Biomechanical Comparison of Anterolateral Procedures Combined With Anterior Cruciate Ligament Reconstruction

Background: Anterolateral soft tissue structures of the knee have a role in controlling anterolateral rotational laxity, and they may be damaged at the time of anterior cruciate ligament (ACL) ruptures. Purpose: To compare the kinematic effects of anterolateral operative procedures in combination with intra-articular ACL reconstruction for combined ACL plus anterolateral-injured knees. Study Design: Controlled laboratory study. Methods: Twelve cadaveric knees were tested in a 6 degrees of freedom rig using an optical tracking system to record the kinematics through 0 degrees to 90 degrees of knee flexion with no load, anterior drawer, internal rotation, and combined loading. Testing was first performed in ACL-intact, ACL-deficient, and combined ACL plus anterolateral-injured (distal deep insertions of the iliotibial band and the anterolateral ligament [ALL] and capsule cut) states. Thereafter, ACL reconstruction was performed alone and in combination with the following: modified MacIntosh tenodesis, modified Lemaire tenodesis passed both superficial and deep to the lateral collateral ligament, and ALL reconstruction. Anterolateral grafts were fixed at 30 degrees of knee flexion with both 20 and 40 N of tension. Statistical analysis used repeated-measures analyses of variance and paired t tests with Bonferroni adjustments. Results: ACL reconstruction alone failed to restore native knee kinematics in combined ACL plus anterolateral-injured knees (P < .05 for all). All combined reconstructions with 20 N of tension, except for ALL reconstruction (P = .002-.01), restored anterior translation. With 40 N of tension, the superficial Lemaire and MacIntosh procedures overconstrained the anterior laxity in deep flexion. Only the deep Lemaire and MacIntosh procedureswith 20 N of tensionrestored rotational kinematics to the intact state (P > .05 for all), while the ALL underconstrained and the superficial Lemaire overconstrained internal rotation. The same procedures with 40 N of tension led to similar findings. Conclusion: In a combined ACL plus anterolateral-injured knee, ACL reconstruction alone failed to restore intact knee kinematics. The addition of either the deep Lemaire or MacIntosh tenodesis tensioned with 20 N, however, restored native knee kinematics. Clinical Relevance: The current study indicates that unaddressed anterolateral injuries, in the presence of an ACL deficiency, result in abnormal knee kinematics that is not restored if only treated with intra-articular ACL reconstruction. Both the modified MacIntosh and modified deep Lemaire tenodeses (with 20 N of tension) restored native knee kinematics at time zero.