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The results of anterior cruciate ligament reconstruction (ACLR) are widely recognized to be satisfactory on the basis of outcome measures such as the International Knee DocumentationCommittee (IKDC)and Lysholmscores. However, there is moderate variation among several series of different techniques. For example, Hussein et al showed a range of residual pivot, from 7% to 33%, depending on the technique used. Furthermore, up to 30% of patients in contemporary series can still experience persistent instability, and only 65% to 83% can return to the preinjury level of sport. The pathophysiology of these important outcomes is multifactorial and may include nonanatomic graft orientation, meniscal deficiency, bone morphology, poor neuromuscular control, and (of particular recent interest) concomitant injury to the anterolateral structures of the knee. Systematic reviews have demonstrated that for those patients with high preoperative grades of pivot shift, the rate of residual pivot shift is significantly lower when a lateral extra-articular tenodesis is performed in addition to ACLR. In addition, Rezende et al showed that patients with combined reconstructions were more likely to demonstrate improved stability based on the pivot-shift test. Even though controversy still exists regarding the biomechanical role of the anterolateral ligament (ALL), these clinical results are consistent with cadaveric sectioning studies that indicate an important role for the ALL in controlling the pivot-shift phenomenon. It has therefore been suggested that when high grades of pivot shift are detected preoperatively, an unrecognized injury to the ALL should be considered because isolated ACLR may fail to restore normal knee stability. Although lateral extra-articular procedures are associated with improved rates of persistent pivot shift, graft rupture, and return to sport when performed at the time of ACLR, the role of isolated ALL reconstruction among those patients presenting with persistent instability after isolated ACLR has not, to our knowledge, been previously evaluated. However, this is an important group of patients, not only because of the functional limitations of persistent instability, but also because of the high rates at which this phenomenon is reported to occur and the fact that alternative surgical strategies (revision ACLR or selective reconstruction of the posterolateral bundle) are associated with specific additional complications. The good short-term clinical outcomes from large series of combined anterior cruciate ligament (ACL) and ALL Address correspondence to Camilo Partezani Helito, MD, PhD, Rua Ovı́dio Pires de Campos 333, São Paulo, SP 05403-010, Brazil (email: camilo_helito@yahoo.com.br). Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil. Hospital Sı́rio Libanês, São Paulo, Brazil. Medical Technologies and Advanced Materials, Clifton Campus, Nottingham Trent University, Nottingham, UK. Renacres Hospital, Lancashire, UK. {Kansas City University, Kansas City, Missouri, USA. University of Rome La Sapienza, Rome, Italy. **Centre Orthopédique Santy, FIFA Medical Centre of Excellence, Groupe Ramsay-Generale de Sante, Hospital Privé Jean Mermoz, Lyon, France. One or more of the authors declared the following potential conflict of interest or source of funding: E.M., A.S. and B.S.-C. are paid consultants for Arthrex. Ethical approval for this study was obtained from the University of São Paulo, São Paulo, Brazil.

Anterolateral Ligament Reconstruction: A Possible Option in the Therapeutic Arsenal for Persistent Rotatory Instability After ACL Reconstruction