Combined ACL and ALL reconstruction reduces ACL failure rates according to a recent clinical study.
The integration of anterolateral ligament (ALL) reconstruction during anterior cruciate ligament (ACL) surgery is an interesting topic in modern orthopaedic surgery. The idea of combining these two procedures aims to improve knee stability and reduce the rate of ACL graft failures.
This article explores the findings of the study "Clinical Outcomes of Isolated ACL Reconstruction Versus Combined ACL and ALL Reconstruction With Indication Guided by Intraoperative Ultrasound", led by Professor Etienne Cavaignac and his colleagues at the University Hospital of Toulouse.
The approach they assessed uses intraoperative ultrasound to guide the decision to perform ALL reconstruction.
For further details on Professor Cavaignac’s work, or to explore additional studies on knee ligament injuries, readers are invited to consult his published research.
The study demonstrates that ALL for ACL reconstruction can contribute to better long-term outcomes by potentially reducing ACL graft failure. Importantly, the decision to reconstruct the ALL was not made preoperatively but based on real-time assessment with intraoperative ultrasound. This ensures that ALL reconstruction with an ACL operation is applied only in relevant cases, avoiding unnecessary procedures and improving the precision of surgical decision-making.
In the study, 260 patients were matched into two groups:
Both groups had a minimum of two years’ follow-up, with an average of 36.7 months. The failure rate for the isolated ACL group was 6.9%, while the combined group showed a lower rate at 2.3%. Although this difference did not reach statistical significance, the trend clearly favours the additional procedure. Particularly in younger patients (≤20 years), the benefit of ALL reconstruction may be more pronounced, as this group was found to have a higher rate of graft failure overall.
In addition to graft survival, the study monitored complications and functional outcomes, which were similar between both groups. This reinforces the idea that the combined reconstruction does not increase risk and may offer protective advantages when indicated.
Perhaps the most important insight from this research is the value of personalisation. Rather than universally applying ALL reconstruction to every ACL procedure, the study advocates a selective strategy. By using intraoperative ultrasound to confirm ALL injury, surgeons can tailor the intervention to the patient’s actual anatomical and clinical findings.
Ultrasound proves to be a reliable and cost-effective diagnostic tool, capable of detecting ALL lesions that may not be visible on MRI. This is particularly valuable in cases where rotational instability is clinically suspected but not confirmed on imaging. The use of real-time imaging empowers the surgeon to adjust the surgical plan intraoperatively, enhancing precision and avoiding over-treatment.
The findings highlight that this technique should not be viewed as a routine addition, but rather as a targeted solution for patients who present with specific biomechanical deficits. This ensures a balance between efficacy and safety, reducing unnecessary procedures while maximising surgical outcomes.
The surgical technique for ALL reconstruction while ACL reconstruction is ongoing has been optimised for safety and efficacy. Intraoperative ultrasound plays a central role. With the knee positioned at 90° flexion and internally rotated, the ultrasound probe is used to visualise the ALL, evaluate its tension and detect any discontinuity or abnormalities.
When an ALL lesion is identified, the surgeon proceeds with a minimally invasive approach to reconstruct it using the gracilis tendon. The semitendinosus tendon is used to prepare the ACL graft. This dual-graft method preserves muscle function while restoring knee stability. The ALL graft is fixed using advanced anchoring techniques, minimising hardware-related complications. The precision offered by ultrasound allows for highly accurate tunnel placement and reduced surgical trauma.
This intraoperative guidance ensures that the combined ALL reconstruction with ACL operation is carried out only when needed, preserving resources and optimising patient outcomes. The technique is particularly beneficial for patients with a high pivot shift or associated meniscal lesions, where rotational instability is more likely.
For ACL and ALL reconstruction, the recovery protocol is rigorous yet structured to ensure optimal healing and return to function. The study employed a standardised rehabilitation plan for all patients:
By the third month, patients begin running and by the seventh month, sport-specific training is introduced under supervision. The overall functional outcomes, assessed by Lysholm, IKDC and SKV scores, were equivalent in both groups. This supports the conclusion that this combined method does not delay or impair the rehabilitation process.
A slightly higher rate of hardware removal was observed in the ALL group, mostly due to earlier techniques using staples. With the transition to knotless anchors, this issue has been significantly reduced in more recent cases.
The study encourages further exploration into the long-term effects of combined reconstruction. While the current follow-up averaged just over three years, extended monitoring will help clarify whether the trend towards fewer failures continues over time. Moreover, the potential preventative benefit of ALL reconstruction in protecting repaired menisci and reducing future joint degeneration warrants deeper investigation.
Professor Cavaignac and his team have also introduced the use of the Orthense digital platform for postoperative follow-up, enabling personalised remote monitoring and better patient adherence to rehabilitation protocols. This technological integration aligns with the study’s emphasis on precision and individualised care.
The study led by Professor Cavaignac reinforces the role of intraoperative ultrasound in guiding ALL reconstruction during an ACL operation and supports a more nuanced, patient-specific approach to ACL surgery.
Although overall graft survival rates were statistically equivalent, the combined procedure shows promising trends in reducing failure, especially in high-risk populations.
These findings provide valuable insights for orthopaedic surgeons and offer reassurance to patients seeking the most effective treatment.
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