Name: Extra-articular Tenodesis and ALL Reconstruction
Uploaded: 2020-06-04T00:00:00Z
Channel: Arthrex
Description: Asheesh Bedi, MD (Ann Arbor, MI), discusses the rationale, research, and techniques for anterolateral ligament reconstruction and iliotibial band (ITB) tenodesis.

<p>Asheesh Bedi, MD (Ann Arbor, MI), discusses the rationale, research, and techniques for anterolateral ligament reconstruction and iliotibial band (ITB) tenodesis.</p>

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VID1-000946-en-US | A | Extra-articular Tenodesis and ALL Reconstruction

Asheesh Bedi

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Extra-articular Tenodesis and ALL Reconstruction

I'm going to transition to the famous and increasingly topical al ligament and the idea of lateral extra articular procedures or or tenodesis. What's the role for it and how should we approach this? And Darrell covered this earlier very nicely in his revision ACL talk. But I think the concept that we recognize is sometimes there is still some increased risk of failure that we recognize, whether it's that 15 or 20,000 patients, he pointed out, despite a so-called AnaToemic ACL reconstruction. And there's many factors that can play into it. Even if you do a good job, maybe it's alignment we all are recognizing from an increasing body of literature that patients that have increased slope greater than 12 or 13 degrees has been a published number. What about the patient at the right there, with an increased Beighton score and severe recurvatum? We know in some studies, recent one from Chris Larson, that 20 to 25% of increased heel to table height like this with with hyperextension can be a risk for ACL stretch or failure. And we all think about these so-called occult instability patterns that Daryl mentioned. The most common. And it's going to be addressed shortly the posterolateral corner PCL, occult MCL or posterior oblique ligament injury. But I would argue that the al or this concept of an Al really links to the anterolateral capsule in complex. And just like we were taught in our textbooks, to recognize that, you know, posterior horn, medial meniscus tears or deficient medial meniscus horn can increase our instability. Anterolateral capsule injury is just harder to quantify. But in that same spectrum. So this is just an example of that. When we see this in the Or. This is a video courtesy of Charlie Brown. You can look here. This is a grade three pivot shift right. All of us see these sometimes in the clinic. But if you look at the MRI scan on this it's diagnosed as just an ACL tear. And I would argue that knees like this have something more going on. It's either a capsular injury or al injury, perhaps associated ramp lesions or root injuries. And if we just treat the ACL, probably there's some There's some increased risk of failure related to missing that additional injury. And it's not that new a concept. Every time we think something is new in orthopedics, if you look back, there's often some hints at it. Segond fractures. We're all familiar with our concept of this. Both Last and Houston described this idea of a short lateral or middle third lateral capsular ligament, which in many ways, if you look in the historical literature, looks a lot like what we call the Al today. So I just put this picture in here to show this, the modern Al image on the right. But if you look at what Houston described as this mid third lateral capsular ligament looks very similar in location to what he was describing in that work. And in fact, if you look at the description from Houston, it was the capsule osseous fibers and deep band fibers that serve as a sling around the lateral femoral condyle to control the pivot shift. Very much. The concept of these lateral extra articular procedures that we're embarking on today. I don't want to belabor this, but just to share with you what all goes into the anterolateral capsule when you're in the O.R. today or in the lab today. Please take a look at these layers. If you dissect carefully there, you'll find the superficial IT band as you go deeper. A bit of the middle and deep IT band. But it's this critical layer three and four, the CapsuleLink osseous layer, which is the deepest and most medial portion of the IT band that actually runs and makes contact to the lateral aspect of the distal femoral condyle, and then the anterolateral capsule. And these Caplan fibers have gotten much more attention, has described even three distinct segments by relative position to the epicondyle. Godin described two distinct layers and work with Rob Lapradd. And so whether or not you want to consider these discrete structures, the key is that there is a sleeve of important tissue that makes direct contact and insertion to the lateral condyle, acting like a sling around it on the all in terms of if you're thinking of it as a distinct ligament, is this concept and a number of papers. Steve Klaus, Daggett, Caamano and others have described that it's a confluence of tissues that take origin, generally speaking, posterior and proximal to the lateral epicondyle. It inserts about 5 to 10mm distal to the joint line. And if you were to take a half way point between the anterior aspect of the fibular head and gerdy's tubercle, that's a good, reasonable landmark for where you would expect this capsular tissue to insert. So if you dissect it out, it often looks like what the asterisk is here in a variable in different knees, how thick it is, whether it's bifurcate, if it originates just distal or proximal to the lateral epicondyle. And in fact, the reason that you see that anatomic variation is because it exists. So if you look at this paper from Topol, they looked at 70 different specimens. And they described a type one through five, all based on that variability in anatomy. So again, I think the important takeaway concept for me isn't necessarily whether or not it is an anterolateral distinct ligament, but that it's a variable thickening of the tissue and capsule connected to those capsule osseous fibers that we're trying to sometimes reconstruct in the form of a distinct ligament. Professor Ferretti, who's done a lot of work in this area, has quantified this, in my opinion, in a way that's much more meaningful than just anatomic. And he describes a type one through four. And all this really means is progressive severity of injury. A type one is just the anterolateral capsule. A type two extends posterolaterally. Type three traverses the whole structure and goes distal to the lateral meniscus. And a type four is what we sometimes see on the x ray, which is a full bony avulsion and Saigon fracture. And why is that important? Because likely as you increase in the severity here from 1 to 4, you increase in the corresponding functional instability and the severity of the pivot shift that you get in your exam under anesthesia. Are there some things that can help you to reconstruct this sleeve of tissue? There are. Al Getgood has done some of this work in London. Describes these radiographic landmarks, much like we use for an mpfl when we're looking for shadows. Point here you can look at the bloom ansatz line and the posterior cortical line of the tibia. And you can see the blue confluence of points, which is a generally good location to place your all origin and insertion. This was also corroborated here by Toledo and others that look at this posterior cortical arc line, and the line connecting the anterior and posterior tibial cortices, and looking at the intersection of those to place your your insertion. Generally speaking, as I pointed out here, if you go 5 to 10mm distal to the joint line and about halfway between gerdy's and the fibular head on the tibial side, you'll end up in a good location. Well, does all of this, in fact pan out? Biomechanically. And there's lots of questions here. Volker, Musil and Rich at the University of Pittsburgh recently looked at this and said, well, if you just look at that anterolateral capsule and you load it, it doesn't have great strain patterns in it. So is there, in fact, any real function to that tissue? And it turns out that it's not as simple as just taking that tissue and pulling on it. Why is that? Because if you look at these studies here, remember, as we talked about the capsule, osseous fibers are part of that sleeve. And if you think about it more in a in a concept like this, like an inverted horseshoe. You have the ACL in the center of the notch that's controlling the central pivot, but you have this confluence of tissue posterolaterally and anterolateral that's making a sling like an inverted horseshoe around the lateral femoral condyle that's controlling the pivot. So it isn't just one or the other that you're looking to control. It's the combination of the two that's probably critical for the pivot shift. So does this in fact make a difference when you add in some lateral extra articular reconstruction? Well, if you look at Bertrand Coty's recent publication in Agsm, he would argue it makes a big difference in his study here he looked at TBS versus hamstring ACL reconstructions, but he looked at a third group where he added in an all type of construct or a lateral extra articular procedure to control the pivot. And when he looked at a longitudinal Survivor Series, you can see here all the way out to 50 to 60 months, he found that his hamstring grafts, in which he had augmented with an all, in fact, had better survivorship than his TBS and better than his isolated hamstring reconstructions. In fact, he took that to another level and started looking at whether or not that improved meniscus healing. And in this series of patients, just recently published last year from the Sante group, at two years out, his route repairs and medial meniscus repairs fared better when he augmented with a lateral extra articular procedure. So again, maybe this improved stability is in fact part of the solution. Bony landmarks are marked, including the head of the fibula. Gerdy's tubercle. I'm just going to turn the volume off here and sort of move through this video quickly. But this is Bertrand doing this. Of course, he's very elegant at this and can do this even with a percutaneous approach showing here. He actually makes two insertion points on the tibia tunnels between the two there to make sort of a continuous place to pass the graft, and then puts his anatomic graft at the origin, posterior and proximal to the lateral epicondyle, and then subsequently tunnels through. Here I'm just showing it quickly here. And fixes on both sides with the SwiveLock in neutral rotation in about 30 degrees of flexion. And I think there's a number of different techniques that have now evolved from this concept, including la mer techniques or Mackintosh techniques, where whether you're using a free graft or a slip of the IT band, the concept is the same. And I would point out, where do we want to think about this in our practices in 2020? This is kind of what it looks like for me. If you have a revision ACL that looks like the tunnels were reasonably well done. If you see increased slope, if you have a patient that has a meniscal root or ramp lesion, if they have a high grade pivot shift or an increased Beighton score with Recurvatum, what about a chronic ACL where they've started to wear out those secondary stabilizers, or a high risk pivot activity or associated medial meniscus repair as as Bertrand just recently published. And I would argue if you add all those list of things together, it's not an insignificant number of cases in your practice where you might start thinking about an all or lateral extra articular procedure. I've evolved this technique in my practice to now be different. I used to do it a bit the way Bertrand showed with a free graft. I've now wanted to take advantage of those capsule osseous fibers here. So here. This is just taking a small incision on the lateral side of the knee. You identify the central slip of the IT band. You can take an 8 millimeter to 1cm wide slip. You just need it to be 6 to 7cm distal or proximal to the gerdy's tubercle. You then just simply harvest that. You can use a FiberLoop to whip stitch this free graft. I do tunnel it deep to the LCL and then simply fix it with a swivel lock at its anatomic origin, just posterior and proximal to your LCL and lateral epicondyle. And the end result of that ends up being a nicely well placed lateral extra articular tenodesis here that gives you control of the pivot shift, particularly in the revision setting or in the high risk knee. So for sake of time, I'll move through this quickly. But this is a case example where you may want to think about some form of lateral extra articular procedure. No matter how good a job you did. This is a patient who's a high level high jumper at the University of Michigan. Has Michigan, has had three prior ACL reconstructions and presents to me for a fourth one. If you look at the prior reconstructions done by capable surgeons, reasonably well placed tunnels in 2011, revised in 2013 with the same tunnels with a different graft, revised subsequently in 2016, you can see the tunnels are starting to widen, but they're not looking malpositioned. If you start to look, you see some medial meniscus injury. You see again, the ACL graft is gone, but the tunnels look reasonably well placed. But now you appreciate some challenges with alignment, slight valgus alignment, widening of tunnels. In this particular case, significant widening of the tibial tunnel with eccentricity. And this situation I chose to bone graft the tunnels, revise the ACL in a staged fashion, but in this situation also adding the extra articular tenodesis as I described, and at least to date, this patient has gotten back to sport in a situation that is tough with a fourth ACL. Thank you.

Extra-articular Tenodesis and ALL Reconstruction

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