Name: Management of the Anterolateral Complex of the Knee
Uploaded: 2020-01-29T00:00:00Z
Channel: Arthrex
Description: Seth L. Sherman, MD (Redwood City, CA), discusses managing injuries to the anterolateral complex of the knee.

<p>Seth L. Sherman, MD (Redwood City, CA), discusses managing injuries to the anterolateral complex of the knee.</p>

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VID1-000592-en-US | A | Management of the Anterolateral Complex of the Knee

Seth L. Sherman

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Management of the Anterolateral Complex of the Knee

Seth Sherman, University of Missouri, soon to be Stanford. Next month, I'd like to thank the Arthrex team for the opportunity to come and talk about management of the anterolateral complex of the knee. And so we know that the rerupture rates are just, frankly, alarming when we look at a study that we put together in the Yellow Journal, the return to play rates are really not much better, really, in the 60 to 70%. So we have a lot of work to do here together. There's certainly room to improve. I think the days of Lockman and high fives are over. We know that it's the persistent pivot shift that really correlates with functional instability, poor patient satisfaction and decreased rate of return to sport. We've all started to think more about rotational instability. This coupled anterior translation and internal rotation giving you this explosive pivot shift as you see in this example. And we know that there's increased interest in the anterolateral complex of the knee, as the ACL is not the only structure controlling rotation. We've heard about and will continue to think about the role of the meniscus and also these secondary stabilizers. Now the anterolateral ligament is not a new ligament as probably your lay friends and families texted you in 2016. In fact, the lateral side has been talked about for hundreds of years with the pearly fibers band. Andrew Amos talking about the oblique lateral ligament at the ACL study group in years past, and Doctor Houston talking about his middle third capsular ligament. But really in America, the concept of anterolateral rotatory instability fell out of favor until about 2013. There was a lot of focus on novel ways to do intra-articular surgery for ACL. There were concerns and some fairly limited reports on overconstrained and lateral arthritis. And so really, not until Steven Kleiser's work did we start thinking about the anterolateral complex again. And any of you guys who are going to be doing this, I'd recommend you print and get this paper. This is the anterolateral consensus group. It really summarizes everything you need to know in 2019 for doing anterolateral reconstructions. And so what I've taken from this and summarized here for you is that really it's more about the many primary stabilizers on the lateral side. It's not just the anterolateral ligament, it's the iliotibial band. It's the Kaplan deep fiber systems, and it's also the lateral meniscus and the anterolateral capsule. What we do know is that the all exists. It's superficial to the lateral collateral ligament. It's femoral origin is eight millimeters proximal and four millimeters posterior to the lateral collateral ligament. And its tibial origin is midway between Gerdy's tubercle and the fibular head. Doctor Labrada showed us that it's mostly isometric from 0 to 60 degrees, which makes sense. It's tight in extension, looser inflection. Your pivot shift occurs near extension. And so that's where this may help us to obliterate the pivot shift in our surgeries. This anterolateral complex is a secondary stabilizer to anterolateral rotation only after loss of the ACL. If you have both an ACL and an anterolateral complex injury, you get this grade three pivot shift. Isolated ACL reconstruction in this setting fails to restore normal knee kinematics and may lead to failure of your ACL reconstructions. We know we can identify the anterolateral ligament on MRI routinely. We also know that it's injured and up to 79%. However, I would caution you that lateral capsular structures have an intrinsic ability to heal with pre rehabilitation. And so we do not need to be treating 79% of these injuries. Here's the consensus group. Surgical indications. They're really not perfectly clear. And this is a moving target for discussion. But they agree that revision ACL should be considered high grade pivot shifts generalized ligament laxity. So recurvatum. And then young patients returning to pivoting activities. So the first one revisions. We know there's increased failure rates associated with not getting it right the first time. We're addressing just like the other speakers have talked about GraftPro tunnels, meniscus alignment. And we should clearly talk about secondary stabilizers, including collateral ligaments. And now the anterolateral complex. It really can protect your intra-articular reconstruction. And I use it liberally in this setting. How about those at higher risk. So hyper laxity particularly those young females recurvatum greater than ten degrees. Excessive anterior translation. Those three be lockman's and those that have just physiologic rotatory laxity. I also started considering these in the primary setting for contact or collision athletes. These are typically young males who are going hard after their ACL reconstruction. I worry about doing it without hyper laxity. I've not yet really jumped to that group yet, but I think it's worth a discussion. Other groups so chronic or subacute ACL where the ALC was injured initially, but maybe it didn't heal or through repeat giving way. It's just attritional. Those have a grade three pivot shift. I'd consider fixing them. And then rarely more in the lower demand. Middle aged population. Lower demand. Prior vertical but intact ACL functional instability. I've used isolated extra articular procedures to try to solve this problem. So there's really two schools of thought. We need to hear about the anterolateral ligament reconstruction. And then the lateral extra articular tenodesis. The reconstruction is anatomic. It's minimally invasive. You go superficial to the LCL typically using an allograft. And there's more concern with femoral ACL tunnel overlap. I think the clear points that I've learned is that we really, if we're doing all reconstruction, have to pay strict attention to the femoral location. We need to get it right and also to tensioning it needs to be proximal and posterior to the lateral collateral ligament. You need to tension this at full extension. And it's a low level of tension about 20 Newtons. There's animations on the site that we do not have time for in this presentation, and my colleague Pat Smith from Missouri has an excellent technique video on this minimally invasive technique as well. I think key points is that we can make small stab incisions. I find that it's very easy to palpate the fibular head and to palpate Gerdy's tubercle and to go midway between them. 15mm from the joint line. I find it somewhat more challenging to get it perfectly right. Minimally invasive on the femoral side. However, we can place guide pins as you see here. And then this is Bertrand Coté. He's testing isometry. And so what we want is a tighter in extension and looser inflection. We do not want to over constrain if we're doing this percutaneously. So this step is critical in my mind. And then basically this is familiar techniques. We can use it gracilis. We use a 4.75mm swivel lock on the femur as you see here. Alternatively for this and other constructs I tend to tend to use a TightRope on one side and a SwiveLock on the other side. This will allow me provisional fixation on the femur, as you see here, and then we'll see what I do on the on the tibial side in a moment. Here we shuttle Percutaneously. This technique calls for going above the lateral collateral ligament and bringing the graft down to the tibia. And then we drill to a depth of 20 with a seven millimeter drill, and then typically use a seven millimeter SwiveLock tenodesis to complete the anterolateral ligament reconstruction. Again fixing an extension and neutral tibial rotation. Alternatively, on the tibial side, you can use a tibial SwiveLock tenodesis so whip stitching two centimeters from the location of your tunnel and then 6.5mm reaming, as you see here. And placing the SwiveLock tenodesis which goes quite easily. What I like about this technique is then afterwards I can set my resting length using the TightRope on the femoral side. So it's quite modular. We can cycle and retention. It gives you some flexibility. You'd consider using fluoroscopy to make sure you're getting it right. You really don't want to over constrain. And if in doubt, just find the lateral collateral ligament and go posterior and proximal. So lateral extra articular tenodesis is kind of a different philosophy. It's non anatomic. It's an open procedure using either iliotibial band autograft or allograft deep to the lateral collateral ligament. There's less concern with overlap of the femoral ACL tunnel. And it's more forgiving. You can basically place this graft anywhere along the corridor near the intermuscular septum. You can tension it at any flexion angle in a variable position, without changing the kinematics or without concern of over constraint. So here we can see an ITB tenodesis. Basically we typically leave it attached on Gerdy's tubercle. It's about a centimeter wide and eight centimeters long. So it does have to obviously be a larger incision than we may be used to or comfortable with, with doing minimally invasive anterolateral techniques. Here you can see us kind of mapping this out. And there's certainly a learning curve. I think the Europeans and others around the world are very facile with this, but I'm kind of in the mid learning curve using Autograft. I started out using allograft for ALS and Let us, but you can see you can take a nice chunk of tissue. We can measure and whipstitch, as you'll see in a moment. And here identifying the lateral collateral ligament. So basically using a right angle clamp putting the leg in figure four and spreading will allow you to to see it. And really you can palpate it easier than you can see it initially. But once you get it then basically we go posterior and proximal. It's really quite easy once you know where it inserts to do that. This dealer's choice for fixation basically here I'm using a FiberTak. Most have studied this with a staple. Or you can use any other type of fixation of choice, basically bringing the graft underneath the lateral collateral ligament as you see here. And then fixating just with a simple horizontal mattress. Sutures. Once you fix the graft, we'll see. We can again test the isometry. Here I was doing it at 30 but now I'm at 90 and it's quite loose. So it's not going to over constrain at 30. It's taking up some more tension. And then in full physiologic hyperextension that's really where it dials in and prevents that tibial anterior translation and internal rotation. If you go under the LCL you're going to get this antisymmetry every single time. And then we can close and retention the iliotibial band as you see here. So outcomes Bertrand and team have looked at this with several year follow up and basically found that when you include all, it fails less than BTB alone and also fails less than hamstring alone and there were a higher odds of returning to sport. They also looked that this was meniscus protective, particularly after meniscus repairs a greater than two times lower rate than with just ACL reconstruction alone. Lateral. Extra articular. Similar obliteration of the pivot shift. Decreased failure rates in revision. This is a study from Al Getgood. It's winning the O'Donoghue Award this year at Aossm. Basically nine centers looking at ACL reconstruction with or without lateral tenodesis in high risk patients. And the results are clearly in favor of adding the extra articular for those select populations. And so in conclusion, ACL injuries do not occur in isolation. Persistent anterolateral laxity is associated with poor patient outcomes. High failure rates of ACL in young active populations using contemporary techniques and anterolateral reconstructions. Reduce anterolateral rotatory laxity, ACL reconstruction and protect our meniscus repairs. I thank you very much for your attention.

Management of the Anterolateral Complex of the Knee

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