Graft choices for anterolateral ligament knee reconstruction surgery: Current concepts

Table 1 Graft choices and fixation methods

Ref.	ACL graft type	ALL graft type	Femoral fixation point	Tibial fixation point	Fixation Technique	Knee flexion/rotation
Lemaire and Combelles[36], 1980	BTB (hole for ITB graft)	ITB	Above the lateral epicondyle, proximal to the LCL insertion	Maintain attachment to Gerdy’s tubercle	Two bone tunnels, suture on itself	30º flexion/external rotation
Andrews and Sanders[41], 1983		ITB (two strips)	Lateral femoral epicondyle	Maintain attachment to Gerdy‘s tubercle	Suture strips together at medial femoral condyle after passing through two parallel lateral-to-medial tunnels	90º flexion/external rotation
Amirault et al[40], 1988		ITB	Above the lateral epicondyle, proximal to the LCL insertion	Maintain attachment to Gerdy’s tubercle	Suture fixation to ITB after passing through the lateral intermuscular septum	90º flexion/external rotation
Christel and Djian[37], 2002		ITB	Above the lateral epicondyle, proximal to the LCL insertion	Maintain attachment to Gerdy’s tubercle	Interference screw	30º flexion
Mathew et al[38], 2018		ITB	Anterior and proximal to the lateral gastrocnemius tendon	Maintain attachment to Gerdy’s tubercle	Richards staple and sutures to itself	60º flexion/neutral rotation
Abusleme et al[39], 2021		ITB	Above the lateral epicondyle, proximal to the LCL insertion	Maintain attachment to Gerdy’s tubercle	Suture fixation to ITB after passing through the lateral intermuscular septum	30º flexion/neutral rotation
Colombet[49], 2010	Quadruple (Semitendinosus double-bundle and gracilis double-bundle) or Double (single-bundle each)	Gracilis -semitendinosus (one bundle each)	Proximal to lateral epicondyle	Gerdy’s tubercule	Absorbable screws at each fixation point	90º flexion/neutral rotation
Helito et al[29], 2015	Quadruple (semitendinosus triple-bundle and gracilis single-bundle)	Gracilis (single-bundle)	3-4 mm below the halfway point on the Blumensaat’s line in the AP direction	5-10 mm below the lateral tibial plateau, between fibular head and Gerdy’s tubercle	One 5 mm metal anchors at each fixation point	60-90° of flexion/nm
Smith et al[45], 2015	Semitendinosus graft	Gracilis (double-bundle)	Anterior to lateral femoral epicondyle	Midway between fibular head and the Gerdy’s tubercle, 11 mm distal to joint line	4.75 or 5.5 mm bioabsorbable knotless suture anchor at each fixation point	30° of flexion/neutral rotation
Ferreira et al[48], 2016	Semitendinosus triple-bundle	Gracilis (double-bundle)	8 mm posterosuperiorly from lateral epicondyle	9-13 mm distal to lateral joint line, between fibular head and the Gerdy’s tubercle	Interference screw 2 mm larger than tunnel	45-60° flexion/nm
Sonnery-Cottet et al[44], 2016	Semitendinosus SAMBBA	Gracilis (double-bundle)	Proximal and posterior to lateral epicondyle	One superolateral margin of the Gerdy’s tubercle and one midway between fibular head and the Gerdy’s tubercle	4.75 or 5.5 mm bioabsorbable knotless suture anchor at each fixation point	Full extension/neutral rotation
Delaloye et al[47], 2018	Internal brace	Gracilis (double-bundle)	Proximal and posterior to lateral epicondyle	Bone tunnel: One point just anterior to the fibular head and second posterior to Gerdy’s tubercle	4.75 bioabsorbable knotless suture anchor at femoral fixation point	Full extension/neutral rotation
Saithna et al[18], 2018	Quadruple (Semitendinosus triple-bundle and gracilis single-bundle)	Gracilis (single-bundle)	Proximal and posterior to lateral epicondyle	Bone tunnel: One point just anterior to the fibular head and second posterior to Gerdy’s tubercle	Ethibond suture around the graft	Full extension/neutral rotation
Goncharov et al[46], 2019	BTB autograft	Gracilis or semitendinosus tendon autograft	Proximal to lateral epicondyle	10 mm distal to joint line, between fibular head and the Gerdy’s tubercle	Interference screws	Full extension/nm
Kim et al[50], 2020		Semitendinosus autograft	Proximal and posterior to lateral epicondyle	Midway between fibular head and the Gerdy’s tubercle	Interference screw at femur, adjustable length loop button at tibia	30° flexion/neutral rotation
Escudeiro de Oliveira et al[52], 2021	Quintuple, Semitendinosus double-bundle, gracilis double-bundle and peroneous longus single-bundle	Peroneous longus	Proximal and posterior to lateral epicondyle	15 mm distal to joint line, between fibular head and the Gerdy’s tubercle	Interference screws	30° flexion/nm
Josipovic et al[53], 2020	Quintuple, Semitendinosus triple-bundle, plantaris longus double-bundle	Plantaris longus	Proximal and posterior to lateral epicondyle	10 mm distal to joint line, between fibular head and the Gerdy’s tubercle	Interference screw at tibia	Full extension/nm
Wagih and Elguindy[59], 2016		Polyester tape	Distal and anterior to lateral femoral condyle	Midpoint between the Gerdy’s tubercle and the fibular head	Cortical suspension button proximally, tie on a bone bridge of two bone tunnels distally	30° flexion/nm
Lee et al[25], 2019	Tibialis anterior tendon allograft	Gracilis tendon allograft	Proximal and posterior to lateral epicondyle	10 mm distal to joint line, between fibular head and the Gerdy’s tubercle	Interference screws	30° flexion/neutral rotation
Chahla et al[57], 2016		Semitendinosus allograft	4.7 mm proximal and posterior to LCL insertion site	9.5 mm distal to joint line, between fibular head and the Gerdy’s tubercle	Interference screws	30° flexion/nm
Fernández et al[58], 2020	Achilles tendon allograft	Achilles tendon allograft	Proximal and posterior to lateral epicondyle	15 mm distal to joint line, between fibular head and the Gerdy’s tubercle	Staple at distal site	30° flexion/neutral rotation
Benum[42], 1982		Patellar tendon (lateral one-third with proximal bone block)	Femoral origin of LCL	Maintain attachment to tibial tubercle	Staple at femoral side	45º flexion/external rotation

ACL: Anterior cruciate ligament; ALL: Anterolateral ligament; AP: Anteroposterior; BTB: Bone-patellar tendon-bone; LCL: Lateral collateral ligament; ITB: Iliotibial band; nm: Not mentioned; SAMBBA: Single anteromedial bundle biological augmentation.

Table 2 Lateral extraarticular tenodesis and anterolateral ligament reconstruction Techniques: Advantages and disadvantages[39,72,73]

Advantages	Disadvantages
1. Lateral extraarticular tenodesis
Improvement of rotational knee stability	Non-anatomic procedure
Reduction of ACL graft failure rate	Possible over-constraining
Reproducible, easy-to-learn technique	May add pain to postoperative rehabilitation
Inexpensive procedure, especially when using high-resistance suture	Muscle herniation, if ITB closure is not performed in proper way
No risk of tunnel coalition when fixed with sutures proximally
2. Anterolateral ligament reconstruction
Improvement of rotational knee stability	Need ability to identify anatomic landmarks
Reduction of ACL graft failure rate	Use of allograft or synthetic results in increased cost
Preserves iliotibial band	Use of autograft requires additional surgery for graft harvest and possible donor site morbidity
Avoids lateral collateral ligament attachment
Secure graft fixation allows for early motion and accelerated anterior cruciate ligament rehabilitation

ACL: Anterior cruciate ligament; ITB: Iliotibial band.