Editorial Commentary: Anterolateral Ligament Augmentation for the Anterior Cruciate Ligament–Deficient Knee Debate—The Proof Is in the Pudding

Abstract

The highly debatable and contentious anterolateral ligament (ALL) and its use as an augmentation for the anterior cruciate ligament (ACL)edeficient knee during ACL reconstruction continue to flourish in the literature, but the proof will be in the clinical outcome. Despite the ALL controversy, what clearly stands out from authors on either side of the debate is that there is much more going on than just the ACL in the ACL-deficient knee. Techniques of ALL augmentation or lateral extra-articular tenodesis continue to show promise that the lateral soft-tissue structures may provide the answer for the residual pivot and for better outcomes, higher return-to-sport rates, and lower rupture rates. Many authors and researchers believe that this may be a critical adjunct in high-risk situations during ACL reconstruction. But the proof of the pudding will be in the eating.

Editorial Commentary: This Is the Way: Extra-Articular Augmentation Is an Essential Consideration in Contemporary Anterior Cruciate Ligament Surgery

“…I will further echo Getgood's 2018 piece in which he called for moving past the debate on whether the ALL exists to work on advancing evidence-based surgical solutions to address pathologic rotational knee instability. 8 Finally, I recommend everyone review Rossi's 2019 editorial 9 for an excellent chronology of landmark studies that have shaped our growing understanding of the ALC; I agree that the debate and controversy around ALL reconstruction has progressed from a question of "if" to questions of "when" and "how." Put another way, we need to know which ACL patients will benefit significantly from concurrent extra-articular augmentation.…”

Editorial Commentary: Extension of Knowledge—and the Knee! New Biomechanical Study Suggests the Clinical Practice of Anterolateral Ligament Fixation Near Extension

“…But, as pointed out recently by Rossi in an Arthroscopy editorial (and matching my personal opinion), "The story is not any more 'if' augmentation should be considered but 'when' and, maybe more important, 'how' to augment." 31 Considering all these points, I read with great interest the article entitled "Elongation Patterns of the Anterior and Posterior Borders of the Anterolateral Ligament of the Knee," by Ahn, Koh, McGarry, Patel, Lin, and Lee. 32 This cadaveric biomechanical study is important because it investigates ALL behavior during knee flexion-extension, internal-external rotation, anteroposterior translation, and varus-valgus angulation.…”

Editorial Commentary: Lateral Extra-Articular Tenodesis Results in Better Stability After Anterior Cruciate Ligament Reconstruction for Patients With High-Grade Pivot Shifts

“…As Rossi 1 pointed out, throughout this process "what clearly stands out . is that there is much more going on than just the ACL in the ACL-deficient knee."…”

“…Is today's discussion not if augmentation should be considered, but when and how? 1 The actual problem is the ACL graft failure rate. As mentioned, many excellent commentaries and publications have addressed this subject, but as the coach always said, don't forget the basics.…”