Multiligament Knee Injury:Does the ALL Matter? · PDF file4/13/2016 1 Adam Anz, MD Andrews Institute Gulf Breeze, Florida Multiligament Knee Injury:Does the ALL Matter?The Case for

4/13/2016

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Adam Anz, MD

Andrews Institute

Gulf Breeze, Florida

Multiligament Knee Injury:Does

the ALL Matter?The Case for ALL

Reconstruction

• Segond Fracture

• 1879

• Synonymous with a tear of the ACL

• Cadaver Study which

demonstrated this fracture pattern

Description of “A pearly, resistant fibrous band” attached to this fracture fragment

History• Dr. Hughston – 1976

• The middle third of the lateral capsular ligament

attaches proximally to the lateral epicondyle and distally to the tibial joint margin

• Anterolateral Rotatory Instability

History

Anterolateral Instability Surgery

Andrews CORR 1983

• 70’s: Restore Rotational Anatomy Lateral-Plasty + ACL Repair

Tenodesis


Tenodesis

Andrews AJSM 1985

History



Tenodesis

• 80‘s: Arthroscopic ACL

History


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7


Tenodesis


• 90‘s: Intra- Articular Double Bundle “A method to better restore rotational stability”

History


8


Tenodesis



• 00’s: “Anatomic ACL”

History



Tenodesis




• 10’s:

Fast Forward to 2014 !!!!

History



Tenodesis




• 10’s:


History


The Decade of the ALL

11


Tenodesis




• 10’s:


History


The Decade of the ALL

“Back to the Future”

The Science

• METHODS-41 Unpaired Human Cadaveric Knees, Dissected and Examined for anatomic attachments of the ALL

• RESULTS-All but 1 specimen (97%) contained an ALL (Anterolateral Ligament)

• CONCLUSION-The ALL was found to be a DISTINCT LIGAMENTOUS

STRUCTURE

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Do You Buy It?

Kennedy Laprade AJSM 2015

• Femoral Insertion

- Area 67.7 mm2

- 2.7 mm proximal to FCL

- 2.8 mm posterior to FCL

• Tibial Insertion

- Area 64.9 mm2

Anatomy:



- Area 67.7 mm2




- Area 64.9 mm2

- 24.7 mm Posterior to Gerdy

- 26.1 mm Anterior to Fibula

- 9.5 mm Distal to the Joint

Anatomy:

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Anatomy:

Branch Anz OJSM 2015


- Area 67.7 mm2




- Area 64.9 mm2

- 24.7 mm posterior to Gerdy



- Intimate with Tibial Band of BF

- Intimate with Iliotibial Band

20Branch Anz OJSM 2015

Anatomy:


- Area 67.7 mm2




- Area 64.9 mm2






21Branch Anz OJSM 2015

Anatomy:


- Area 67.7 mm2




- Area 64.9 mm2






Anatomy:

• Simple Biomechanics

- Failure Load: 175 N

- Stiffness: 20 N/mm

- Segond Fracture: 30%





• Complex Biomechanics

Anatomy:






-Does It Do Anything?

Anatomy:

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Anatomy:

Kittl Amis AJSM 2016• Simple Biomechanics






Anatomy:

Kittl Amis AJSM 2016







Anatomy:

Kittl Amis AJSM 2016• Simple Biomechanics






-No

Anatomy:

Kittl Amis AJSM 2016







-No

Anatomy:

Rasmussen Laprade AJSM 2016







-No

Anatomy:


ACL Deficient Alone

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-No

Anatomy:


ACL + ALL Deficient







-No

-Yes

Anatomy:


ACL + ALL Deficient







-No

-Yes

Anatomy:


ACL + ALL Deficient

Whose Right? • Complex Biomechanics


-No

-Yes

Anatomy:

Whose Right?



-No

-Yes

Anatomy:



-No

-Yes

Anatomy:

Whose Right?

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-No

-Yes

Anatomy:



-No

-Yes

Anatomy:

Whose Right?



-No

-Yes

Anatomy:



-No

-Yes

Anatomy:

Whose Right?



-No

-Yes

Anatomy:



-No

-Yes

Anatomy:

Whose Right?

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-No

-Yes

Anatomy:



-No

-Yes

Anatomy:

Whose Right?

TextProbably Cut Elements of BF and ITB



-No

-Yes

Anatomy:

Whose Right?

Text

Both Right

Probably Cut Elements of BF and ITB



-No

-Yes

Anatomy:

Whose Right?

Text

Both Right

Intimate Confluence of ITB, BF, and ALL

Probably Cut Elements of BF and ITB

Technique:• Femoral Footprint- Guide Pin

• 2.7 mm proximal to FCL’s Femoral Insertion

• 2.8 mm posterior to FCL’s femoral Insertion





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- Aim Distal and Anterior





• Tibial Footprint- Guide Pin

• 24.7 mm posterior to the center Gerdy’s

• 26.1 mm proximal to anterior margin of fibular head

• 9.5 mm distal to the joint line

- Aim Straight In

• Graft- Allograft SemiT or Gracilis

- 6mm or 7mm

• Fixation- Line to Line





• Tibial Footprint- Guide Pin

• 24.7 mm posterior to the center Gerdy’s

• 26.1 mm proximal to anterior margin of fibular head

• 9.5 mm distal to the joint line

- Aim Straight In

• Graft- Allograft SemiT or Gracilis

- 6mm or 7mm

• Fixation- Line to Line

Steven Claes, MD:ALL Surgical Technique

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1. Guide Pin for the 4.75 mm SwiveLock

2. Aim Anterior and Distal

3. Split the Iliotibial band


1. Guide Pin for the 4.75 mm SwiveLock

2. Aim Anterior and Distal

3. Split the Iliotibial band


4. 4.5 mm Drill to drill to a depth of 24 mm.

5. Whipstitched Gracilis Graft

6. 4.75 mm SwivelLock


7. Insert and Secure the Graft


8. Create a plane underneath the iliotibial band

9. Passing suture from distal to proximal with the hemostat.

10. Pass the graft to the tibial side. 11. Guide Pin between Gerdy’s Tubercle and Fibular Head.


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11. Guide Pin between Gerdy’s Tubercle and Fibular Head.


12. Check isometry: Should be isometric between 30-90 degrees of flexion.



13. Drill to a depth of 20 mm with the 7 mm drill.


14. Secure with a 7 mm Tenodesis screw over the graft.

15. Push the graft end into the tunnel and adjust tension by pulling on the

graft.

16. Do Not Over constrain


17. Secure in 30˚ of flexion and neutral tibial rotation.

18. Cut the excess graft exiting the tibial socket.

How Do Reconstructions

Perform:

• Biomechanically

- Laprade: Epub AJSM 2016

• Pretty GoodACL Recon Alone

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Perform:

• Biomechanically

- Laprade Epub AJSM 2016

• Pretty GoodACL + ALL Recon


Perform:

• Biomechanically



Tension at 30 Degrees


Perform:

• Biomechanically



You Can Over Constrain


Perform:

• Biomechanically



You Can Over Constrain

ACL + ALL Recon

Use Collagen


Perform:

• Clinically

-Zaffagnini: KSSTA 2006

• Prospective RCT

• Better Subjective Outcome Scores

• Sooner Return to Sports

Maracci Combined Intra/Extra-Articular


Perform:

• Clinically


• Prospective RCT



- Vadala: Int Orthop 2013

•Modified MacIntosh + Hamstring

•Prospective RCT

•Significant Reduction in Rotational Instability

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Perform:

• Clinically


• Prospective RCT



- Vadala: Int Orthop 2013

•Modified MacIntosh + Hamstring

•Prospective RCT

•Significant Reduction in Rotational Instability

- Sonnery-Cottet: AJSM 2015

• 91.6% without a Pivot at Minimum of 2 Years

Surgical Indications:

• Sonnery-Cottet: AJSM 2015

- Patients with Grade 2 or 3 Pivots

- Segond Fracture Accompanying ACL

- Chronic ACL Injury

- High Level of Sporting Activity

- Participation in Pivoting Sports

- Lateral Femoral Notch Sign

• Ferretti

- Severe Rotational Instability with Pivot Shift Exam

- Women

-High Level Athletes

- Revision Cases

• Further Clinical Outcome Data is Necessary

Where Do We Go

• Biomechanical Comparison

Where Do We Go


- Graft Reconstruction

Where Do We Go



- IT Band Tenodesis

Where Do We Go



- IT Band Tenodesis

- Combined Procedures

vs

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Where Do We Go



- IT Band Tenodesis


vs vs

Where Do We Go



- IT Band Tenodesis


vs vs

• Clinical Outcome Studies

81

QuickTime™ and aH.264 decompressor

are needed to see this picture.





Case Example22 yo Male

7 months out from Failed

Hamstring ACL

Thank You!

Documents

Multiligament Knee Injury:Does the ALL Matter? · PDF file4/13/2016 1 Adam Anz, MD Andrews Institute Gulf Breeze, Florida Multiligament Knee Injury:Does the ALL Matter?The Case for