Does graft choice affect your knee surgery outcome? New evidence on ACL and ALL reconstruction offers a reassuring answer. Two surgical techniques for anterolateral ligament reconstruction produce equivalent clinical outcomes, offering surgeons genuine flexibility when stabilising ACL-deficient knees.
This article is based on a detailed peer-reviewed study published by the SANTI Study Group: Comparison Between Continuous and Separate Grafts for ALL Reconstruction When Combined With ACL Reconstruction: A Retrospective Cohort Study From the SANTI Study Group. For the complete methodology and raw data, readers are encouraged to consult the original publication directly.
Understanding anterolateral augmentation in ACL reconstruction
Anterior cruciate ligament (ACL) reconstruction is one of the most common orthopaedic procedures worldwide, yet some patients continue to experience rotational instability after surgery. To address this, surgeons increasingly combine ACL reconstruction with procedures that reinforce the anterolateral side of the knee, the outer-front region responsible for rotational control.
Two main approaches exist for this augmentation:
- Lateral extra-articular tenodesis (LET): a non-anatomical technique that reroutes a tendon over the outside of the knee to limit internal rotation.
- Anterolateral ligament reconstruction (ALLR): an anatomical technique that reproduces the native anterolateral ligament (ALL), a distinct structure running along the outer knee that resists excessive tibial rotation.
For ALLR, surgeons typically harvest the gracilis tendon (a slender muscle from the inner thigh) as a graft. The question addressed by the SANTI Study Group was straightforward but clinically meaningful: does it matter whether that gracilis graft is used continuously, sharing a single femoral tunnel with the ACL graft, or separately, with its own independent femoral tunnel?
Study design and patient population
This retrospective cohort study analysed data from 415 patients treated at two hospitals between 2015 and 2020. One centre routinely used a continuous gracilis graft (CG) with a single femoral tunnel; the other preferred a separate gracilis graft (SG) with independent tunnels. All patients were aged 18 to 60, had surgery within 24 months of injury, and were followed for a minimum of two years.
Outcomes were assessed using two validated scoring tools:
| Score | What it measures |
| IKDC-SKF (International Knee Documentation Committee Subjective Knee Form) | Patient-reported knee function and symptoms |
| Lysholm score | Knee-specific functional outcomes including pain, instability, and activity level |
Results: two techniques, one outcome
The findings showed no meaningful difference between the two configurations. Key results included:
- Graft rupture rate: 3.4% (CG) vs 2.8% (SG), no statistically significant difference (p = 0.785)
- Complication rate: 6% (CG) vs 10% (SG), no statistically significant difference (p = 0.112)
- IKDC-SKF score: 88.1 (CG) vs 87.9 (SG), virtually identical (p = 0.267)
- Lysholm score: both groups reached excellent results, with 90.0 (CG) and 92.4 (SG)
These numbers tell a consistent story: whether the gracilis tendon is used as a continuous graft sharing a femoral tunnel or as a separate graft with its own anchor point, patients recover with comparable knee stability, function and satisfaction.
For a full breakdown of preoperative characteristics, intraoperative data, and subgroup analyses, the original study provides considerably more depth, it is well worth consulting for surgeons refining their technique.
Conclusion & Findings
The SANTI Study Group’s findings offer reassuring evidence that both gracilis graft configurations for combined ACL and ALL reconstruction yield equivalent outcomes in terms of graft rupture rates, complication rates, and patient-reported functional scores. Surgeons can therefore select the technique that best suits their training and intraoperative context, without compromising results.
If you found this scientific publication useful, Professor Cavaignac has conducted several other studies on knee reconstruction and anterolateral anatomy, exploring them is a worthwhile step for anyone seeking to deepen their understanding of this field.
Professor Cavaignac brings a rigorous, research-driven approach to knee surgery, and his published work continues to shape how surgeons approach complex ACL-related instability.