Background: Anterolateral soft tissue structures of the knee have a role in controlling anterolateral rotational laxity, and they may
be damaged at the time of anterior cruciate ligament (ACL) ruptures.
Purpose: To compare the kinematic effects of anterolateral operative procedures in combination with intra-articular ACL reconstruction
for combined ACL plus anterolateral–injured knees.
Study Design: Controlled laboratory study.
Methods: Twelve cadaveric knees were tested in a 6 degrees of freedom rig using an optical tracking system to record the kinematics
through 0 to 90 of knee flexion with no load, anterior drawer, internal rotation, and combined loading. Testing was first
performed in ACL-intact, ACL-deficient, and combined ACL plus anterolateral–injured (distal deep insertions of the iliotibial band
and the anterolateral ligament [ALL] and capsule cut) states. Thereafter, ACL reconstruction was performed alone and in combination
with the following: modified MacIntosh tenodesis, modified Lemaire tenodesis passed both superficial and deep to the
lateral collateral ligament, and ALL reconstruction. Anterolateral grafts were fixed at 30 of knee flexion with both 20 and 40 N
of tension. Statistical analysis used repeated-measures analyses of variance and paired t tests with Bonferroni adjustments.
Results: ACL reconstruction alone failed to restore native knee kinematics in combined ACL plus anterolateral–injured knees (P\
.05 for all). All combined reconstructions with 20 N of tension, except for ALL reconstruction (P 5 .002-.01), restored anterior
translation. With 40 N of tension, the superficial Lemaire and MacIntosh procedures overconstrained the anterior laxity in deep
flexion. Only the deep Lemaire and MacIntosh procedures—with 20 N of tension—restored rotational kinematics to the intact
state (P . .05 for all), while the ALL underconstrained and the superficial Lemaire overconstrained internal rotation. The same
procedures with 40 N of tension led to similar findings.
Conclusion: In a combined ACL plus anterolateral–injured knee, ACL reconstruction alone failed to restore intact knee kinematics.
The addition of either the deep Lemaire or MacIntosh tenodesis tensioned with 20 N, however, restored native knee kinematics.
Clinical Relevance: The current study indicates that unaddressed anterolateral injuries, in the presence of an ACL deficiency,
result in abnormal knee kinematics that is not restored if only treated with intra-articular ACL reconstruction. Both the modified
MacIntosh and modified deep Lemaire tenodeses (with 20 N of tension) restored native knee kinematics at time zero.