anterolateral ligament & extra-articular...

EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION

AnteroLateral Ligament & Extra-articular

Reconstructions

R O B E RT N A S C I M E N TO , M D, M S

C H I E F O F S P O RT S M E D I C I N E & S H O U L D E R S U RG E RY

N E W TO N - W E L L ES L E Y H O S P I TA L

M E D I C A L D I R EC TO R & H EA D T EA M P H YS I C I A N , B O STO N C O L L EG E AT H L E T I C S


Disclosures

Depuy Mitek Sports Medicine – Speaker / Education

Smith & Nephew - Consultant


This is not a new phenomenon!!

1989


Recommended against combination procedures ◦ No discernable differences in patient reported

outcomes (Excel/Good 67% IR vs Combo), Radiographs, or residual laxity

◦ Two failures in IR alone group, One in combo

◦ 90% no or mild Ant Drawer, 99% no or mild Pivot shift

◦ More patients with higher grades of instability were treated with combination reconstruction –> based only on anterior drawer


The AnteroLateral Ligament

1879 – Paul Segund described the “Segund” fracture – avulsion off antero-lateral tibia◦ “pearly, resistant, fibrous band which invariably showed

extreme amounts of tension during forced internal rotation

2012 – Vincent et al. (KSSTA 2012) but popularized by Claes et al. (J Anat 2013)


Originates at or posterior and proximal to the lateral epicondyle

Attachment on tibia is 9.5mm distal from joint line, 25mm posterior to the center of gerdy’stubercle and 26mm proximal to the anterior fibular head

Mean Length: 33-38mm

Mean Width: 7.4mm

Mean Thickness: 2.7mm

26mm

24.5mm


ALL Function & Biomechanics

Secondary stabilizer to the ACL in preventing:◦ Anterior tibial translation

◦ Tibial internal rotation

◦ Pivot shift phenomenon

Biomechanical testing has shown load to failure between 50-200N with location of failure ◦ Ligament tear at femoral or tibial attachment sites

◦ Intrasubstance

◦ With bony avulsion (Segund fracture)


Extra-articular Reconstructions

1970’s and 1980’s – goal was to restore anterolateral tibial subluxation and thus extra-articular techniques were described ◦ Over time found to stretch out -> residual laxity -> graft

failure -> poor outcomes


Randomized controled trial of three different ACLR methods◦ BTB◦ Hamstring with extra-articular

reconstruction◦ Hamstring alone

3 year follow up; 35 patients in each group

No differences found for IKDC scores

Higher incidence of loss of motion and PF crepitis with HS + EAR

Both BTB and HS alone groups had 1 graft failure each while HS + EAR did not

Conclusion -> EAR did not improve results compared with HS alone

2001


Combined ACLR with Extra-articular Reconstructions

Have been thought to potentially increase OA by capturing the knee

Results have been favorable in small studies

◦ 54 high level athletes◦ 11 year follow-up◦ No increased rate of OA◦ 90% G/E results

o 103 patients

o 17 year follow-up

o OA increased only in PMM patients

o 84% subjective satisfied or very satisfied results

AJSM 2009 Knee 2006


Since the rediscovery . . .

Biomechanical testing has demonstrated extra-articular reconstructions should run deep the the LCL and attach proximal to the lateral epicondyle for proper length and tension

Anatomic ALL reconstruction has not been shown to change internal rotation at low knee flexion angles but has been shown to restore internal rotation stability in the combined ACL / Anterolateral capsule injury at higher flexion angles of 60 and 90 degrees

Spencer AJSM 2015Guenther JBJS 2017

Kittl AJSM 2015


75 patients in each group

Group 1 = standard ACL ; Group 2 = standard ACL with extra-articular reconstruction

Group 2 patients “high risk” –severe pivot shift +++ or high level sports

Less OA in Tib-Fem and PFJ in Group 2

No failures in Group 2, 8 failures in Group 1 (failure= side to side arthrometric difference >5mm, pivot ++ or +++, or any giving way episode post-op

2016

EAR NOT ALL Reconstruction!


Retrospective review of 396 cases of which 92 combined ACLR with ALLR

Mean f/u 32 months

Indications:

2015


2015


Outcomes Cont’d◦ 71% return to prior level of activity

(59)◦ 28.9% returned at another level (24)

◦ 10 due to knee◦ 14 for other non-knee related reasons

Complications◦ 1 ACL graft rupture at 1 year (1.1%)◦ 1 cyclops◦ 1 PLM◦ 5 PMM after failed repair

2015


Pearls for ALL Reconstruction

Indications:◦ Revision ACL cases◦ High Grade pivot shift◦ Participation in pivoting sports◦ High level – “elite” athletes◦ Patients with hypermobility◦ Lateral femoral condyle sulcus sign

Graft type◦ No true gold standard

◦ Allograft or autograft Semi-T or Gracilis◦ Autograft ITB


Location and Angle of Fixation

Tibial location similar in differing studies

Femoral fixation posterior and superior, at, or anterior to the lateral epicondyle

Fixation Knee Angle: No consensus: Several authors fix at 30 deg but accounts of 0, 45, 60, and 90 exist

Helito et al. Arthrosc Tech 2015


Pre-op PlanningAlways think of how you will fix the grafts . . . All of them

LCL

ALL graft

ITB

LE

Femoral pin

Tibial pin

Spinal needle in joint


Thank you!

anterolateral ligament & extra-articular...

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