Reverse Passing of Anterior Cruciate Ligament Reconstruction With Simultaneous Anterolateral Ligament Reconstruction Using Hamstring Autograft

Anterior cruciate ligament reconstruction continues to evolve as surgical techniques aim to optimize graft placement, increase rotational control, and reduce graft failure in high-risk populations. This technical note describes an inverse anterior cruciate ligament reconstruction combined with an anatomic anterolateral ligament reconstruction, incorporating a retrograde tibial half-tunnel and outside-in femoral drilling. The technique is compatible with hamstring, quadriceps tendon, and bone-patellar tendon-bone autografts. Tibial fixation is achieved using a suspensory button that can be directly visualized on the anteromedial cortex, while femoral fixation is performed with an interference screw. The remaining semitendinosus strand or the FiberTape reinforcement is routed beneath the iliotibial band and lateral collateral ligament and anchored at Gerdy's tubercle to anatomically recreate the anterolateral ligament. This procedure is indicated for young athletes, patients with high rotational demands, positive pivot-shift or Jerk tests, primary cases with high rerupture risk, and selected revision scenarios. Advantages of the technique include enhanced anteroposterior and rotational stability, improved graft-bone interface healing through circumferential tunnel contact, preservation of the iliotibial band, minimized morbidity of anterolateral ligament augmentation, and reliable intraoperative visualization of tibial fixation. Additionally, the outside-in femoral approach offers versatility for revision surgery and physeal-sparing application in skeletally immature patients.