Editorial Commentary: Extension of Knowledge—and the Knee! New Biomechanical Study Suggests the Clinical Practice of Anterolateral Ligament Fixation Near Extension

Abstract

The knee anterolateral ligament (ALL) is one of the most hotly debated topics in sports medicine in the last decade. Once one aspect of discussion regarding the ALL reaches a consensus, attention immediately turns to the next one. This has already happened with the existence of the ALL itself, its anatomic features, the ability to visualize the ALL with magnetic resonance imaging, and many other topics. In the end, the most important aspect must be clinical outcomes, and existing studies are trying to find the optimum surgical technique to best restore knee stability and reduce failure rates. It appears that, when doing an anatomic ALL reconstruction, fixation must be performed in full extension. The literature regarding ALL reconstruction shows promising results, with a strong tendency to present better knee stability, improved functional scores, and lower failure rates.

Regarding “The Effect of Combined Anterolateral and Anterior Cruciate Ligament Reconstruction on Reducing Pivot Shift Rate and Clinical Outcomes: A Meta-analysis”

“…5,6 This is an important point because the potential consequences of malpositioning the femoral insertion, or fixing the graft in any position except full extension, include rendering the reconstruction ineffective or even worse, overconstraining the knee. 7,8 It is therefore our opinion that studies using femoral tunnel positions or surgical techniques inconsistent with the current consensus regarding the anatomy (Ibrahim et al, 9 femoral tunnel proximal and anterior to lateral collateral ligament insertion; Zhang et al, 10 femoral tunnel anterior to origin of lateral collateral ligament, Zaffagnini et al, 11 over the top position) or biomechanics of the ALL (Goncharov et al, 12 isometric reconstruction) should have been excluded from this analysis. Furthermore, it should be noted that Ibrahim et al 9 stated (prior to widespread consensus) that "there is some disagreement in the literature as to the precise anatomy of the ALL and the best means of reconstructing it.…”