Anterolateral ligament reconstruction is a supplemental procedure performed alongside ACL reconstruction in selected patients to address rotational instability that the ACL alone cannot fully control. The ALL is a small ligament on the lateral side of the knee, recently better characterized in the orthopaedic literature. ALL reconstruction is most often added to ACL reconstruction in young athletes returning to pivoting sport, particularly those with high pivot shift on examination or revision cases.
What Is ALL Reconstruction?
The anterolateral ligament is a thin ligament running from the lateral femoral epicondyle to the proximal tibia, just anterior to the lateral collateral ligament. It contributes to control of internal tibial rotation, working alongside the ACL.
ALL reconstruction replaces the torn or insufficient ALL with a tendon graft (typically a strip of iliotibial band or a separate tendon graft). The graft is secured to the femur and tibia at the native ALL attachments. The procedure adds approximately 30 minutes to a standard ACL reconstruction and uses a small additional incision on the lateral knee.
Who Is a Candidate?
Candidates for ALL reconstruction added to ACL reconstruction typically have:
- High pivot shift on examination, indicating residual rotational instability after ACL repair alone
- Young age and return to high-demand pivoting sport
- Revision ACL reconstruction where rotational stability is a concern
- Generalized ligamentous laxity
- Lateral femoral notch sign on imaging (a marker of high-energy ACL injury with associated rotational instability)
Patients with low pivot shift and low-demand activity goals do not typically require ALL reconstruction added to standard ACL repair.
How the Procedure Is Performed
The procedure is performed alongside ACL reconstruction through standard arthroscopic portals plus a small lateral incision. The lateral femoral epicondyle and proximal tibia are exposed at the native ALL attachments.
A tendon graft is harvested or prepared. Bone tunnels or anchor points are created at the femoral and tibial ALL footprints. The graft is secured at both ends with interference screws or cortical buttons.
The ACL reconstruction is performed first, with the ALL reconstruction added to address residual rotational instability.
Recovery and Rehabilitation
Recovery follows the ACL reconstruction timeline because the ACL is the larger procedure:
- Brace and progressive weight-bearing as for ACL reconstruction
- Range of motion and strengthening per ACL protocol
- Return to sport at six to nine months following objective testing
The ALL reconstruction does not significantly extend the recovery timeline beyond what ACL reconstruction alone requires.
Risks and Outcomes
Risks include hardware irritation at the lateral femur, persistent instability, infection, and complications of the donor site (when autograft is used). Outcomes data are still emerging because the procedure has been widely adopted only in the past decade.
Initial studies show improved rotational stability and reduced ACL re-tear rates when ALL reconstruction is added to primary ACL reconstruction in selected high-risk patients.
Why Dr. Chudik for ALL Reconstruction
Dr. Chudik treats ACL injury across the spectrum, from primary anatomic reconstruction to revision and combined procedures. ALL reconstruction is added when individual factors warrant it, particularly in young high-demand athletes and revision cases. His arthroscopic experience and high case volume of complex knee reconstruction inform candidate selection and surgical technique.