The Anterolateral Ligament of the Knee

Dr. Matt Daggett, D.O./M.B.A. Founded by Dr. Larry Lemak and Dr. James Andrews

Epicenter of Sports Medicine: Over 300 publications

Overhead athlete injuries

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ACL injuries Shoulder Fellowship, Lyon France

Dr. Gilles Walch

Designer of Reverse TSA

400+publications

Authority on Shoulder Extended sports experience with Dr. Bertrand Sonnery-Cottet

Anterolateral Ligament

Biologic ACL

Lower Extremity “YOU ARE CRAZY”

“FRANCE RUINED EVERYTHING YOU LEARNED” “I’VE NEVER SEEN IT”

“MY ACLS DO GREAT!” CURRENT ISSUES WITH ACL RECONSTRUCTION

Revision for Re-rupture:10%

20% in collegiate athletes with pre- college ACL

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Rotational Control

20% continued rotational instability in double bundle RE-RUPTURE

7.8% (MOON AJSM-2013)

<18 years old: 31% at 15 years (AJSM 2016-Morgan)

BTB Auto: 9.8% ( AJSM 2016-Benner RW)

Hamstring Auto: 10% RETURN TO PLAY

High School/College Football: 63%/ 69% (MOON AJSM 2012)

NFL 63% (ASMI) (55% at 2yrs)

MLS:77%%: OJSM

NBA:78% (Arthroscopy) ACL MECHANISM History

Paul Ferdinand Segond – 1879 Recherches cliniques et expérimentales sur les épanchements sanguins du genou par entorse

‘fibreuse bande nacrée’ ACL History

Anterolateral Rotatory Instability is caused by a tear of the middle one third of the lateral capsular ligament but may be accentuated by other tears, principally a tear of the ACL !

Jack Hughston, 1976

Hughston JC, Andrews JR et al. Classification of the knee ligament instabilities. Part II. The lateral compartment. J Bone Joint Surg Am. 1976. TERRY-THE “DEEP ITB” TERRY-THE “DEEP ITB” Anterolateral Ligament

Claes S, Bellemans et al. Anatomy of the anterolateral ligament of the knee. J Anat. Oct 2013

Gobbi RG, Camanho GL et al. Anatomy and Histology of the Knee Anterolateral Ligament. Orthop J Sports Med. Dec 2013

Dodds AL, Amis AA et al. The anterolateral ligament: Anatomy, length changes and association with the Segond fracture. Bone Joint J. March 2014

Claes S et al. Gobbi et al. Dodds et al.

Directly on LE

Slightly Proximal and Posterior to LE

Completely Proximal and Posterior to LE Mid capsular / capsulo-osseous layer or Ligament ?

J. VINCENT, KSSTA 2012

C.HELITO , OJSM 2013 C. SCOTT, KSSTA 2014 ALL function: Controversy

LCL

ALL tibial insertion

Sectioning the anterolateral ligament did not increase tibiofemoral translation or rotation in an ACL-deficient cadaveric model. Yousif Al Saiegh et al. KSSTA 2015

Introduction ALL function:

Monaco E et al. Orthopedics 2010

“The lesion of the AnteroLateral FemoroTibial Ligament increases tibial rotation and could be correlated to the pivot shift phenomenon.”

Claes et al. ISAKOS 2013, AAOS 2013 Selective cutting of ACL bundles/ALL

“Ruptured ALL is prerequisite for grade 3 Pivot shift in ACL deficient knee” Introduction ALL function: Internal Tibial rotation stabilizer

• Zens, Niemeyer et al. AJSM 2015

• Tavlo, Ejaja et al. Scand J Med SCI Sports 2015 Med Lat

• Parsons, Gee et al. AJSM 2015 Introduction ALL function: AP translation control

Med Lat • Tavlo, Ejaja et al. Scand J Med SCI Sports 2015

• Spencer, Burkhart, et al AJSM 2015 Introduction

Med Lat + Med Lat Selective Sections The Involvement of the ALL in the rotational control of the Knee Selective Sections • 12 cadaver knees • Selective section ACL, ALL, ITB • Internal rotation at 20° and 90° + coupled axial rotation = simulated PS Selective Sections

ITB Intact ACL ALL SECTION 1 Selective Sections

ALL ITB Intact ACL SECTION 2 Selective Sections 1

Intact ACL ACL+ALL ACL+ALL+ITB Selective Sections 1

Intact ACL ACL+ALL ACL+ALL+ITB Selective Sections 2

Intact ITB ITB+ALL ITBL+ALL+ACL Selective Sections 2

Intact ITB ITB+ALL ITBL+ALL+ACL Selective Sections

The ALL is involved in the rotational control of the knee at varying degrees of knee flexion and during a simulated pivot shift.

A combined rupture of the ALL with ITB or ACL induces a significant increase in rotational laxity. ACL + ALL appears to be a consistent clinical scenario.

ITB is an important internal rotational stabilizer Why using it for our tenodesis ????

The Involvement of the ALL in the rotational control of the Knee Sonnery-Cottet, Daggett, et al. Am J Sport Med Accepted Question ?

ALL Efficient close to flexion? Or close to extension ? ALL Kinematic

For most authors: ALL efficient in flexion (30° to >90°)

• Zens, Niemeyer et al. AJSM 2015

• Tavlo, Ejaja et al. Scand J Med SCI Sports 2015

• Parsons, Gee et al. AJSM 2015

Parsons AJSM ALL Kinematic

Isometric Characteristics of the Anterolateral Ligament of the Knee: A cadaveric navigation study ALL Kinematic

• 12 cadavers knees • Distance variation between femoral and tibial paired points: • Flexion Extension • Internal Rotation at 20 and 90° ALL kinematic: basics ALL Kinematic

Proximal to LE

ALL Slack

IR allowed

Isometric Characteristics of the Anterolateral Ligament of the knee Imbert P, Daggett M et al. Arthroscopy Revision ALL Kinematic ALL kinematic

The ALL is tight in extension and slack in flexion allowing

• the internal rotational control

• without limitation of the physiological IR at 90°

Isometric Characteristics of the Anterolateral Ligament of the knee Imbert P, Daggett M et al. Arthroscopy History

Paul Ferdinand Segond – 1879 Recherches cliniques et expérimentales sur les épanchements sanguins du genou par entorse

‘fibreuse bande nacrée’ 48

ALL Reconstruction

Basics Reconstruction

Load at failure. N 300

225

150 209 175 75 135 +/- 30.7 +/- 35 +/- 6.8 0 Single Double Native ALL Reconstruction

The effect of an iliotibial tenodesis on intraarticular graft forces and knee joint motion. Engebretsen L et al. Am J Sport Med 1990 My Indications??? • Strong • Pivot Shift ++ • Chronic ACLs • Lateral notch X-rays • Segond facture • ACL revision • Relative • Pain at ALL • Female ACCEPTED • Pivoting Athletes ACL Graft Rupture

2011-2014 1751 primary ACL Reconstructions FU=33 months – Graft Rupture = 2,8%

16-32 years, Competitors, Sport Pivoting = 1071 Patients FU=33 months – Graft Rupture = 4,20%

ACL Contralateral rupture = 6 %

Graft rupture Mean delay 16,7 months

ACCEPTED BPTB Hamstring ACL+ALL = 6,95 % = 4,97 % = 2,14 %

RTP=84% OTHER FACTOR: BIOLOGIC ACL OTHER FACTOR: BIOLOGIC ACL “YOU ARE CRAZY”

“FRANCE RUINED EVERYTHING YOU LEARNED” “I’VE NEVER SEEN IT”

“MY ACLS DO GREAT!”

Questions?