Anterolateral ligament reconstruction in addition to primary double-bundle anterior cruciate ligament reconstruction for grade 3 pivot shift improves residual knee instability during surgery

Purpose High-grade pivot shift in the anterior cruciate ligament (ACL) injured knee is a risk factor for postoperative residual pivot shift. Procedures in addition to ACL reconstruction such as anterolateral ligament (ALL) reconstruction have been performed for patients with a high-risk of residual pivot shift. The aim of this study was to investigate the effect of the addition of ALL reconstruction to primary double-bundle ACL reconstruction in patients with preoperative high-grade pivot shift to improve stability as evaluated by quantitative measurement. Methods Patients with ACL injuries who showed preoperative grade 3 subjective pivot shift and who underwent primary double-bundle ACL reconstruction combined with ALL reconstructions were retrospectively enrolled. Anterior tibial translation (ATT) in the Lachman test, and acceleration and external rotational angular velocity (ERAV) in the pivot shift were measured as quantitative values. Quantitative values before surgical intervention for ACL-injured knees (ACLD) and uninjured contralateral knees (intact), after temporary fixation of the isolated ACL grafts (ACLR), and subsequently after temporary fixation of both ACL and ALL grafts (ACLR + ALLR) were measured with the patient under general anaesthesia. Results In total, 18 patients were included. The ATT was lower in ACLR and ACLR + ALLR than in intact ( P = .008 and .005), while there was no significant difference between ACLR and ACLR + ALLR ( P > .05). The acceleration of ACLR + ALLR was lower than that for ACLR ( P = .008), while there was no significant difference between intact and ACLR or ACLR + ALLR ( P > .05). The ERAV of ACLR was higher than that of intact ( P < .001), while that of ACLR + ALLR was lower than that of ACLR ( P < 0.001), and there was no significant difference in ERAV between intact and ACLR + ALLR ( P > 0.05). Conclusion According to quantitative assessment of the pivot shift, the addition of ALL reconstruction to primary double-bundle ACL reconstruction improved residual knee instability and restored knee stability during surgery. Combination of ALL reconstruction with primary double-bundle ACL reconstruction was effective for patients with ACL injuries exhibiting a preoperative grade 3 subjective pivot shift. Level of evidence IV