Knee Surgery, Sports Traumatology, Arthroscopy

, Volume 26, Issue 12, pp 3652–3659 | Cite as

Combined reconstruction of the anterolateral ligament in chronic ACL injuries leads to better clinical outcomes than isolated ACL reconstruction

  • Camilo Partezani HelitoEmail author
  • Danilo Bordini Camargo
  • Marcel Faraco Sobrado
  • Marcelo Batista Bonadio
  • Pedro Nogueira Giglio
  • José Ricardo Pécora
  • Gilberto Luis Camanho
  • Marco Kawamura Demange



To evaluate the results of combined anterior cruciate ligament (ACL) and anterolateral ligament (ALL) reconstruction in patients with chronic ACL injury. It was hypothesized that patients who underwent combined ACL and ALL reconstruction would exhibit less residual laxity and better clinical outcomes.


Two groups of patients were evaluated and compared retrospectively. Both groups consisted only of patients with chronic (more than 12 months) ACL injuries. Patients in group 1 underwent anatomical intra-articular reconstruction of the ACL and patients in group 2 underwent anatomic intra-articular ACL reconstruction combined with ALL reconstruction. The presence of associated meniscal injury, the subjective International Knee Documentation Committee (IKDC) and Lysholm functional outcome scores in the postoperative period, KT-1000 evaluation, the presence of residual pivot shift and graft rupture rate were evaluated.


One hundred and one patients who underwent reconstruction of chronic ACL injuries were evaluated. The median follow-up was 26 (24–29) months for group 1 and 25 (24–28) months for group 2. There were no significant differences between groups regarding gender, age, duration of injury until reconstruction, follow-up time or presence of associated meniscal injuries in the preoperative period. Regarding functional outcome scores, patients in group 2 presented better results on both the IKDC (p = 0.0013) and the Lysholm (p < 0.0001) evaluations. In addition, patients in group 2 had better KT-1000 evaluation (p = 0.048) and a lower pivot shift rate at physical examination, presenting only 9.1% positivity versus 35.3% in the isolated ACL reconstruction (p = 0.011). Regarding re-ruptures, group 1 presented 5 (7.3%) cases, and group 2 presented no cases.


The combined ACL and ALL reconstruction in patients with chronic ACL injury is an effective and safety solution and leads to good functional outcomes with no increase in complication rate. The clinical relevance of this finding is the possibility to indicate this type of procedure when patients present with more than 12 months after injury for surgery.

Level of evidence

Level III.


Anterior cruciate ligament Anterior cruciate ligament reconstruction Anterolateral ligament Anterolateral ligament reconstruction Pivot shift 



Anterior cruciate ligament


Anterolateral ligament


International Knee Documentation Committee


Iliotibial band


Magnetic resonance imaging


Author contributions

CPH—designed the study, analyzed the data and wrote the manuscript. DBC—designed the study, analyzed the data and wrote the manuscript. MFS—analyzed the data and wrote the manuscript. PNG—analyzed the data and wrote the manuscript. MBB—analyzed the data and wrote the manuscript. JRP—supervision of the study. GLC—manuscript review, and supervised the study. MKD—analyzed the data, and supervised the study.


No funding was obtained.

Compliance with ethical standards

Conflict of interest

The authors report no conflict of interest in relation to this study.

Ethical approval

Ethical approval was obtained at University of São Paulo (number 2.472.968).

Informed consent

Informed consent was obtained from all individual participants included.


  1. 1.
    Amis AA (2017) Anterolateral knee biomechanics. Knee Surg Sports Traumatol Arthrosc 25:1015–1023CrossRefGoogle Scholar
  2. 2.
    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 20:767–777CrossRefGoogle Scholar
  3. 3.
    Chambat P, Guier C, Sonnery-Cottet B, Fayard JM, Thaunat M (2013) The evolution of ACL reconstruction over the last 50 years. Int Orthop 37:181–186CrossRefGoogle Scholar
  4. 4.
    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 80:45–49PubMedGoogle Scholar
  5. 5.
    Claes S, Vereecke E, Maes M, Victor J, Verdonk P, Bellemans J (2013) Anatomy of the anterolateral ligament of the knee. J Anat 223:321–328CrossRefGoogle Scholar
  6. 6.
    Engebretsen L, Lew WD, Lewis JL, Hunter RE (1990) The effect of an iliotibial tenodesis on intraarticular graft forces and knee joint motion. Am J Sports Med 18:169–176CrossRefGoogle Scholar
  7. 7.
    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 33:147–154CrossRefGoogle Scholar
  8. 8.
    Ferretti A, Monaco E, Labianca L, De Carli A, Conteduca F (2008) Double bundle or single bundle plus extra-articular tenodesis in ACL reconstruction? A CAOS study. Knee Surg Sports Traumatol Arthrosc 16:98CrossRefGoogle Scholar
  9. 9.
    Ferretti A, Monaco E, Ponzo A et al (2016) Combined intra-articular and extra-articular reconstruction in anterior cruciate ligament-deficient knee: 25 years later. Arthroscopy 32:2039–2047CrossRefGoogle Scholar
  10. 10.
    Guenther D, Irarrázaval S, Bell KM, Rahnemai-Azar AA, Fu FH, Debski RE, Musahl V (2017) The role of extra-articular tenodesis in combined ACL and anterolateral capsular injury. J Bone Jt Surg Am 99(19):1654–1660CrossRefGoogle Scholar
  11. 11.
    Helito CP, Bonadio MB, Gobbi RG et al (2015) Combined intra- and extra-articular reconstruction of the anterior cruciate ligament: the reconstruction of the knee anterolateral ligament. Arthrosc Tech 4:e239–e244CrossRefGoogle Scholar
  12. 12.
    Helito CP, Demange MK, Bonadio MB et al (2013) Anatomy and histology of the knee anterolateral ligament. Orthop J Sports Med 1:2325967113513546CrossRefGoogle Scholar
  13. 13.
    Helito CP, Demange MK, Bonadio MB et al (2014) Radiographic landmarks for locating the femoral origin and tibial insertion of the knee anterolateral ligament. Am J Sports Med 42:2356–2362CrossRefGoogle Scholar
  14. 14.
    Helito CP, do Amaral C Jr, Nakamichi YD et al (2016) Why do authors differ with regard to the femoral and meniscal anatomic parameters of the knee anterolateral ligament? Dissection by layers and a description of its superficial and deep layers. Orthop J Sports Med 4:2325967116675604CrossRefGoogle Scholar
  15. 15.
    Helito CP, do Prado Torres JA, Bonadio MB et al (2017) Anterolateral ligament of the fetal knee. Am J Sports Med 45:91–96CrossRefGoogle Scholar
  16. 16.
    Helito CP, Helito PV, Costa HP, Demange MK, Bordalo-Rodrigues M (2017) Assessment of the anterolateral ligament of the knee by magnetic resonance imaging in acute injuries of the anterior cruciate ligament. Arthroscopy 33:140–146CrossRefGoogle Scholar
  17. 17.
    Helito CP, Helito PV, Leao RV, Demange MK, Bordalo-Rodrigues M (2017) Anterolateral ligament abnormalities are associated with peripheral ligament and osseous injuries in acute ruptures of the anterior cruciate ligament. Knee Surg Sports Traumatol Arthrosc 25:1140–1148CrossRefGoogle Scholar
  18. 18.
    Herbst E, Albers M, Burnham JM, Shaikh HS, Naendrup JH, FU FH, Musahl V (2017) The anterolateral complex of the knee: a pictorial essay. Knee Surg Sports Traumatol Arthrosc 25:1009–1014CrossRefGoogle Scholar
  19. 19.
    Hewison CE, Tran MN, Kaniki N, Remtulla A, Bryant D, Getgood AM (2015) Lateral extra-articular tenodesis reduces rotational laxity when combined with anterior cruciate ligament reconstruction: a systematic review of the literature. Arthroscopy 31:2022–2034CrossRefGoogle Scholar
  20. 20.
    Hussein M, van Eck CF, Cretnik A, Dinevski D, Fu FH (2012) Prospective randomized clinical evaluation of conventional single-bundle, anatomic single-bundle, and anatomic double-bundle anterior cruciate ligament reconstruction: 281 cases with 3- to 5-year follow-up. Am J Sports Med 40:512–520CrossRefGoogle Scholar
  21. 21.
    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. Am J Sports Med 45:1558–1566CrossRefGoogle Scholar
  22. 22.
    Inderhaug E, Stephen JM, Williams A, Amis AA (2017) Anterolateral tenodesis or anterolateral ligament complex reconstruction: effect of flexion angle at graft fixation when combined with ACL reconstruction. Am J Sports Med 45:3089–3097CrossRefGoogle Scholar
  23. 23.
    Inderhaug E, Stephen JM, Williams A, Amis AA (2017) Biomechanical comparison of anterolateral procedures combined with anterior cruciate ligament reconstruction. Am J Sports Med 45:347–354CrossRefGoogle Scholar
  24. 24.
    Isberg J, Faxen E, Laxdal G, Eriksson BI, Karrholm J, Karlsson J (2011) Will early reconstruction prevent abnormal kinematics after ACL injury? Two-year follow-up using dynamic radiostereometry in 14 patients operated with hamstring autografts. Knee Surg Sports Traumatol Arthrosc 19:1634–1642CrossRefGoogle Scholar
  25. 25.
    Jakob RP, Staubli HU, Deland JT (1987) Grading the pivot shift. Objective tests with implications for treatment. J Bone Jt Surg Br 69:294–299CrossRefGoogle Scholar
  26. 26.
    Järvelä S, Kiekara T, Suomalainen P, Järvelä T (2017) Double-bundle versus single-bundle anterior cruciate ligament reconstruction: a prospective randomized study with 10-year results. Am J Sports Med 45:2578–2585CrossRefGoogle Scholar
  27. 27.
    Liu A, Sun M, Ma C et al (2017) Clinical outcomes of transtibial versus anteromedial drilling techniques to prepare the femoral tunnel during anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 25:2751–2759CrossRefGoogle Scholar
  28. 28.
    Logan M, Dunstan E, Robinson J, Williams A, Gedroyc W, Freeman M (2004) Tibiofemoral kinematics of the anterior cruciate ligament (ACL)-deficient weightbearing, living knee employing vertical access open “interventional” multiple resonance imaging. Am J Sports Med 32:720–726CrossRefGoogle Scholar
  29. 29.
    Lopomo N, Signorelli C, Rahnemai-Azar AA et al (2017) Analysis of the influence of anaesthesia on the clinical and quantitative assessment of the pivot shift: a multicenter international study. Knee Surg Sports Traumatol Arthrosc 25:3004–3011CrossRefGoogle Scholar
  30. 30.
    Magnussen RA, Reinke EK, Huston LJ, Group M, Hewett TE, Spindler KP (2016) Factors associated with high-grade lachman, pivot shift, and anterior drawer at the time of anterior cruciate ligament reconstruction. Arthroscopy 32:1080–1085CrossRefGoogle Scholar
  31. 31.
    Marcacci M, Zaffagnini S, Giordano G, Iacono F, Presti ML (2009) Anterior cruciate ligament reconstruction associated with extra-articular tenodesis: A prospective clinical and radiographic evaluation with 10- to 13-year follow-up. Am J Sports Med 37:707–714CrossRefGoogle Scholar
  32. 32.
    Nakamura K, Koga H, Sekiya I et al (2017) Evaluation of pivot shift phenomenon while awake and under anaesthesia by different manoeuvres using triaxial accelerometer. Knee Surg Sports Traumatol Arthrosc 225:2377–2383CrossRefGoogle Scholar
  33. 33.
    Noyes FR, Huser LE, Jurgensmeier D, Walsh J, Levy MS (2017) Is an anterolateral ligament reconstruction required in ACL-reconstructed knees with associated injury to the anterolateral structures? Am J Sports Med 45:1018–1027CrossRefGoogle Scholar
  34. 34.
    Pomajzl R, Maerz T, Shams C, Guettler J, Bicos J (2015) A review of the anterolateral ligament of the knee: current knowledge regarding its incidence, anatomy, biomechanics, and surgical dissection. Arthroscopy 31:583–591CrossRefGoogle Scholar
  35. 35.
    Rezende FC, de Moraes VY, Martimbianco AL, Luzo MV, da Silveira Franciozi CE, Belloti JC (2015) Does combined Intra- and extraarticular ACL reconstruction improve function and stability? A meta-analysis. Clin Orthop Relat Res 473:2609–2618CrossRefGoogle Scholar
  36. 36.
    Seebacher JR, Inglis AE, Marshall JL, Warren RF (1982) The strucuture of the posterolateral aspect of the knee. J Bone Jt Surg Am 64:536–541CrossRefGoogle Scholar
  37. 37.
    Schon JM, Moatshe G, Brady AW, Serra Cruz R, Chahla J, Dornan GJ, Turnbull TL, Engebretsen L, LaPrade RF (2016) Anatomic anterolateral ligament reconstruction of the knee leads to overconstraint at any fixation angle. Am J Sports Med 44:2546–2556CrossRefGoogle Scholar
  38. 38.
    Sonnery-Cottet B, Daggett M, Fayard JM et al (2017) Anterolateral ligament expert group consensus paper on the management of internal rotation and instability of the anterior cruciate ligament-deficient knee. J Orthop Traumatol 18:91–106CrossRefGoogle Scholar
  39. 39.
    Sonnery-Cottet B, Saithna A, Cavalier M et al (2017) Anterolateral ligament reconstruction is associated with significantly reduced ACL graft rupture rates at a minimum follow-up of 2 years. Am J Sports Med 45:1547–1557CrossRefGoogle Scholar
  40. 40.
    Sonnery-Cottet B, Thaunat M, Freychet B, Pupim BH, Murphy CG, Claes S (2015) Outcome of a combined anterior cruciate ligament and anterolateral ligament reconstruction technique with a minimum 2-year follow-up. Am J Sports Med 43:1598–1605CrossRefGoogle Scholar
  41. 41.
    Stijak L, Bumbasirevic M, Radonijc V, Kadija M, Puskas L, Milovanovic D, Filipovic B (2016) Anatomic description of the anterolateral of the knee. Knee Surg Sports Traumatol Arthrosc 24:2083–2088CrossRefGoogle Scholar
  42. 42.
    Thaunat M, Clowez G, Saithna A, Cavalier M, Choudja E, Vieira TD, Fayard JM, Sonnery-Cottet B (2017) Reoperation rates after combined anterior cruciate ligament and anterolateral ligament reconstruction: a series of 548 patients from the SANTI Study Group with a minimum follow-up of 2 years. Am J Sports Med 45:2569–2577CrossRefGoogle Scholar
  43. 43.
    Trojani C, Beaufils P, Burdin G et al (2012) Revision ACL reconstruction: Influence of a lateral tenodesis. Knee Surg Sports Traumatol Arthrosc 20:1565–1570CrossRefGoogle Scholar
  44. 44.
    Vadala AP, Iorio R, De Carli A et al (2013) An extra-articular procedure improves the clinical outcome in anterior cruciate ligament reconstruction with hamstrings in female athletes. Int Orthop 37:187–192CrossRefGoogle Scholar
  45. 45.
    Van Dyck P, Clockaerts S, Vanhoenacker FM et al (2016) Anterolateral ligament abnormalities in patients with acute anterior cruciate ligament rupture are associated with lateral meniscal and osseous injuries. Eur Radiol 26:3383–3391CrossRefGoogle Scholar
  46. 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 15:688–696PubMedPubMedCentralGoogle Scholar

Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2018

Authors and Affiliations

  • Camilo Partezani Helito
    • 1
    Email author
  • Danilo Bordini Camargo
    • 1
  • Marcel Faraco Sobrado
    • 1
  • Marcelo Batista Bonadio
    • 1
  • Pedro Nogueira Giglio
    • 1
  • José Ricardo Pécora
    • 1
  • Gilberto Luis Camanho
    • 1
  • Marco Kawamura Demange
    • 1
  1. 1.Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de MedicinaUniversidade de São PauloSão PauloBrazil

Personalised recommendations