Anterior cruciate ligament reconstruction achieved noninferior patient reported outcome measures while residual rotational instability depends on anterolateral ligament femoral tunnel position: A matched analysis

Abstract

Background: The efficacy of anterolateral ligament (ALL) reconstruction in low-demand patients remains unclear. Therefore, we aimed to analyse the outcomes of ALL reconstruction with anterior cruciate ligament (ACL) reconstruction in low-demand patients. Methods: Patients who underwent arthroscopic ACL reconstruction using the transportal technique between March 2010 and December 2022 with a minimum 2-year follow-up were retrospectively reviewed. Patients with preoperative high-grade pivot shifts (grades 2 and 3) were classified into two groups based on whether ALL reconstruction was performed. Matched cohort analysis, including noninferiority analyses for subjective and objective outcomes, was performed. Additionally, a subgroup analysis of postoperative outcomes was performed based on the position of the anterolateral ligament-femoral tunnel. Results: Twenty-nine patients were included in each group. No significant differences were found in the preoperative or postoperative variables. Patient-reported outcome measures (PROMs) met the noninferiority trial criteria, whereas the residual pivot shift did not. Subgroup analysis comparing results according to the femoral tunnel of the ALL resulted in a significantly higher proportion of patients with a residual pivot shift when the femoral tunnel was positioned anterior to the lateral epicondyle compared to posterior placement (P = 0.035 and 0.021 at 1 and 2 years postoperatively). Conclusions: ACL reconstruction without ALL reconstruction was noninferior for PROMs. However, residual rotational instability was affected by the ALL femoral tunnel position, which favours femoral tunnel posterior to the lateral epicondyle. Therefore, routine addition of ALL reconstruction in low-demand patients may not be necessary, and greater emphasis should be placed on precise ALL femoral tunnel positioning. (c) 2026 Elsevier B.V. All rights are reserved, including those for text and data mining, AI training, and similar technologies.