It’s the sort of ‘belt and braces’ treatment that can prove particularly valuable for patients planning a return to sports with a high risk of retearing the ACL. But does anterolateral ligament reconstruction lead to greater risk? Jim Newman reviews the evidence.
Not so long ago, tearing the ACL was often a ‘career ender’ for high level athletes. It’s still a major injury, but we now know that it’s much more of a spectrum injury. You can partially tear your ACL. You could have a full tear. And you could have a full tear of the ACL and the anterolateral ligament (ALL). This latter injury is relatively newly understood. The notion of the ALL has existed since 1879, but it was only formally identified in 2013, and it’s changed our understanding of ACL injuries.
The ALL is essentially a thickening of the tissue at the side of the knee. It acts as a sort of secondary stabiliser. A solution for an ACL tear may be a reconstruction. But for some injuries that have left the knee in a particularly unstable condition, knee surgeons might also look to augment the lateral ligament.
Yes, it’s a little bit belt and braces. But the patients who have combined ACL and ALL reconstruction will be returning to high level, high impact sport (football, netball, rugby) with a high risk of retearing the ACL. Augmenting the ALL helps guard against reinjury.
Assessing the risk
There has, however, always been a slight concern that combining ACL and ALL reconstruction could lead to an increase in adverse outcomes (compared with reconstructing the ACL alone). There is, for example, a theoretical risk that the combined procedure could ‘tighten up’ the joint too much, so that it increases the risk of wear on the lateral side of the knee that could lead to early arthritis.
To assess the risk of adverse events, world-renowned orthopaedic surgeon Bertrand Sonnery-Cottet and others launched a study. It was a good study – a randomised trial comparing outcomes from ACL reconstruction alone with combined ACL and ALL reconstruction, with a minimum one year follow up.
The study found no significant difference between the groups in terms of risk. Having the ALL augmentation does not mean you are more likely to experience complications. That’s great news for athletes and anyone else who needs a reliably stable knee post-ACL reconstruction.
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