Clinical Outcomes of Isolated ACL Reconstruction Versus Combined ACL and ALL Reconstruction With Indication Guided by Intraoperative Ultrasound: A Propensity Score–Matched Study of 260 Patients With a Minimum 2-Year Follow-up

Background: Additional anterolateral ligament (ALL) reconstruction has been associated with improved clinical outcomes and reduced failure rates in anterior cruciate ligament (ACL) reconstruction. Despite the excellent clinical results reported, there is still a heated debate about its indications. Currently, the indications are mainly based on the patient’s clinical criteria and not the imaging diagnosis of the injury of this ligament. Purpose: To compare the clinical outcomes of patients undergoing isolated ACL reconstruction and combined ACL and ALL reconstruction conditioned to intraoperative ultrasound-guided diagnosis of the ALL lesion. Study design: Cohort study; Level of evidence, 3. Methods: A retrospective analysis of prospectively collected data was performed. Patients undergoing primary ACL reconstruction between January 2017 and January 2022 were included. Patients were excluded if they had a previous history of ipsilateral knee surgery or if they underwent other concomitant procedures, including multiligament reconstruction surgery or osteotomy. The decision to perform an ALL reconstruction in addition to isolated ACL reconstruction was based on ultrasound diagnosis of this lesion. At the end of the study period, further knee injury and any other reoperations or complications were recorded and compared between patients who had isolated ACL reconstruction (no-ALLR group) and combined ACL and ALL. Propensity score matching was performed between groups. A multivariable analysis using the penalized Cox model was performed to explore the relationship between the graft rupture, surgical procedure type, and potential explanatory variables. Results: A total of 339 patients met the predefined eligibility criteria; 146 ACL reconstructions were performed in an isolated manner (no-ALLR group) and 193 were combined with ALL (ALLR group). After matching, 130 patients were allocated to each group. The mean follow-up was 36.7 months. The overall graft failure rate was 4.6% (6.9% in the no-ALLR group and 2.3% in the ALLR group; P = .076). The adjusted Cox regression showed that graft failure rate was nonsignificantly different between the groups (adjusted hazard ratio [HR], 0.36 [95% CI, 0.096-1.364]; P = .133). Younger age (≤20 years) was associated with graft failure (adjusted HR, 0.29 [95% CI, 0.121-0.719]; P = .007). Conclusion: Combined ACL and ALL reconstruction conditioned to intraoperative ultrasound-guided diagnosis of the ALL lesion has an equivalent ACL graft failure rate to isolated ACL. Intraoperative ultrasound diagnosis of an ALL injury may be an indication for the addition of an ALL reconstruction.