Abstract
Background:
Combined reconstruction of the anterolateral ligament (ALL) and anterior cruciate ligament (ACL) has shown excellent results. It could potentially reduce graft failure and improve outcomes in high-risk patients. There are several surgical techniques described. Hamstrings are the most frequently used graft for ALL reconstruction. The distal portion of the iliotibial band is used for the modified Lemaire procedure.
Indications:
Anterior cruciate ligament reconstructions associated with the following risk factors: pivoting sports, high-demand athletes, high-grade pivot-shift, chronic ACL injury, lateral femoral condyle notch, Segond fractures, young patients (<20 years), ACL revision, generalized hyperlaxity, and Lachman >7 mm.
Technique Description:
Semitendinosus and gracilis tendons are harvested and their extremities are prepared with continuous suture. The semitendinosus graft is folded in 3 parts leaving the ends of the graft internalized. The triple semitendinosus will be the main component of the ACL and the single gracilis will be used for both ACL and ALL. Anterolateral ligament anatomical landmarks are proximal and posterior to the lateral epicondyle in the femur, and in the mid distance from the fibular head and the Gerdy tubercle in the tibia. The ALL is fixed in knee extension with interference screws. This video also includes a brief demonstration of graft preparation for the modified Lemaire procedure.
Results:
Results from our group using this technique have shown excellent clinical outcomes, minimal complications, and low failure rates in high-risk populations. This graft preparation shows excellent diameter and length for combined ACL and ALL reconstruction.
Conclusion:
This technique is easy to perform, with minimal complications, and should be considered in high-risk patients undergoing ACL reconstruction.
This is a visual representation of the abstract.
Video Transcript
Combined reconstruction of the anterolateral ligament (ALL) and anterior cruciate ligament (ACL) has shown excellent results. It could potentially reduce graft failure and improve outcomes in high-risk patients. There are several surgical techniques described. Hamstrings are the most frequently used graft for ALL reconstruction. The distal portion of the iliotibial band (ITB) is used for the modified Lemaire procedure. In this video, we will show a graft preparation for ALL reconstruction and a brief demonstration of graft preparation for the modified Lemaire procedure.
Possible indications for associated reconstruction of the ACL and ALL mainly include patients who are at increased risk of failure after reconstruction:
Sports in which there are frequent changes of direction
High-level athletes
High-grade pivot-shift
Chronic ACL injury
Impaction of the lateral femoral condyle
Segond fractures
Young patients aged <20 years
Anterior cruciate ligament revision
Hyperlaxity
Lachman >7 mm
In the demonstrated technique, gracilis and semitendinosus tendon grafts were used. The 4 ends of the grafts are prepared with continuous absorbable suture. The semitendinosus graft is folded into 3 parts, with the sutured threads being passed through, leaving the graft ends internalized. The triple semitendinosus will be the main component of the ACL.
This triple graft, in most cases, is more than 9 cm long, being sufficient for ACL reconstruction. One end of the simple gracilis graft is passed through the triple semitendinosus graft. The thickness of the total graft is measured. It is often more than 9 mm in diameter. A high resistance suture is passed through each end of the graft, which will help the graft to pass through the tunnels. To ensure uniformity and regularity of the graft, circumferential sutures are made at both ends of the graft. During the suture, it is important to maintain the tension in the graft to ensure its uniformity.
In our series of cases with this technique, we observed that the triple semitendinosus graft associated with the simple gracilis has an excellent thickness, even greater than the double semitendinosus and gracilis.
A 2-cm incision is made, proximal and posterior to the lateral epicondyle in the femur. Another 2-cm incision is made, halfway between the fibular head and Gerdy tubercle.
The arthroscopic view shows the ACL graft passing. It is passed from the tibia to the femur, and the tip with the simple gracilis graft is passed first and will be used for reconstruction of the ALL after leaving the femur.
The graft is passed in such a way that the outer limit of the femoral tunnel coincides with the limit of the triple semitendinosus graft, with only the simple arm of the gracilis out of the tunnel.
After fixation of the ACL with interference screws, the simple gracilis is passed under the iliotibial tract toward the anterolateral incision of the proximal tibia.
The graft is mobilized and must present free excursion. It is fixed in extension with neutral knee rotation. It is possible to palpate the graft in the anatomical topography, with greater tension in knee extension.
Our experience with the technique presented in this video shows good results in patients with risk factors such as chronic injury and patients with knee hyperextension, and has a low failure rate. The surgical technique has rare complications and an increase of 10 minutes in the total time of the procedure after training.
Alternatively, in those cases we perform ACL reconstruction with patellar tendon graft, our preferred technique for extraarticular augmentation is the modified Lemaire technique.
A 5- to 6-cm incision is performed in the lateral aspect of the knee, posterior to the lateral epicondyle, over the distal portion of the ITB. The ITB is incised at its posterior third, and a 1-cm–width and 8-cm–long strip is created, leaving its distal end attached to Gerdy tubercle. A continuous suture is performed at the free end of the graft. The ACL is fixed with interference screws. We determine a point posterior and proximal to the lateral epicondyle for the proximal fixation of the tenodesis. We check for isometry in flexion and in extension. The plane underneath the lateral collateral ligament (LCL) is dissected, and the ITB is passed below the LCL. We perform the tenodesis with an anchor. As we perform internal rotation of the tibia, we can see the increased tension of the graft.
Thank you for your attention.
Footnotes
Submitted February 21, 2021; accepted March 1, 2021.
The authors declared that they have no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.