Anterolateral Ligament Reconstruction Techniques, Biomechanics, and Clinical Outcomes: A Systematic Review

Abstract

Purpose: To perform a systematic review of the described anterolateral ligament (ALL) reconstruction techniques, biomechanical performance, and clinical outcomes of ALL reconstruction in the setting of concurrent anterior cruciate ligament (ACL) reconstruction.

Methods: A systematic review was performed according to PRISMA guidelines using the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed, MEDLINE, and Embase, from 1980 to present. Inclusion criteria were as follows: ALL reconstruction techniques, ALL reconstruction biomechanical studies, ALL surgical outcomes, English language, human studies with at least 2 years of follow-up, and cadaveric studies. Exclusion criteria were lateral extra-articular tenodesis, ALL anatomic studies, ALL radiographic studies, animal studies, clinical studies with <2 years of follow-up, editorial articles, and surveys.

Results: The systematic review identified 12 articles that met the inclusion criteria: 6 techniques, 5 biomechanical studies, and 1 outcome study were available. Five studies described ALL reconstruction in the setting of ACL reconstruction, whereas 1 study described isolated ALL reconstruction. Femoral tunnel location was most commonly placed posterior and proximal to the lateral epicondyle, whereas 2 studies reported a distal tunnel location. There was little variability in tibial tunnel location. The most common ALL reconstruction graft used was the gracilis tendon. Review of the biomechanical studies revealed internal rotation overconstraint with the posterior/proximal femoral tunnel position but not anterior/distal, although fixation angle and graft tension were inconsistent. Only 1 clinical study with 2 years' follow-up was available and reported improvement in the majority of cases. Complications occurred in 15 patients, including a residual pivot shift in 8% of patients at 2 years after a combined ACL and ALL reconstruction.

Conclusions: There is inconsistency in the selection of ALL graft femoral attachment location as well as in the biomechanical performance of ALL reconstruction techniques.

Level of evidence: Level IV, systematic review of Level IV studies.