ACL Reconstruction with Anterolateral Ligament (ALL) Reconstruction or Lateral-Extra-Articular Tenodesis (LET)

Graft ruptures are a major concern after anterior cruciate ligament(ACL) reconstruction. Reported rates vary from 1.4% to 18%, reflecting that the cause of re-ruptures is multifactorial. Graft choice has been extensively studied as a potential prognosticator of re-ruptures after primary reconstruction, but despite several randomized controlled trials and meta-analyses, no major difference has been demonstrated between the most common autograft types utilized. There were many attempts to prevent failure by drilling a more anatomic position of the femoral tunnel using either anteromedial or outside-in techniques or using the double-bundle technique. However, the majority of studies revealed that none of these methods reduced the rate of revision surgery. It is for this reason that there is currently great interest in the role of the anterolateral structures of the knee in controlling rotatory laxity and their ability to share loads with the ACL graft. Several studies concluded that anatomical single-bundle reconstruction fails to confer control of rotational stability and does not reduce the risk of knee arthritis. Recently, light has been thrown on the ALL and its precise anatomy, which contributes to the rotator stability. Many surgeons now have many interests in ALL reconstruction and lateral extra-articular tenodesis (LET). Many studies attempted to compare several outcomes between ACL reconstruction, ACL and ALL reconstruction, ACL reconstruction and LET procedure. Mogos et al. performed a prospective RCT, including 57 patients, to compare two groups (group 1, isolated ACL reconstruction; group 2, ACL reconstruction combined with ALL reconstruction). They found out that although there were no significant differences in anterior laxity, group 2 was statistically superior to group 1 in the residual pivot shift test and IKDC objective score. Also, there were no significant differences in associated lesions or complications between the two groups. Porter et al. compared outcomes between the isolated ACL reconstruction group and the ACL reconstruction with LET group after 2 years of follow-up. The study revealed that the recurrence rate of the former one was lower than the other (P < 0.001). Also, although not statistically significant, residual pivot shift was lower in ACL reconstruction with the LET group. Some authors say differently about performing LET with ACL reconstructions. Castoldi et al. performed an RCT, including 79 ACL rupture patients. After an average of 19.4 years of follow-up, the study compared several outcomes between two groups (group 1, isolated ACL reconstruction; group 2, combined ACL reconstruction and LET). They found out that there were no significant differences in long-term outcomes but rather an increased risk of developing lateral compartment OA. There are many complications, including infection, stiffness, arthrofibrosis, reoperation for removal of metal work, and over-constraint. To evaluate the result of ALL reconstruction, Sonnery et al. performed an RCT, including 224 patients with a mean follow-up of 12.3 months. A significantly higher rate of reoperation for cyclops syndrome was noted in the isolated ACLR group compared with the combined ACL þ ALLR group (8.9% vs 0%, respectively; P ¼ 0.0012). No significant differences were found in the frequency of graft rupture (ACLR, 5.4%; ACL þ ALLR, 0.9%; P ¼ 0.1191), range of motion deficits, pain, or reoperation for meniscectomy between groups. No cases of postoperative infection, venous thromboembolism, or arthrofibrosis were seen. Subjective IKDC (81.2 vs 86.8; P = 0.0048), Lysholm (88 vs 92; P = 0.0131), and some components of the KOOS were significantly better in the combined ACL and ALLR group.