A 37-year-old female professional dancer sustained an ACL injury to her right knee in a motorcycle accident in 2011. She underwent subsequent ACLR. At the time of surgery, examination revealed 3+ Lachman and 3+ pivot-shift tests, with no concomitant injuries. The reconstruction was performed with 8-mm-diameter quadrupled hamstring tendons, normally the first choice for women at this age in our country. The femoral tunnel was drilled close to the anteromedial bundle position with an outside-in technique. The fixation was performed with metal interference screws at 30  of knee flexion.
Postoperatively, the patient participated in standard rehabilitation for ACLR and underwent an uncomplicated recovery. Even though an improvement in instability was noted in activities of daily living, the patient still complained of episodes of giving way with rotational movements, mainly during dance-related jumping and landing exercises. As a result, further rehabilitation was prescribed focusing on quadriceps and gluteal muscle strengthening and proprioception. One year following ACLR, the patient had good core stability and negative Lachman (KT-1000 of 4 mm) and anterior drawer test results but had a residual pivot glide. Despite continued participation in rehabilitation, the patient was unable to perform professional dance activity owing to persistent rotatory instability.
Given the failure of this additional nonoperative treatment at 2 years following ACLR, a surgical procedure was considered. It was noted that the first reconstruction was technically adequate, with an intact graft (Figure 1) and appropriate tunnel positioning (Figure 2). There was no clinical or magnetic resonance imaging evidence of concomitant intra-articular pathology (eg, altered bony morphology, tibial slope, or meniscal/chondral lesions). The surgical options initially proposed were ACL revision or an augmentation of the posterolateral bundle. The patient was counseled regarding the surgical morbidity and possible complications of a revision procedure. In addition, the possibility of performing an isolated reconstruction of the ALL was discussed. It was specifically stated that isolated ALL reconstruction had not previously been reported as a treatment for persistent instability after a technically adequate ACLR but that we had experience of good results of combined ACL and ALL reconstructions for the treatment of patients with high-grade pivot shift. The patient was completely aware and accepted the risks of ALL reconstruction in preference to a revision ACL procedure.
Initially, knee arthroscopy was performed to assess the integrity of the ACL graft and any associated lesions. The ACL graft, though with an imperfect vascularized appearance and minimal laxity, was intact and functional, and no associated lesions were found. For the ALL reconstruction, a lateral incision was made in line with the iliotibial band, and a femoral tunnel on the posterior border of the lateral epicondyle and a tibial tunnel between the Gerdy tubercle and the fibular head (7 mm distal to the lateral tibial plateau) were created with a 7-mm drill. An allograft semitendinosus tendon from our institution's tissue bank was used as a graft, and fixation was performed at 30  of flexion and neutral rotation with absorbable 7 x 25-mm interference screws (Smith & Nephew) (Figures 3 and 4). The allograft was chosen because, despite being a low-morbidity solution, we did not want to harvest either the iliotibial band or the contralateral side. After the ALL reconstruction was performed, repeat clinical examination revealed that the preoperative pivot glide had been abolished (see the Video Supplement).
Postoperative rehabilitation comprised immediate range of motion exercises and full weightbearing with a brace worn while walking for 3 weeks. At 6 weeks postoperatively, the patient stated that the knee was more stable, and at 3 months, she returned to her dance activities without restriction and without subjective complaints of rotational instability. At 4 months after the ALL reconstruction, she was back to her preinjury level of dance participation. At 2 years after reconstruction of the ALL, the patient experienced no further instability and had negative pivot-shift and Lachman test results. The IKDC score increased from 87.4 at 4 years after ACLR to 96.6 at final follow-up after ALL reconstruction.
Informed consent was obtained from the patient for publication, including photographs and video material.