IMPROVEMENT OF ROTATIONAL KNEE STABILITY USING LATERAL EXTRA-ARTICULAR TENODESIS AND ANTEROLATERAL LIGAMENT RECONSTRUCTION: INDICATIONS, COMPLICATIONS, AND COMPARISON OF TECHNIQUES — A REVIEW OF THE LITERATURE

Maciej Sokołowski; Karolina Oskroba; Estera Graczyk; Joanna Kryślak; Katarzyna Skibicka; Adam Solarz; Szymon Szabelski; Jakub Filip Turcza

doi:10.31435/ijitss.3(47).2025.4078

Maciej Sokołowski Specialist Hospital named after Stefan Żeromski in Kraków, Kraków, Poland https://orcid.org/0009-0009-8559-0620
Karolina Oskroba Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Bydgoszcz, Poland https://orcid.org/0009-0003-7169-2841
Estera Graczyk University Clinical Hospital No. 2 of the Medical University of Łódź, Łódź, Poland https://orcid.org/0009-0006-4901-0172
Joanna Kryślak University Clinical Hospital in Poznań, Poznań, Poland https://orcid.org/0009-0004-5678-2643
Katarzyna Skibicka University Hospital No. 2 named after Jan Biziel in Bydgoszcz, Bydgoszcz, Poland https://orcid.org/0009-0001-3192-9301
Adam Solarz Specialist Hospital named after Stefan Żeromski in Kraków, Kraków, Poland https://orcid.org/0009-0005-6039-8449
Szymon Szabelski University Clinical Hospital No. 2 of the Medical University of Łódź, Łódź, Poland https://orcid.org/0009-0002-5621-2590
Jakub Filip Turcza Department of Cosmetology and Aesthetic Medicine, Medical University of Lublin, Lublin, Poland https://orcid.org/0009-0004-3609-8772

DOI: https://doi.org/10.31435/ijitss.3(47).2025.4078

Keywords: ACL, ACLR, ALLR, LET, Comparison

Abstract

The anterior cruciate ligament (ACL) is one of the most frequently injured structures of the knee. To restore joint function, ACL reconstruction surgery is commonly performed. However, despite successful reconstruction, some patients fail to regain full function due to residual rotational instability. Procedures aimed at improving rotational stability include anterolateral ligament reconstruction (ALLR) and lateral extra-articular tenodesis (LET). This article reviews the anatomy of the ACL and the anterolateral complex. The techniques of ALLR and LET are described, and the two methods are compared. Indications, complications, clinical outcomes, and potential long-term effects of these procedures are also discussed.

References

Evans J, Mabrouk A, Nielson Jl. Anterior Cruciate Ligament Knee Injury. [Updated 2023 Nov 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499848/#

Macaulay AA, Perfetti DC, Levine WN. Anterior cruciate ligament graft choices. Sports Health. 2012 Jan;4(1):63-8. doi: 10.1177/1941738111409890. PMID: 23016071; PMCID: PMC3435898.

Na BR, Kwak WK, Seo HY, Seon JK. Clinical Outcomes of Anterolateral Ligament Reconstruction or Lateral Extra-articular Tenodesis Combined With Primary ACL Reconstruction: A Systematic Review With Meta-analysis. Orthop J Sports Med. 2021 Sep 13;9(9):23259671211023099. doi: 10.1177/23259671211023099. PMID: 34541008; PMCID: PMC8442508.

Jonsson H, Riklund-Ahlström K, Lind J. Positive pivot shift after ACL reconstruction predicts later osteoarthrosis: 63 patients followed 5-9 years after surgery. Acta Orthop Scand. 2004 Oct;75(5):594-9. doi: 10.1080/00016470410001484. PMID: 15513493.

Mascarenhas R, Cvetanovich GL, Sayegh ET, Verma NN, Cole BJ, Bush-Joseph C, Bach BR Jr. Does Double-Bundle Anterior Cruciate Ligament Reconstruction Improve Postoperative Knee Stability Compared With Single-Bundle Techniques? A Systematic Review of Overlapping Meta-analyses. Arthroscopy. 2015 Jun;31(6):1185-96. doi: 10.1016/j.arthro.2014.11.014. Epub 2015 Jan 14. PMID: 25595691.

Lee, J.H., Lee, G.B., Chung, W. et al. Addition of anterolateral ligament reconstruction to primary anterior cruciate ligament reconstruction could benefit recovery of functional outcomes. Sci Rep 14, 11440 (2024). https://doi.org/10.1038/s41598-024-62444-x

Śmigielski R, Zdanowicz U, Drwięga M, Ciszek B, Williams A. The anatomy of the anterior cruciate ligament and its relevance to the technique of reconstruction. Bone Joint J. 2016 Aug;98-B(8):1020-6. doi: 10.1302/0301-620X.98B8.37117. PMID: 27482012.

Siegel L, Vandenakker-Albanese C, Siegel D. Anterior cruciate ligament injuries: anatomy, physiology, biomechanics, and management. Clin J Sport Med. 2012 Jul;22(4):349-55. doi: 10.1097/JSM.0b013e3182580cd0. PMID: 22695402.

Domnick C, Raschke MJ, Herbort M. Biomechanics of the anterior cruciate ligament: Physiology, rupture and reconstruction techniques. World J Orthop. 2016 Feb 18;7(2):82-93. doi: 10.5312/wjo.v7.i2.82. PMID: 26925379; PMCID: PMC4757662.

Herbst E, Albers M, Burnham JM, Fu FH, Musahl V. The Anterolateral Complex of the Knee. Orthop J Sports Med. 2017 Oct 6;5(10):2325967117730805. doi: 10.1177/2325967117730805. PMID: 29051903; PMCID: PMC5638167.

Park JG, Han SB, Lee CS, Jeon OH, Jang KM. Anatomy, Biomechanics, and Reconstruction of the Anterolateral Ligament of the Knee Joint. Medicina (Kaunas). 2022 Jun 10;58(6):786. doi: 10.3390/medicina58060786. PMID: 35744048; PMCID: PMC9228568.

Sayac G, Goimard A, Klasan A, Putnis S, Bergandi F, Farizon F, Philippot R, Neri T. The anatomy of Kaplan fibers. Arch Orthop Trauma Surg. 2021 Mar;141(3):447-454. doi: 10.1007/s00402-020-03718-7. Epub 2021 Jan 8. PMID: 33417018.

Getgood A, Brown C, Lording T, Amis A, Claes S, Geeslin A, Musahl V; ALC Consensus Group. The anterolateral complex of the knee: results from the International ALC Consensus Group Meeting. Knee Surg Sports Traumatol Arthrosc. 2019 Jan;27(1):166-176. doi: 10.1007/s00167-018-5072-6. Epub 2018 Jul 25. PMID: 30046994.

Willinger L, Athwal KK, Holthof S, Imhoff AB, Williams A, Amis AA. Role of the Anterior Cruciate Ligament, Anterolateral Complex, and Lateral Meniscus Posterior Root in Anterolateral Rotatory Knee Instability: A Biomechanical Study. Am J Sports Med. 2023 Apr;51(5):1136-1145. doi: 10.1177/03635465231161071. Epub 2023 Mar 14. PMID: 36917838; PMCID: PMC10068405.

Kim MS, Koh IJ, In Y. Isometric Anterolateral Ligament Reconstruction Using the Semitendinosus Tendon With Suspensory Tibial Fixation. Arthrosc Tech. 2020 Jun 6;9(7):e941-e945. doi: 10.1016/j.eats.2020.03.017. PMID: 32714802; PMCID: PMC7372517.

Geeslin AG, Chahla J, LaPrade RF. Combined Anterior Cruciate Ligament and Lateral Extra-Articular Reconstruction. Arthroscopy. 2022 Sep;38(9):2600-2601. doi: 10.1016/j.arthro.2022.07.001. PMID: 36064274.

Ohliger J 3rd, Haus A, Fong R, Lang S, Gilmer BB, Wahl CJ. Modified Bosworth Technique for Medial Collateral Ligament Reconstruction of the Knee Using Semitendinosus Tendon Autograft. Arthrosc Tech. 2022 Sep 8;11(11):e1903-e1909. doi: 10.1016/j.eats.2022.07.003. PMID: 36457399; PMCID: PMC9705397.

Grimm NL, Modrow K, Ryan E, Curran J, Jimenez AE, Levy BJ. All-Onlay Anterolateral Ligament Reconstruction Technique of the Knee. Arthrosc Tech. 2024 May 24;13(9):103060. doi: 10.1016/j.eats.2024.103060. PMID: 39308579; PMCID: PMC11411354.

Bosco F, Giustra F, Ghirri A, Cacciola G, Massè A, Capella M. All-Inside Anterior Cruciate Ligament Reconstruction Technique: Tips and Tricks. J Clin Med. 2023 Sep 6;12(18):5793. doi: 10.3390/jcm12185793. PMID: 37762734; PMCID: PMC10532376.

Barroso BG, Canuto SMG, Helito CP, Rêgo MCF, Martins FS, Rêgo MCF. Combined Anterior Cruciate Ligament and Anterolateral Ligament Reconstruction Using the Superficial Layer Quadriceps Tendon Graft: Surgical Technique Description. Arthrosc Tech. 2024 May 30;13(10):103067. doi: 10.1016/j.eats.2024.103067. PMID: 39479041; PMCID: PMC11519883.

Inderhaug E., Stephen J.M., Williams A., Amis A.A. Anterolateral Tenodesis or Anterolateral Ligament Complex Reconstruction: Effect of Flexion Angle at Graft Fixation When Combined With ACL Reconstruction. Am. J. Sports Med. 2017;45:3089–3097. doi: 10.1177/0363546517724422

Nitri M., Rasmussen M.T., Williams B.T., Moulton S.G., Cruz R.S., Dornan G.J., Goldsmith M.T., LaPrade R.F. An In Vitro Robotic Assessment of the Anterolateral Ligament, Part 2: Anterolateral Ligament Reconstruction Combined With Anterior Cruciate Ligament Reconstruction. Am. J. Sports Med. 2016;44:593–601. doi: 10.1177/0363546515620183

Schon J.M., Moatshe G., Brady A.W., Serra Cruz R., Chahla J., Dornan G.J., Turnbull T.L., Engebretsen L., LaPrade R.F. Anatomic Anterolateral Ligament Reconstruction of the Knee Leads to Overconstraint at Any Fixation Angle. Am. J. Sports Med. 2016;44:2546–2556. doi: 10.1177/0363546516652607

Saithna A., Thaunat M., Delaloye J.R., Ouanezar H., Fayard J.M., Sonnery-Cottet B. Combined ACL and Anterolateral Ligament Reconstruction. JBJS Essent. Surg. Tech. 2018;8:e2. doi: 10.2106/JBJS.ST.17.00045

Neri T., Dabirrahmani D., Beach A., Grasso S., Putnis S., Oshima T., Cadman J., Devitt B., Coolican M., Fritsch B., et al. Different anterolateral procedures have variable impact on knee kinematics and stability when performed in combination with anterior cruciate ligament reconstruction. J. ISAKOS. 2021;6:74–81. doi: 10.1136/jisakos-2019-000360

Figueroa D, Gonzalez W, Figueroa L, Figueroa F, Vaisman A. Complications in anterior cruciate ligament reconstruction. J Clin Orthop Trauma. 2024 Dec 17;61:102876. doi: 10.1016/j.jcot.2024.102876. PMID: 39816721; PMCID: PMC11731265.

Saithna A, Thaunat M, Delaloye JR, Ouanezar H, Fayard JM, Sonnery-Cottet B. Combined ACL and Anterolateral Ligament Reconstruction. JBJS Essent Surg Tech. 2018 Jan 10;8(1):e2. doi: 10.2106/JBJS.ST.17.00045. PMID: 30233974; PMCID: PMC6143299.

Cheng YH, Chiu CH, Chen AC, Chan YS, Hsu KY. Outcomes of Combined Anterior Cruciate Ligament and Anterolateral Ligament Reconstruction According to GNRB Arthrometer Measurement. Medicina (Kaunas). 2023 Feb 14;59(2):366. doi: 10.3390/medicina59020366. PMID: 36837568; PMCID: PMC9966521.

LEMAIRE, M. Ruptures anciennes du ligament croise anterieur du genou. J Chir, 1967, 93.3: 311-320.

Ayeni OR, Chahal M, Tran MN, Sprague S. Pivot shift as an outcome measure for ACL reconstruction: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2012 Apr;20(4):767-77. doi: 10.1007/s00167-011-1860-y. Epub 2012 Jan 5. PMID: 22218828.

Delaloye JR, Hartog C, Blatter S, Schläppi M, Müller D, Denzler D, Murar J, Koch PP. Anterolateral Ligament Reconstruction and Modified Lemaire Lateral Extra-Articular Tenodesis Similarly Improve Knee Stability After Anterior Cruciate Ligament Reconstruction: A Biomechanical Study. Arthroscopy. 2020 Jul;36(7):1942-1950. doi: 10.1016/j.arthro.2020.03.027. Epub 2020 Apr 3. PMID: 32251683.

Haus A, Chand A, Dawson K, Lang S, Gilmer BB, Wahl CJ. Modified Lemaire Lateral Extra-Articular Tenodesis Using an Inlay Technique and All-Suture Knotless Anchor Fixation. Arthrosc Tech. 2023 Aug 28;12(9):e1607-e1613. doi: 10.1016/j.eats.2023.05.004. PMID: 37780650; PMCID: PMC10533872.

Getgood A. Editorial Commentary: Indications for Lateral Extra-Articular Tenodesis in Primary Anterior Cruciate Ligament Reconstruction. Arthroscopy. 2022 Jan;38(1):125-127. doi: 10.1016/j.arthro.2021.07.005. PMID: 34972553.

Zabrzyński J, Kwapisz A, Erdmann J, Zabrzyńska M, Błachowski M, Ohla J, Adamczyk M, Sokołowski M, Majchrzak B, Huri G. Indications for Lateral Extra-articular Tenodesis in Anterior Cruciate Ligament Reconstruction: A Systematic Review. Am J Sports Med. 2025 Feb 4:3635465241309282. doi: 10.1177/03635465241309282. Epub ahead of print. PMID: 39903008.

Zabrzyński, J., Erdmann, J., Zabrzyńska, M. et al. Are there any complications after lateral extra-articular tenodesis in anterior cruciate ligament reconstruction? – a systematic review. J Orthop Surg Res 20, 451 (2025).

Devitt B.M., Bouguennec N., Barfod K.W., Porter T., Webster K.E., Feller J.A. Combined anterior cruciate ligament reconstruction and lateral extra-articular tenodesis does not result in an increased rate of osteoarthritis: A systematic review and best evidence synthesis. Knee Surg. Sports Traumatol. Arthrosc. 2017;25:1149–1160. doi: 10.1007/s00167-017-4510-1.

IMPROVEMENT OF ROTATIONAL KNEE STABILITY USING LATERAL EXTRA-ARTICULAR TENODESIS AND ANTEROLATERAL LIGAMENT RECONSTRUCTION: INDICATIONS, COMPLICATIONS, AND COMPARISON OF TECHNIQUES — A REVIEW OF THE LITERATURE

Abstract

References

Most read articles by the same author(s)