Thank you very much for the introduction and the offer to speak today, and for the warm welcome we've received from Ireland, particularly last night. So I've been asked to talk about the fact that AL is needed for the perfect ACL reconstruction. Paul Sagan originally described this very important ligament back in 1879. The poor man would probably be turning in his grave today if he thought we were still debating this, but nonetheless it arises. Houston et al. also outlined the importance of this ligament back in the 70s when they spoke about the anterolateral instability pattern of the knee and its association with the ALL itself. More recent studies have identified and reaffirmed for us the fact that the ALL is part of normal knee anatomy. In this study of 40 knees, it was present and easily identifiable in all patients. And in this other study of 41 dissected cadaver knees, again it was seen in 97% of knees. Combined ALL and ACL injuries are very common. In this retrospective study looking at MRIs of 206 patients undergoing ACL reconstruction, a significant ALL injury was identified and seen in 79% of these scans. Another study published by Ferretti et al. looking at 60 patients who underwent ACL reconstruction who had their lateral compartment exposed and dissected out during the ACL reconstruction, 91% were found to have significant ALL injuries, although only 10% had Sagan fractures, reaffirming to us again that even when a Sagan fracture is not seen, there may be a significant ALL injury. Unfortunately for those of us who do ACL reconstruction surgery, residual instability is still quite common, seen and reported in approximately 25% of patients, and failure or relatively early failure of grafts is reported between 1.7 and 7% of patients on an ongoing basis. We know that the ALL is a significant secondary stabilizer of the knee. Leprad and co. have done extensive studies of this in cadaver models. They've shown the combined sectioning of the ACL and ALL resulted in significant increases in tibial translation and internal rotation when compared with both the intact and ACL deficient knee states. The flip side of that is that when they reconstructed these ligaments in the cadaver models, they were able to show a significant reduction in tibial translation and internal rotation compared to isolated ACL reconstruction alone. Now, what is important to understand, and it relates to this debate in particular, is the fact that ALL reconstruction is not the same as lateral extra-articular tenodesis. Lateral extra-articular tenodesis has been shown to reduce the forces through an ACL graft by up to 43%. However, it fell out of favor largely because of reported cosmetic problems, a feeling that crepitations and anterior knee pain were becoming a problem because of it, and a theory that lateral compartment degenerate change over time may be an issue. However, this was related to the lateral extra-articular non-anatomic tenodesis. We're talking about ALL anatomic reconstruction. The Santee Group have looked at this. They looked at 548 patients undergoing quadruple hamstring graft ACL reconstruction and ALL reconstruction and showed that this knee stiffness and higher re-operation rates should really be confined to the history books. That relates to a previous operation, but in these ALL anatomic reconstructions, this is no longer seen or a problem. Similarly, combined ALL and ACL reconstruction results in lower ACL re-rupture rates. This has to be the goal for all of us. In this systematic review, graft re-rupture rates in the combined group were 3.1 times lower than the hamstring group and 2.5 times lower than the patella tendon group. Combined ACL and ALL reconstruction has been shown to be meniscal protective. In this comparative study of 196 isolated ACL reconstructions compared with 184 combined reconstructions, the survival rate of all meniscal repairs was superior in the combined group and the probability of failure of a medial meniscal repair was two times lower in the combined group also. ALL reconstruction then is also important in the revision ACL setting. This is a study from Korea looking at 87 patients. They had 45 who underwent isolated reconstruction and 42 who went combined reconstruction. They used a Tibant allograft for their ACLs and a gracilis allograft for their ALLs. They showed lower rates of pivot-shift positive patients post-op in the combined group. More important than that, as we all know, is that the return to sport at the same level was statistically higher again in the combined group. So in conclusion, ladies and gentlemen, the ALL is part of normal anatomy. Reoperation rates are not higher. Rerupture rates are lower. Combined ALL and ACL reconstruction is meniscal protective and same-level return to sport is higher in revision patients. Thanks for your attention.

anterolateral ligament

ACL reconstruction surgeries

knee anatomy

ALL injuries

graft failure