Anterolateral ligament reconstruction is associated with significantly reduced ACL graft rupture rates at a minimum follow-up of 2 years: a prospective comparative study of 502 patients from the SANTI Study Group. Am J Sports Med 45(7):1547–1557

    PubMed  Google Scholar 

  38. Sonnery-Cottet B, Thaunat M, Freychet B, Pupim BH, Murphy CG, Claes (2015) Outcome of a combined anterior cruciate ligament and anterolateral ligament reconstruction technique with a minimum 2-year follow-up. Am J Sports Med 43(7):1598–1605

    PubMed  Google Scholar 

  39. Thein R, Boorman-Padgett J, Stone K, Wickiewicz TL, Imhauser CW, Pearle AD (2016) Biomechanical assessment of the anterolateral ligamen of the knee: a secondary restraint in simulated tests of the pivot shift and of anterior stability. J Bone Joint Surg Am 98(11):937–943

    PubMed  Google Scholar 

  40. Trojani C, Beaufils P, Burdin G et al (2012) Revision ACL reconstruction: influence of a lateral tenodesis. Knee Surg Sports Traumatol Arthrosc 20(8):1565–1570

    PubMed  Google Scholar 

  41. Van der Watt L, Khan M, Rothrauff BB et al (2015) The structure and function of the anterolateral ligament of the knee: a systematic review. Arthroscopy 31(3):569–82.e3

    PubMed  Google Scholar 

  42. Van Dyck P, Clockaerts S, Lambrecht V, Wouters K, De Smet E, Gielen JL, Parizel PM (2016) Anterolateral ligament abnormalities in patients with acute anterior cruciate ligament rupture are associated with lateral meniscal and osseous injuries. Eur Radiol 26(10):3383–3391

    PubMed  Google Scholar 

  43. Wasserstein D, Khoshbin A, Dwyer T, Chahal J, Gandhi R, Mahomed N, Ogilvie-Harris D (2013) Risk factors for recurrent anterior cruciate ligament reconstruction: a population study in Ontario, Canada, with 5-year follow-up. Am J Sports Med 41(9):2099–2107

    PubMed  Google Scholar 

  44. Wilson AJ, Yasen SK, Nancoo T, Stannard R, Smith JO, Logan JS (2013) Anatomic all-inside anterior cruciate ligament reconstruction using the translateral technique. Arthrosc Tech 2(2):99–104

    Google Scholar 

  45. Zaffagnini S, Signorelli C, Lopomo N, Bonanzinga T, Marcheggiani Muccioli GM, Bignozzi S, Visani A, Marcacci M (2012) Anatomic double-bundle and over-the-top single-bundle with additional extra-articular tenodesis: an in vivo quantitative assessment of knee laxity in two different ACL reconstructions. Knee Surg Sports Traumatol Arthrosc 20:153–159

    CAS  PubMed  Google Scholar 

  46. Zhang H, Qiu M, Zhou A, Zhang J, Jiang D (2016) Anatomic anterolateral ligament reconstruction improves postoperative clinical outcomes combined with anatomic anterior cruciate ligament reconstruction. J Sports Sci Med 15:688–696

    PubMed  PubMed Central  Google Scholar 

Download references

Funding

No specific grant from any funding agency in the public, commercial or not for profit sectors.

Author information

Authors and Affiliations

  1. Division of Sports Medicine, Al-Razi Orthopaedic Hospital, Ministry of Health, Kuwait, Kuwait

    Fawzy Hamido, Abdelrahman A. Habiba, Yousef Marwan, Wael Shoaeb & Ahmed Nagi

  2. Division of Orthopaedic Surgery, Department of Surgery, Faculty of Medicine, Health Sciences Center, Kuwait University, Kuwait, Kuwait

    Yousef Marwan

  3. Department of Orthopaedic Surgery, Faculty of Medicine, Alexandria University, Alexandria, Egypt

    Aymen S. I. Soliman, Tarek A. Elkhadrawe & Mohamed G. Morsi

  4. Department of Orthopaedic Surgery, Al-Razi Orthopaedic Hospital, Safat, P.O. Box 24923, 13110, Kuwait, Kuwait

    Fawzy Hamido

Authors
  1. Fawzy Hamido
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Abdelrahman A. Habiba
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Yousef Marwan
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Aymen S. I. Soliman
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Tarek A. Elkhadrawe
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Mohamed G. Morsi
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Wael Shoaeb
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Ahmed Nagi
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

FH—The principal investigator. Participated in designing the study, data collection, data interpretation and writing the paper. Performed all the operations. Approved the final version of the manuscript. AAH—Participated in designing the study, data collection, data interpretation, writing the paper and performed all the statistical tests. Approved the final version of the manuscript. YM—Participated in designing the study, data collection, data interpretation, writing the paper and assisting in the operation room. Performed all the statistical tests. Approved the final version of the manuscript. AS—Participated in designing the study, data collection, data interpretation, writing the paper and assisting in the operation room. Approved the final version of the manuscript. TAE—Participated in designing the study, data interpretation and writing the paper. Approved the final version of the manuscript. MGM—Participated in designing the study, data interpretation and writing the paper. Approved the final version of the manuscript. WS—Participated in designing the study, data collection, data interpretation, writing the paper and assisting in the operation room. Approved the final version of the manuscript. AN—Participated in designing the study, data collection, data interpretation, writing the paper and assisting in the operation room. Approved the final version of the manuscript.

Corresponding author

Correspondence to Fawzy Hamido.

Ethics declarations

Conflict of interest

This research received no conflict of interest.

Ethical approval

All procedures performed in the studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Hamido, F., Habiba, A.A., Marwan, Y. et al. Anterolateral ligament reconstruction improves the clinical and functional outcomes of anterior cruciate ligament reconstruction in athletes. Knee Surg Sports Traumatol Arthrosc 29, 1173–1180 (2021). https://doi.org/10.1007/s00167-020-06119-w

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00167-020-06119-w

Keywords

Search

Navigation