The description of the anterolateral ligament (ALL) and its effect on controlling internal rotation has led to the development of ALL reconstruction techniques in an effort to better restore native knee biomechanics and stability. As a model, anatomic-based and biomechanically validated reconstructions have led to improved outcomes for other knee ligaments. However, up to 25% of all anterior cruciate ligament (ACL) reconstruction patients have been re- ported to have residual rotational instability. Moreover, isolated ACL reconstruction failure rates range from 1.8% to 14%. Thus, the need for improving rotational laxity control in the setting of ACL injuries has led to the development of various anterolateral knee reconstruction techniques.
Historically, multiple extra-articular procedures were developed to reduce anterolateral rotational instability (ALRI), collectively referred to as lateral extra-articular tenodesis (LET) procedures. However, concerns regarding the nonanatomic nature of LET procedures and the potential for overconstraint led to a decrease in their popularity. Additionally, overconstraint can potentially lead to graft elongation, changes in the knee biomechanics, and ultimately to accelerated joint degeneration. Several ALL reconstruction techniques have emerged as a result of the recharacterization of the anterolateral knee structures, along with their potential role in resisting tibial internal rotation.
It has been proposed that the ALL assists the ACL as a stabilizer against internal rotation and anterior tibial translation, thus reducing anterolateral rotatory instability (ALRI). However, because of variability in anatomic descriptions, authors have proposed different ALL reconstruction techniques, specifically involving different femoral attachment positions. Renewed concerns have been raised, because biomechanical studies have suggested that this procedure can over- constrain internal rotation. Given the relative paucity of literature reviewing the techniques, biomechanics, and outcomes of ALL reconstructions, the purpose of this study was to perform a systematic review of the described ALL reconstruction techniques, biomechanical performance, and clinical outcomes of ALL reconstruction in the setting of concurrent ACL reconstruction. We hypothesized that there would be inconsistency in techniques and therefore biomechanical characteristics, as well as a relative paucity of clinical outcomes studies.