Reconstruction of anterior cruciate ligament and anterolateral ligament using interlinked hamstrings – technical note

Abstract

Recent anatomical and biomechanical studies on the anterolateral ligament (ALL) of the knee have shown that this structure has an important function in relation to joint stability, especially when associated with anterior cruciate ligament (ACL) injury. However, the criteria for its reconstruction have not yet been fully established and the surgical techniques that have been described present variations regarding anatomical points and fixation materials. This study presents a reproducible technique for ALL and ACL reconstruction using hamstring tendons, in which three interference screws are used for fixation.

Decision-Making for ALL Reconstruction and Surgical Techniques

“…The mechanical properties of the IT band (stiffness, 39.9 N/mm; maximum load to failure, 161.1 N) most closely resembled those of the ALL. However, many authors have published techniques using a gracilis graft for ALL reconstruction and a tripled semitendinosus auto-or allograft or quadrupled semitendinosus autograft with all-inside technique for the reconstruction of ACL [39][40][41]. The use of polyester tape [42] or a single-bundle semitendinosus auto-or allograft has also been described in the literature [43].…”

“…Since the origin of the femoral insertion of the ALL varies, the location of femoral fixation during ALLR is a debate. Many authors [40,46,47] described a fixation at a point posterior and superior to the lateral femoral epicondyle; however, some [41,42] described a fixation slightly anterior to the lateral epicondyle. As a radiological reference point, Helito et al used Blumensaat's line and identified the femoral attachment at approximately halfway along Blumensaat's line from the anterior edge of the femoral condyle [44].…”

“…After the isometry test, the graft is passed under the ITB and fixed with interference screws or anchors on both sides, while the knee is 30° flexed and at neutral rotation (Figure 2). However, fixation in full extension at 45-60° of flexion or fixation at 60-90° of flexion have also been described in the literature [39,40,47]. Different surgical techniques and indications are summarized in Table 1.…”

Solving the Mystery of the Antero Lateral Ligament

“…This information has developed a paradigm shift in the management of ACL injuries. Recent studies have proved that ALL injury correction along with ACL reconstruction provides more rotational stability to the knee joint [13]. The role of anatomists in providing background information on this ligament will be vital for the orthopaedic surgeons in performing functionally effective reconstructive surgeries involving both the ACL and ALL.…”

Absolute Isolated Avulsion of the Anterolateral Complex of the Knee: A Segond Fracture

“…Both grafts are fixed with interference screws. 24 Due to the close relationship between the Segond fracture and ACL lesion, combined ACL and anterolateral complex lesions could be considered a Segond-like lesion.…”