Role of anterolateral reconstruction in ACL surgery. Why, When and How?

Journal of Clinical Orthopaedics | Vol 6 | Issue 1 |  Jan-Jun 2021 | page: 45-52 | Philippe Landreau

Author: Philippe Landreau [1]

[1] DxBone, Bone and Joint Excellence Center Dubai, United Arab Emirates

Address of Correspondence
Dr. Philippe Landreau,
DxBone, Bone and Joint Excellence Center Dubai, United Arab Emirates


Ruptures of the anterior cruciate ligament (ACL) cause both abnormal anterior translation and anterolateral rotation of the tibia under the femur. Isolated intra-articular ACL reconstruction has evolved significantly over the past years, but in many cases it is insufficient to correct rotational laxity. There are several justifications for anterolateral plasty in the context of ACL surgery: The persistence of anterolateral laxity after some isolated ACL intra-articular reconstructions, the evidence of traumatic lesions of these anterolateral structures after ACL tear and the recent anatomical and biomechanical research on the anterolateral complex of the knee. One more justification is that some recent studies comparing the outcomes after isolated ACL reconstruction and those after ACL reconstruction combined with anterolateral reconstruction are in favor of the simultaneous procedures. The addition of an extra-articular procedure to the intra-articular reconstruction of the ACL can improve the outcomes particularly in these situations: Young age (<25 ans), sports with pivot contact particularly if high level, pivot-shift Grades 2–3, recurvatum of the knee and generalized hyperlaxity, posterior tibial slope superior to 12°, meniscus deficiency, and ACL revision. Different surgical techniques have been proposed and described. They can be classified in two groups: The techniques using an ilio-tibial band graft to perform a lateral tenodesis and the procedures aiming to reconstruct the anterolateral ligament. Both techniques intend to control the anterolateral displacement of the tibial plateau.
Keywords: Anterolateral ligament, anterior cruciate ligament, anterolateral reconstruction, lateral tenodesis, condylar strap


  1. Lemaire M. Rupture ancienne du ligament croisé antérieur du genou: fréquence, clinique, traitement (46 cas). J Chir 1967;83:311:311.
  2. Macintosh D, Darby T. Lateral substitution reconstruction. In: Proceedings of the Canadian Orthopaedic Association. J Bone Joint Surg Br 1976;58(1):142.
  3. Losee RE, Johnson TR, Southwick WO. Anterior subluxation of the lateral tibial plateau. Adiagnostic test and operative repair. J Bone Joint Surg Am. 1978 Dec;60(8):1015-30.
  4. Ellison AE. Distal iliotibial-band transfer for anterolateral rotatory instability of the knee. J Bone Joint Surg Am. 1979 Apr;61(3):330-7.
  5. Andrews JR, Sanders R. A “mini-reconstruction” technique in treating anterolateral rotatory instability (ALRI). Clin Orthop Relat Res. 1983;(172):93-6.
  6. Marshall JL, Warren RF, Wickiewicz TL. Primary surgical treatment of anterior cruciate ligament lesions. Am J Sports Med. 1982;10(2):103-7.
  7. Sonnery-Cottet B, Thaunat M, Freychet B, et al. Outcome of a combined anterior cruciate ligament and anterolateral ligament reconstruction technique with a minimum 2-year follow-up. Am J Sports Med 2015;43:1598–43:1.
  8. Ardern CL, Webster KE, Taylor NF, et al. Return to sport following anterior cruciate ligament reconstruction surgery: a systematic review and meta-analysis of the state of play. Br J Sports Med. 2011;45:596–45:5.
  9. Ardern CL, Webster KE, Taylor NF, et al. Return to the preinjury level of competitive sport after anterior cruciate ligament reconstruction surgery. Two-thirds of patients have not returned by 12 months after surgery. Am J Sports Med. 2011;39:538–39.
  10. Wright RW, Magnussen RA, Dunn WR, et al. Ipsilateral graft and contralateral ACL rupture at five years or more following ACL reconstruction. Asystematic review. J Bone Joint Surg Am. 2011 Jun 15;93(12):1159-65.
  11. Wiggins AJ, Grandhi RK, Schneider DK, Stanfield D, Webster KE, Myer GD. Risk of Secondary Injury in Younger Athletes After Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis. Am J Sports Med. 2016 Jan 15.
  12. Segond P. Recherches cliniques et expérimentales sur les épanchements sanguins du genou par entorse. Prog Med. 1879;7: 297–9 3:297–9, 319–21, 340–1.
  13. Monaco E, Helito CP, Redler A, Argento G, De Carli A, Saithna A, Helito PVP, Ferretti A. Correlation Between Magnetic Resonance Imaging and Surgical Exploration of the Anterolateral Structures of the Acute Anterior Cruciate Ligament-Injured Knee. Am J Sports Med. 2019 Apr;47(5):1186- 1193.
  14. Vesalius A. De Humani Corporis Fabrica. Lib II, Cap 53. Padua: University of Padua; 1543.
  15. Kaplan EB. The iliotibial tract; clinical and morphological significance. J Bone Joint Surg Am. 1958 Jul;40-A(4):817-32.
  16. Terry GC, Hughston JC, Norwood LA. The anatomy of the iliopatellar band and iliotibial tract. Am J Sports Med. 1986 Jan[1]Feb;14(1):39-45.
  17. Vieira EL, Vieira EA, da Silva RT, Berlfein PA, Abdalla RJ, Cohen M. An anatomic study of the iliotibial tract. Arthroscopy. 2007 Mar;23(3):269-74.
  18. Vincent JP, Magnussen RA, Gezmez F, et al. The anterolateral liga- ment of the human knee: an anatomical and histologic study. Knee Surg Sports Traumatol Arthrosc. 2012;20(1):147- 152.
  19. Claes S, Vereecke E, Maes M, Victor J, Verdonk P, Bellemans J. Anatomy of the anterolateral ligament of the knee. J Anat 2013;223:321–22.
  20. Claes S, Luyckx T, Vereecke E, Bellemans J. The Segond fracture: a bony injury of the anterolateral ligament of the knee. Arthroscopy. 2014 Nov;30(11):1475-82.
  21. Geeslin AG, Chahla J, Moatshe G, Muckenhirn KJ, Kruckeberg BM, Brady AW, Coggins A, Dornan GJ, Getgood AM, Godin JA, LaPrade RF. Anterolateral Knee Extra-articular Stabilizers: A Robotic Sectioning Study of the Anterolateral Ligament and Distal Iliotibial Band Kaplan Fibers. Am J Sports Med. 2018 May;46(6):1352-1361.
  22. Landreau P, Catteeuw A, Hamie F, Saithna A, Sonnery-Cottet B, Smigielski R. Anatomic Study and Reanalysis of the Nomenclature of the Anterolateral Complex of the Knee Focusing on the Distal Iliotibial Band: Identification and Description of the Condylar Strap. Orthop J Sports Med. 2019 Jan 17;7(1):2325967118818064.
  23. Engebretsen L, Lew WD, Lewis JL, Hunter RE. The effect of an iliotibial tenodesis on intraarticular graft forces and knee joint motion. Am J Sports Med. 1990 Mar-Apr;18(2):169-76.
  24. Monaco E, Maestri B, Conteduca F, Mazza D, Iorio C, Ferretti A. Extra-articular ACL reconstruction and pivot shift: in vivo dynamic evaluation with navigation. Am J Sports Med 2014;42:1669–42
  25. Marom N, Ouanezar H, Jahandar H, Zayyad ZA, Fraychineaud T, Hurwit D, Imhauser CW, Wickiewicz TL, Pearle AD, Nawabi DH. Lateral Extra-articular Tenodesis Reduces Anterior Cruciate Ligament Graft Force and Anterior Tibial Translation in Response to Applied Pivoting and Anterior Drawer Loads. Am J Sports Med. 2020 Nov;48(13):3183-3193.
  26. Noyes FR, Barber SD. The effect of an extra-articular procedure on allograft reconstructions for chronic ruptures of the anterior cruciate ligament. J Bone Joint Surg Am. 1991;73(6):882-892.
  27. O’Brien SJ, Warren RF, Wickiewicz TL, et al. The iliotibial band lateral sling procedure and its effect on the results of anterior cruciate ligament reconstruction. Am J Sports Med. 1991;19(1):21-24.
  28. Devitt BM, Bouguennec N, Barfod KW, Porter T, Webster KE, Feller JA. Combined anterior cruciate ligament reconstruction and lateral extra-articular tenodesis does not result in an increased rate of oste- oarthritis: a systematic review and best evidence synthesis. Knee Surg Sports Traumatol Arthrosc. 2017;25(4):1149-1160.
  29. Pernin J, Verdonk P, Si Selmi TA, Massin P, Neyret P. Long-term follow-up of 24.5 years after intra-articular anterior cruciate ligament reconstruction with lateral extra-articular augmentation. Am J Sports Med. 2010;38(6):1094-1102.
  30. Zaffagnini S, Marcheggiani Muccioli GM, Grassi A, et al. Over[1]the-top ACL reconstruction plus extra-articular lateral tenodesis with ham- string tendon grafts: prospective evaluation with 20- year minimum follow-up. Am J Sports Med. 2017;45(14):3233- 3242.
  31. Getgood AMJ et al. Lateral Extra-articular Tenodesis Reduces Failure of Hamstring Tendon Autograft Anterior Cruciate Ligament Reconstruction: 2-Year Outcomes From the STABILITY Study Randomized Clinical Trial. Am J Sports Med. 2020 Feb;48(2):285-297.
  32. Trojani C, Beaufils P, Burdin G, Bussière C, Chassaing V, Djian P, Dubrana F, Ehkirch FP, Franceschi JP, Hulet C, Jouve F, Potel JF, Sbihi A, Neyret P, Colombet P. Revision ACL reconstruction: influence of a lateral tenodesis. Knee Surg Sports Traumatol Arthrosc. 2012 Aug;20(8):1565-70.
  33. Bertoia JT, Urovitz EP, Richards RR, Gross AE. Anterior cruciate reconstruction using the MacIntosh lateral-substitution over[1]the-top repair. J Bone Joint Surg Am. 1985 Oct;67(8):1183-8.
  34. Duthon VB, Magnussen RA, Servien E, Neyret P. ACL reconstruction and extra-articular tenodesis. Clin Sports Med. 2013 Jan;32(1):141-53.
  35. Lerat JL, Dupré La Tour L, Herzberg G, Moyen B. Revue de 100 patients opérés pour laxité chronique antérieure du genou par un procédé dérivé des méthodes de K. Jones et de D. MacIntosh. Intérêt de la radiographie dynamique pour l’analyse objective des résultats [Review of 100 patients operated on for chronic anterior laxity of the knee by a procedure derived from the Jones and MacIntosh methods. Value of dynamic radiography for the objective analysis of the results]. Rev Chir Orthop Reparatrice Appar Mot. 1987;73 Suppl 2:201-4.
  36. Zaffagnini S, Marcheggiani Muccioli GM, Grassi A, et al. Over[1]the-top ACL reconstruction plus extra-articular lateral tenodesis with ham- string tendon grafts: prospective evaluation with 20- year minimum follow-up. Am J Sports Med. 2017;45(14):3233-3242.
  37. Smith JO, Yasen SK, Lord B, Wilson AJ. Combined anterolateral ligament and anatomic anterior cruciate ligament reconstruction of the knee. Knee Surg Sports Traumatol Arthrosc. 2015 Nov;23(11):3151-6.
  38. Helito CP, Bonadio MB, Gobbi RG, da Mota E Albuquerque RF, Pécora JR, Camanho GL, Demange MK. Combined Intra- and Extra-articular Reconstruction of the Anterior Cruciate Ligament: The Reconstruction of the Knee Anterolateral Ligament. Arthrosc Tech. 2015 Jun 1;4(3).

How to Cite this article: SLandreau P. Role of anterolateral reconstruction in ACL surgery, why, when and how?. Journal of Clinical Orthopaedics Jan-Jun 2021;6(1):45-52.

 (Abstract    Full Text HTML)   (Download PDF)