Anatomic Anterolateral Ligament Reconstruction with Iliotibial Band Graft and Concomitant Anterior Cruciate Ligament Reconstruction

Abstract

Anterior cruciate ligament (ACL) reconstruction (ACLR) attempts to restore native ACL function. Persistent anterolateral instability is a common symptom after ACLR that can lead to worse patient outcomes. Additional surgeries, like anterolateral ligament reconstruction (ALLR), can augment the ACL graft and help increase anterolateral rotational stability. Certain indications for ACLR with ALLR include high-grade pivot shift, increased posterior tibial slope (>12°), revision ACLR, and concomitant ligamentous or meniscal injuries. We describe an anatomic ALLR technique using an 8 cm long × 1 cm wide strip of the inferior aspect of the iliotibial band fixed at the native attachment sites of the ALL.

Fig 1

Image depicting the native anatomy of the anterolateral ligament (ALL). The ALL is a ligamentous structure of the lateral capsule located superior to the fibular collateral ligament (FCL). The tibial attachment of the ALL is midway between the center of Gerdy’s tubercle and the anterior aspect of the fibular head and 9.5 mm distal to the joint line. The femoral attachment of the ALL is 4.7 mm posterior and proximal to the femoral attachment of the fibular collateral ligament. (Reprinted with permission from Am J Sports Med 2015;43:1606-1615.)

Fig 2

Image depicting the reconstruction graft of this new anterolateral ligament reconstruction (ALLR) technique surgery (lateral view, right knee). This technique uses an 8 cm long × 1 cm wide graft of the inferior portion of the iliotibial band. The graft flares slightly at Gerdy’s tubercle and is amputated proximally. The distal tibial attachment is 1 cm distal to the joint line and midway between the anterior head of the fibula and Gerdy’s tubercle. The proximal femoral attachment of the graft is 5 mm posterior and proximal to the fibular collateral ligament (FCL) femoral attachment. The distal attachment is fixated first with 2 modified Mason-Allen stiches and proximally at 20° of flexion and neutral rotation using 2 modified Mason-Allen stitches.

Fig 3

Image showing the graft harvested (between black parallel lines) from the iliotibial band for the anterolateral ligament reconstruction (ALLR) (right knee, supine position). The graft is 8 cm long × 1 cm wide and is harvested from the inferior aspect of the iliotibial band. The graft is slightly flared at Gerdy’s tubercle (as depicted with black line). The graft is initially left attached at both the proximal and distal ends to remove any tissues adhered to posterior side of the graft. The graft is the amputated at the proximal end.

Fig 4

Image showing the distal attachment point of the anterolateral ligament reconstruction (ALLR) graft (right knee, supine position). The spinal needle is used to identify the joint line (black arrow). The landmark for the distal attachment is 1 cm distal to the joint line (black arrow) and midway between the anterior aspect of the fibular head and Gerdy’s tubercle. The guide (blue arrow) depicts where the Q-Fix Anchor (Smith & Nephew) will be inserted to fixate the distal portion of the graft.

Fig 5

Before distal fixation of the anterolateral ligament reconstruction (ALLR) graft, the final graft fixation location should be verified to ensure there is enough graft length (right knee, supine position). The distal portion should be held over the distal attachment site (black arrow) that has a Q-Fix Anchor (Smith & Nephew) already placed. The proximal portion of the graft should be held over the fixation site (blue arrow), which is 5 mm posterior and proximal to the femoral attachment of the fibular collateral ligament (FCL).

Fig 6

The distal tibial end of the anterolateral ligament reconstruction (ALLR) graft should be fixated first (right knee, supine position). After the first suture is passed and tightened using a modified Mason-Allen stitch technique, the graft should be tensioned and draped over the general area of the proximal attachment site (blue arrow), which is 5 mm posterior and proximal to the femoral attachment of the fibular collateral ligament (FCL). Then, the second modified Mason-Allen stich can be placed and tightened in a similar location.

Fig 7

The proximal femoral attachment site for the anterolateral ligament reconstruction (ALLR) graft should then be identified (right knee, supine position). This position is about 5 mm posterior and proximal to the femoral attachment of the fibular collateral ligament (FCL). At this position, a second Q-Fix Anchor (Smith & Nephew) is placed (black arrow). The graft will be fixated at this location after the completion of the anterior cruciate ligament reconstruction.

Fig 8

The proximal femoral end of the anterolateral ligament reconstruction (ALLR) graft is fixated after the anterior cruciate ligament reconstruction graft is fully fixated (right knee, supine position). The knee should be placed in 20° of flexion and in neutral rotation, and the graft should be pulled into tension before the first suture is placed. After the first suture is passed and tightened using a modified Mason-Allen stitch technique, the knee should be examined to determine where the second suture should be placed for proper tensioning. Then, the second modified Mason-Allen stitch can be placed and tightened. The knee should be examined for proper knee and graft function. The path of the graft is marked with the black lines.