Anterolateral ligament reconstruction is a procedure performed in addition to ACL reconstruction to control rotational instability of the knee. It addresses the anterolateral structures that contribute to the pivot shift phenomenon.
A tendon graft (typically a strip of iliotibial band, gracilis, or allograft) is used to reconstruct the anterolateral ligament. Through a small incision on the outer side of the knee, the graft is fixed to the lateral femoral epicondyle and the proximal tibia at the anatomical ALL insertion. This is performed in addition to standard ACL reconstruction (not instead of it). The combined procedure takes approximately 90 minutes to two hours.
ALL reconstruction is considered as an addition to ACL reconstruction in patients at high risk of re-rupture: young athletes (under 25) returning to pivoting sports, revision ACL reconstruction, patients with high-grade pivot shift, and those with a Segond fracture (avulsion of the ALL tibial attachment visible on X-ray).
Standard ACL reconstruction alone (without ALL reconstruction) remains appropriate for most patients. Lateral extra-articular tenodesis (LET) is a similar but slightly different technique that also controls rotation.
MRI showing ACL tear with or without ALL injury. Clinical assessment of pivot shift grade. Assessment of risk factors for re-rupture. Standard pre-assessment.
Improved rotational control of the knee, reducing the pivot shift. Studies suggest that adding ALL reconstruction or LET to ACL reconstruction reduces re-rupture rates from approximately 10–15% to 4–7% in high-risk patients.
The ALL reconstruction may restrict terminal flexion slightly.
From the incision.
If the graft is tensioned too tightly, it may limit normal knee kinematics.
The ALL graft may stretch or rupture.
From the femoral tunnel.
Joint infection.
If ITB is used as graft.
General or spinal anaesthesia with nerve block (same as for ACL reconstruction).
Same rehabilitation protocol as ACL reconstruction. Running at four to six months. Pivoting sport at nine to twelve months. The ALL graft heals concurrently with the ACL graft.
Same as ACL reconstruction: reviews at two weeks, six weeks, three months, six months, and one year.
No. ALL reconstruction is an adjunct for high-risk patients — young pivoting athletes, revision ACL surgery, and those with a high-grade pivot shift. Most standard ACL reconstructions do not require an additional lateral procedure.
The STABILITY trial and other studies have shown that adding a lateral extra-articular procedure (ALL or LET) to ACL reconstruction in young athletes reduces re-rupture rates by approximately 50%. This is an evolving area with growing evidence.