Name: ALL Reconstruction: When, Why, and How
Uploaded: 2019-07-15T00:00:00Z
Channel: Arthrex
Description: J. Lee Pace, MD, (Farmington, CT) discusses anterolateral ligament (ALL) reconstruction and supporting research.

<p>J. Lee Pace, MD, (Farmington, CT) discusses anterolateral ligament (ALL) reconstruction and supporting research.</p>

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VID1-000354-en-US | A | ALL Reconstruction: When, Why, and How

J. Lee Pace

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ALL Reconstruction: When, Why, and How

So we'll start with al. Reconstruction. All right. When? Why and how? It's just such the big question right now. So really a big question with the ALS is what is it? Is it a ligament or is it a true capsular thickening? And I think the answer is probably yes to either one. I think that there's been some histologic studies which have shown that in some patients the histology is that of a ligament, and in other patients it's the histology of an actual just capsular thickening. So it's actually probably variable amongst patients as to what this exactly is. But for the most part it is somewhat of a discrete structure. So it's always kind of fun when we talk about the Al to talk about the history of it. Right, because it has been refound and Saigon back in 1979, described as pearly resistant, fibrous band attached this little fracture fragment. And we all understand the Saigon fracture would be pathognomonic for an ACL tear we've just had. The lateral capsule is what pulled it off. And then in the 1970s, Doctor Houston talked about this anterolateral rotatory instability in this middle third lateral capsular ligament attaching to the lateral epicondyle and then distally to the tibial joint margin, sort of describing, you know, this, this potentially pathologic area of the knee. But as we sort of advanced our reconstruction techniques this sort of fell to the wayside as we were able to control the knee better with intra-articular surgery. Recently the all was rediscovered in this journal of anatomy, which made it into, I believe, the New York Times and all these different places. The lay press was a big deal. And in at least his study. And I think you say it even though it's spelled c l e s, I think you say it close. And they all but one of these specimens had this identifiable anterolateral ligament, and they determined that the all was found to be a distinct structure as we've studied it further. I think we now consider that all to be part of the anterolateral complex. So not just a discrete a discrete structure, but I mean, it is, but it's contained within other things out there that works to stabilize the anterolateral aspect of the knee. And within this anterolateral complex or RLC, is the superficial IT band and the patellar band, the deep IT band with the Kaplan fiber system. And then deep to that is the Al and the capsule itself. Okay. When we look at biomechanical assessments of of the Al, which has been sort of a hot topic lately. The question is, is, is the al a primary or secondary stabilizer to the knee? And in this study in particular, they saw that the Al saw higher loads in an ACL deficient knee than in an ACL intact knee. And so there's a certain amount of consensus saying that the Al is a secondary stabilizer to the knee. That becomes more important in an ACL deficient situation. And these people question the need for Or all reconstruction at all if you do a well done AC ACL reconstruction. This is a study that I participated in when I was still in Los Angeles, looking at the role of the Al in different pediatric ACL reconstruction techniques. And we found that at least in our model, the way we studied it is that the Al deficiency increased anterior displacement and rotational movements in the ACL deficient state. So it wasn't the main aim of our study, but we did find that it did seem to be a secondary stabilizer to the knee as well. So this study here Frank Noyes's study most recently used a six degree of freedom robot and looked at translation, internal rotation and valgus. And they did this sectioning sequence where they sectioned the ACL, the Al, and then the IT band. And they found that it took section of the Al and the IT band to create sort of a grade three pivot. So they questioned the need for doing, you know, how much does this all reconstruction actually give you if you've got, you know, an intact ACL? But I think the answer to this comes in the fact that ACL reconstruction alone does not restore native knee kinematics. So if you've got a grade three pivot and you do an ACL reconstruction, you're not taking the knee back to normal and something extra articular might be needed in these situations. And this was a study by Andrew Amos and his group in the UK. And they found in a in a similar study where they sectioned the anterolateral complex and the ACL that it took all reconstruction or IT band along with ACL reconstruction to restore native knee kinematics. So because our intra-articular surgeries aren't perfect yet adding these extra articular procedures for some of these patients may be appropriate. All right. So as far as diagnosis of all injuries or anterolateral complex injuries We're getting better at looking at them on MRI. You can sometimes see some subchondral edema right there on that lateral tibial plateau. Obviously the Saigon fracture is something that is seen. Sometimes it's subtle, but you can see it on the x ray. Physical exam I think is still difficult for us. You know, again it's kind of this is the grade three pivot a sign of it. Hyperextension. Who knows. Right. So I think that that's still up in the air when we talk about surgical indications. This is this is what was put forth from the ALC consensus Group meeting. This was just published in Kista just a couple months ago. And while there's still no clear indications for our gold standard indications for doing this, it can be considered in any one of these situations. Revision, ACL reconstruction, high grade pivot shifts, generalized ligamentous laxity, general recurvatum, and young patients returning to cutting. Pivoting sports. All the things that have already been mentioned are all reasonable surgical indications for Were all reconstruction. Now, the thing that's nice about all surgery is that you have a few different ways of doing it. You can do it open or you can do it percutaneous. And if we do, most of the stuff that we'll show here is going to be some level of percutaneous technique. Sonore in France has done a lot of these percutaneous and lateral epicondyle for the femur, posterior and superior to the LCL tibia, again halfway between Gerdy's tubercle and the fibular head likes this sort of two limb tibial method here, where it's sort of an inverted V, is how he likes to do his all surgical technique. Now, obviously in one of his many fantastic anatomic studies has given us some radiographic landmarks. I find the tibia fairly easy to find, but it's really hard to palpate that lateral femoral condyle. Sometimes you think you got it and you just don't. So this is a 2000, I believe A 2015 study at Agsm, so you can use radiographs to find your all footprint posterior and superior to the LCL. So this is a nice thing to to use Intraoperatively. And you can do it for femur and the tibia okay. So I'll walk you through the the the technique here for for a percutaneous al reconstruction femoral guide pin again posterior and superior lateral epicondyle. If you have an ACL reconstruction you do it at the same time. You're going to aim a little bit superior and proximal to avoid your ACL tunnel. Split the ITB around the the femoral pin and place your guide pin in the tibia at the desired spot again, about ten millimeters to the joint line halfway between gerdy's and the and the fibular head. You can test isometry with the suture, but I don't know if that's totally reliable if you're outside the skin because your femoral guide pins kind of up. So it's probably not the same distance. So I think that relying on your landmarks is probably probably better, honestly, than I think this isometry test may throw you off a little bit. Okay. Based on what you're doing, if you're using a tendon graft like a gracilis, then you probably want to use a little bit bigger SwiveLock like a 4.75, which is what's shown here. If you just use an internal brace alone, I'll just use 3.5 swivel locks and just plug the brace in with those. It's a little bit smaller. But drill the appropriate size tunnel. Place the place, the graft on the femur. And then just use the it band is pretty well identified through that incision. So you can easily tunnel deep to the IT band into the tibial incision, pull a passing suture up, and then use that passing suture to bring the graft down into the tibia. And then you're going to if you're going to dunk a graft, you'll use a little bit bigger. Swivelock. Here. So this is this technique calls for a seven millimeter fork tip swivel lock. So you'll drill to a depth of 20 with a seven millimeter drill on the tibia. And then and then this is the critical part here. You want to secure this graft and full extension and neutral rotation. And then in Paul's talk, he showed how he marked the the brace. So you don't over tension it. You want to do the same thing. You don't want to bury this in an over tension thing because then they you know, they can lose some. They can be over constrained. Right. And this is the study sort of this another aspect of the study that showed that a good the best knee flexion Angel angle for all reconstruction is in full extension. So 30 degrees, 60 degrees probably doesn't help as well. If you do it in full extension. That's going to give you your best stability for an all reconstruction. So in conclusion, the all is part of the anterolateral complex. And this is how we should think of it as part of this, this bigger sort of stabilizing structure, the anterolateral knee. It probably is a secondary stabilizer to anterior translation internal rotation.