Anterolateral Ligament Reconstruction

Jacob M. Kirsch

Moin Khan

Asheesh Bedi

Relative Indications for Anterolateral Ligament (ALL) Reconstruction

• Persistent pivot shift test following anterior cruciate ligament (ACL) reconstruction

• Preoperative grade 3 pivot shift test

• Knee hyperlaxity with ACL injury (Beighton criteria ≥ 6)

• Revision ACL reconstruction with rotary instability

Sterile Instruments/Equipment

• Thigh tourniquet

• Leg holder

• Disposable 2.4-mm guide pins, 2X

• 4.5- and 7.0-mm cannulated drills

• 4.75-mm biocomposite SwiveLock anchor and 7-mm biocomposite tenodesis SwiveLock anchor (Arthrex, Naples, FL)

• Disposable tap (available, although not routinely needed)

• No. 2 FiberLoop sutures, 2X (Arthrex, Naples, FL)

• No. 2 FiberWire suture (Arthrex, Naples, FL)

Positioning

• The patient is positioned supine on the operating table.

• An arthroscopic leg holder is used on the operative extremity.

• A well-leg holder is used to position the nonoperative extremity in a flexed and abducted position to protect the femoral and peroneal nerves.

• A sterile tourniquet is placed high on the operative thigh.

• The foot of the operating table is dropped to allow for maximal knee flexion.

Examination Under Anesthesia

• After induction of anesthesia, the following examination maneuvers are performed and compared to the contralateral extremity:

• Lachman test

• Pivot shift

• Dial test

• Posterolateral drawer, drawer in internal rotation (for posterolateral and anteromedial rotatory instability, respectively)

• Varus/valgus stress

• Internal rotation stress of tibia in >35 degrees flexion

Relevant ALL Anatomy

• Proximal origin of the ALL is variable; however, it is typically 5 mm proximal and posterior to the origin of the lateral collateral ligament.¹

• Distal insertion is more broad and inserts approximately midway between the center of the fibular head and Gerdy tubercle,² ˜10-11 mm distal to the lateral tibial plateau.¹,³

• The ALL is ˜4 cm long.³

Surgical Approach

• The anatomic landmarks of the knee are identified (Fig. 45-1).

Figure 45-1 | Surface anatomic landmarks of the knee (A) and a diagrammatic illustration of the ligamentous anatomy of the lateral knee (B). Important landmarks are Gerdy tubercle (1), the fibular head (2), and the lateral femoral epicondyle (3). ALL, anterolateral ligament; LCL, lateral collateral ligament; PT, popliteal tendon. (Courtesy of Arthrex, Inc.)

• Distal landmarks

▪ Inferior pole of the patella and tibial tubercle

▪ Lateral joint line

▪ Gerdy tubercle

▪ Head of the fibula

• Proximal landmark

▪ Lateral femoral epicondyle

• The ALL origin proximal and posterior to the lateral femoral epicondyle is identified (Fig. 45-2).

Figure 45-2 | The origin of the anterolateral ligament is just proximal and posterior to the lateral femoral epicondyle. It is marked with an “X”. Important landmarks are Gerdy tubercle (A), the fibular head (B), and the lateral femoral epicondyle (C). (Courtesy of Arthrex, Inc.)

• With the knee in flexion, a small incision is made ˜8 mm proximal and 4 mm posterior to the lateral femoral epicondyle (Fig. 45-3).

• The incision is carried deep through subcutaneous tissue, and the iliotibial band is split in line with its fibers.

Figure 45-3 | An incision is made centered over the origin of the anterolateral ligament and carried deep through the iliotibial band. (Courtesy of Arthrex, Inc.)

Guide Pin Placement

• Proximal guide pin

• The proximal origin of the ALL is ˜5 mm proximal and posterior to the origin of the lateral collateral ligament.¹

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