Editorial Commentary: Ligamentous Hyperlaxity: A Decisive Factor for the Indication of a Combined Anterior Cruciate Ligament and Anterolateral Ligament Reconstruction?

Abstract

Indications for combined anterior cruciate ligament (ACL) and anterolateral ligament (ALL) reconstruction are not well defined, and the role of ligamentous hyperlaxity on anterolateral rotatory instability in an ACL-deficient knee remains unclear. Possible indications for combine ACL and ALL reconstruction might be a high-grade pivot shift, revision ACL reconstruction, patients with proven anterolateral knee pathology on preoperative imaging, and young patients participating in high-demand sport, and perhaps, finally, patients with ligamentous hyperlaxity as above.

Editorial Commentary: Lateral Extra-Articular Tenodesis Results in Better Stability After Anterior Cruciate Ligament Reconstruction for Patients With High-Grade Pivot Shifts

“…26 However, the role of ligamentous hyperlaxity on anterolateral rotatory laxity of an ACL-deficient knee still remains unclear, and the need for an additional ALL reconstruction is still debatable, according to Brockmeyer. 15 This brings us to the article that is the basis for this commentary. In "A Retrospective Comparison of Single-Bundle Anterior Cruciate Ligament Reconstruction With Lateral Extra-Articular Tenodesis to Double-Bundle Anterior Cruciate Ligament Reconstruction," Ahn, Kim, and Mun 27 report that in ACL-injured knees with a highgrade pivot shift, the pivot shift tests were reduced, and International Knee Documentation Committee (IKDC) objective grades increased by the addition of a LET to a single-bundle ACL reconstruction compared with a double-bundle ACL reconstruction alone, at a mean follow-up of w49 months.…”

“…However, it may be that current clinical follow-up times are insufficient to detect overstraining complications. 15 The proper ALL graft fixation position was assessed using cadaveric knees. With the knee in neutral rotation, Ahn et al 16 compared elongation of the anterior and posterior ALL borders at different flexion angles and using anterior-posterior translation, internal-external rotation, and varus-valgus force.…”

“…8,9 Additional indications include generalized ligamentous hyperlaxity 25 and proven lesions of the anterolateral knee structures. 15 A retrospective review of ACL reconstruction patients with ligamentous hyperlaxity (minimum score of 5 on the modified Beighton scale) found that the addition of an ALL reconstruction to an anatomic ACL reconstruction resulted in lower KT-1000 scores, better pivot shift tests, and lower reconstruction failure rates: 21.7% (ACL group) versus 3.3% (ACL/ALL group); P ¼ .03. 26 However, the role of ligamentous hyperlaxity on anterolateral rotatory laxity of an ACL-deficient knee still remains unclear, and the need for an additional ALL reconstruction is still debatable, according to Brockmeyer.…”