Confronted with subjects demonstrating post-traumatic anterolateral knee laxity in an era before the advent of knee MRI or arthroscopy, many authors in the 1970s published surgical techniques as a proposed treatment for anterolateral tibial subluxation. These so-called ‘extra-articular’ techniques in ACL reconstruction were, for example, popularised by MacIntosh [9, 22], Losee [26], Ellison [14], and Andrews [2] but have largely been abandoned because of the inconsistency in the reported results. Strikingly, although some of these techniques seemed to adequately address the rotational issue [1], no clearer description or characterisation than ‘anterolateral capsular structures’ was at hand to designate the ligamentous structure they were assumed to reconstruct [12]. In this view, the increasing knowledge surrounding the ALL therefore has the potential to deliver the rationale behind some of these ‘empirically’ extra-articular reconstructions from the past.

With increasing knowledge on the ALL, confirming its role as a controller for internal tibial rotation and the pivot-shift phenomenon, a combined treatment regimen for both ACL and ALL has become a significant subject of interest when considering the issue of persistent rotational laxity after ACL reconstruction [27, 30, 35].

In an attempt to integrate these new insights in clinical practice, the authors suggest to consider concomitant ACL and ALL reconstruction in the following:

As described above, the so-called extra-articular ACL reconstruction techniques, which typically consist of fixing an ITB strip left attached to Gerdy’s tubercle to the lateral femoral metaphysis, might possibly be regarded as ‘nonanatomic ALL reconstructions’. Although an (modified) ITB tenodesis type of ALL reconstruction might indeed restrain excessive internal tibial rotation and the pivot shift, emerging knowledge on precise ALL anatomy and function has driven the development of more anatomic ALL reconstruction techniques as a concomitant procedure to ACL reconstruction surgery [36, 39, 42].

Typically, ALL reconstruction initially begins with an examination under anaesthesia to confirm the presence of rotational instability as demonstrated by a high-grade pivot shift. Basically, the procedure itself consists of fixing an auto- or allograft gracilis tendon on the anatomical attachment sites of the native ALL in both femur and tibia. Both single- and double (‘V’)-strand techniques have been proposed in order to maximally mimic the broader ALL’s native footprint on the tibia [39, 40].

The main landmark for the femoral socket is the lateral epicondyle, and a mini-incision over this area in proximal direction is performed. The tibial incision is planned at a point right between Gerdy’s tubercle and the fibular head, just distal to the tibial joint line. Through the femoral incision, the IT band is split in line with its fibres, and the lateral collateral ligament (LCL) is identified and protected. For both single- and double-strand ALL reconstructions, a 2.4 mm guidewire is advanced at a point at 8 mm proximal and posterior to the lateral epicondyle right on the femoral origin of the ALL [11, 23]. It is important to avoid convergence with the ACL femoral socket, so it is suggested to drill the femoral ALL socket before ACL graft insertion while aiming somewhat anteriorly and distally. A longitudinal mini-incision and soft tissue dissection are then made at the site of the tibial fixation socket. The 2.4 mm guidewire is then placed on the anatomical insertion of the ALL at about 9 mm distally to the tibial joint line. A suture can be passed deep to the IT band and passed around the pins to check for isometry of the ALL: typically, the ALL will be relatively isometric in extension and slackens from 60° flexion [13]. If satisfactory, then a single femoral and one or two tibial bone sockets are drilled with a 4.5 mm drill to a depth of 20 mm [39].

After having finished the ACL reconstruction procedure, the ALL graft is finally fixed into the femoral and tibial bone sockets using an appropriate tap and 4.75-mm-diameter bioabsorbable fully threaded knotless anchors (SwiveLock BioComposite, Arthrex Inc., Naples, USA). The whipstitched end is secured into the femoral socket, and then the graft is tensioned from the tibial end, after having passed the graft deep to the iliotibial band and through the distal skin incision. Finally, one or more anchors are then used to secure the graft on the tibia while tensioning the graft in full extension (Fig. 37.2). Different techniques for graft fixing might be used with good success as long as the surgeon adheres to the same principles mentioned above.

Recently, the clinical results of the first series of combined ACL and ALL reconstruction were published [42]. In a consecutive series of 396 ACL reconstructions performed between January 2011 and January 2012, 92 combined ACL reconstructions with minimally invasive ALL reconstructions were carried out.

Indications for a combined procedure were an associated Segond fracture, a chronic ACL lesion, a grade 3 pivot shift, a high level of sporting activity, participation in pivoting sports, and radiographic sign of a lateral femoral notch. The patients were assessed pre- and postoperatively with objective and subjective International Knee Documentation Committee (IKDC) score, Lysholm score, and Tegner activity scale. Objective testing for knee laxity was measured with an instrumented knee laxity testing device (Rolimeter arthrometer). Amongst other complications, graft failure and contralateral ACL rupture were recorded.

The mean follow-up was 32.4 ± 3.9 months, with 83 patients available for final evaluation. At the last follow-up, no patient had restricted range of motion. Significant improvement in the Lysholm, subjective IKDC, and objective IKDC scores was noted (all p < 0.0001). The mean differential anterior laxity was 8 ± 1.9 mm before surgery and significantly decreased to 0.7 ± 0.8 mm at the last follow-up (P < 0.0001). Preoperatively, 41 patients had a grade 1 pivot shift, 23 had grade 2, and 19 had grade 3 according to the IKDC criteria. Postoperatively, 76 patients had a negative pivot shift (grade 0), and 7 patients recorded grade 1 laxity (P < 0.0001). Furthermore, after more than 2 years of follow-up, this series shows a contralateral ACL rate rupture (6.6 %) similar to that described in the recent literature [19, 37, 51]. Interestingly however, over the same time period, the ACL graft rupture rate for the combined ACL and ALL reconstruction group was only 1.1 %, which is definitively lower than typically reported.