Extra-Articular ACL – ALL reconstruction

Presented by: Dr. MilindModerated by: Dr. Ajay

Introduction:• Need - A subset of patients experienced some residual antero-posterior and

rotational instability after ACL reconstruction.*• Anterolateral stabilizing structures in cases of anterior cruciate ligament (ACL)

injuries so came to be recognized.• High incidence of ALL lesions in ACL-injured knees, with high-grade pivot-shift

(ROTATORY INSTABILITY), led us into the anatomy and function of the ALL.

*Bonasia, Davide Edoardo et al. "Anterolateral Ligament Of The Knee: Back To The Future In Anterior Cruciate Ligament Reconstruction". Orthopedic Reviews 7.2 (2015)

• Pivot shift test is considered most specific test for ACL injury• Correlates best with functional instability after ACL injury and

reconstruction.• However, some patients show a persistant pivot shift post ACL

reconstruction.• Question arose: How can a centrally located ligament (ACL) restrict

Axial Rotation????• Answer: ALL was the ligament responsible for rotatory stability.

• It was concluded that ALL is an important internal rotatory stabilzer between 30-90 degree, while ACL limited only ATT.**

• Sectioning of AMB+ PLB – grade 1 pivot positive• Sectioning of ALL- grade 2 and above pivot positive• Ruptured ALL is a pre requisite for Grade 3 Pivot Positive in ACL deficient

knee.

**Claes et al. , ISAKOS 2013, AAOS 2013.

Recent studies:• Monaco et. Al (2012) concluded:

• Cutting the PL bundle did not increase anterior translation and rotation of the knee. • Cutting the AM bundle significantly increased the anteroposterior (AP) translation at

30° and 60° (P=0.01), but did not increase rotation of the knee.• Cutting the ALL increased anterior translation at 60° (P=0.04) and internal rotation

at 30°, 45°, and 60° (P=0.03). • The authors concluded that cutting the ALL increased tibial rotation and could be

related to the pivot shift phenomenon.

• Pearsons et al. (2015) concluded: ALL to be an important stabilizer of internal rotation at flexion angles >35°.

Brief history:• In 1879, Paul Segond described a pearly, resistant, fibrous band

inserting on the anterolateral aspect of the proximal tibia.• Segond fracture: avulsion fracture of LCL attachment at tibial

insertion• Later called by different names:

• Anterior Band of LCL – Irvine et. al• Anterior oblique band- Campos et. al• Antero lateral ligament – Vieria et. al

Anatomy of the ALL:• Origin: Fan like; Femoral epicondyle, anterior-

superior to LCL and posterior and proximal to insertion of popliteus tendon.

• Insertion: thick capsular fold; midway between the fibular head and the gerdy’s tubercle.

Diagnosis:• MRI is the modality of choice. (3.0 T study

with 0.4 mm slice thickness and fat suppression images)*

• Identification of ALL is easier at the meniscal and tibial attachment, due to the ALL’s close relationship with the insertion of the LCL and popliteus tendon proximally.

• Somewhat ill defined and sheet-like, inseparable from the adjacent LCL proximally and iliotibial band distally.

*Gossner J. The anterolateral ligament of the knee. Visibility on magnetic resonance imaging. Rev Bras Ortop 2014;9:98-9.

Treatment & indications of repair:• Recommendation to add a lateral plasty to traditional ACL reconstruction only in

selected cases of: • Marked rotational instability; • In cases of high level athletes & contact athletes;• In selected case of revision ACL surgery.• Post ACL reconstruction- Symptomatic patients with clinical rotatory instability.

• *Bonasia, Davide Edoardo et al. "Anterolateral Ligament Of The Knee: Back To The Future In Anterior Cruciate Ligament Reconstruction". Orthopedic Reviews 7.2 (2015)

• *Monaco E, Maestri B, Conteduca F, et al. Extra-articular ACL reconstruction and pivot shift: in vivo dynamic evaluation with navigation. Am j Sports Med 2014;42:1669-74.

• *Saragaglia D, Pison A, Refaie R. Lateral tenodesis combined with anterior cruciate ligament reconstruction using a unique semitendinosus and gracilis transplant. Int Orthop 2013;37:1575-81.

Techniques of repair:• Main concept is reconstruction of ALL using either ITB, PTB graft, ST

&/or Gracilis graft.• Peripheral location of the ALL is the main contributor to

Rotational/Axial stability in comparison to centrally located PL bundle.• Various surgical procedures for lateral extra articular tenodesis have

been devised since 1967 when Lemaire described it first.

Lemaire’s Procedure:• A strip of iliotibial band was

detached proximally• Passed deep to the FCL, through a

femoral tunnel at the attachment point of lateral gastrocnemius.

• The graft is passed deep to the FCL a second time and fixed with sutures to the iliotibial band with the knee flexed to 30 degree and held in external rotation

MacIntoshprocedure(1976):

• A strip of iliotibial band was detached proximally and passed deep to the FCL, through an osteoperiosteal tunnel posterior to the FCL femoral attachment.

• The graft was then looped through the lateral intermuscular septum and sutured back onto itself at the Gerdy tubercle with the knee flexed to 90 and held in external rotation

Losee technique(1978)A strip of iliotibial band was detached proximally and passed through a femoral tunnel that originated at theattachment point of the lateral gastrocnemius and ended anterodistal to the FCL femoral insertion site.

The graft was then sutured at the Gerdy tubercle with the knee flexed to 30 and held in external rotation

Arnold & Coker (1979)• A strip of iliotibial band was

detached proximally, passed beneath the FCL and popliteus tendon, and sutured to the Gerdy tubercle with the knee flexed to 90-100 and held in external rotation

Ellison (1979):• A distally detached strip of

iliotibial band with a bone flake was passed deep to the FCL and anchored in a bone trough slightly anterior to its original harvest site at the Gerdy tubercle with the knee flexed to 90 and held in external rotation.

• The capsular structures were reefed deep to the FCL

Wilson & Scranton:• A strip of iliotibial band was

detached proximally, passed deep to the FCL and lateral gastrocnemius tendon, and sutured back onto itself with the knee flexed to 60 and held in external rotation.

• This extra-articular reconstruction was used in conjunction with an intra-articular ACL semitendinosus graft reconstruction

Zarins and Rowe technique:

The semitendinosus tendon was detached proximally and passed through an obliquely oriented tibial tunnel,across the knee joint, and over the lateral femoral condyle.

After passing over the lateral femoral condyle,the graft was passed deep to the FCL and sutured onto the iliotibial band. Similarly, the iliotibial band waspassed deep to the FCL and over the superior aspect of the lateral femoral condyle. After passing over the lateral femoral condyle, the graft was passed across the knee joint, through the same obliquely oriented tibial tunnel as the semitendinosus tendon, and fixed with sutures to the semitendinosus tendon with the knee flexed to 60 and held in external rotation

Andrews procedure:Two strips of iliotibial band were detached proximally and sutured at their proximal ends.Then, the sutures were passed through 2 parallel tunnels, which originated at the lateral femoral condyle and exited at the medial femoral condyle. After passing through the tunnels in the lateral-to-medial direction, the suture were tied together over the adductor tubercle. The grafts were fixed with the knee flexed to 90 and held in external rotation.

Benam procedure:• The lateral one-third of the

patellar tendon was harvested proximally with a patellar bone block, passed deep to the FCL, and fixed with a staple within a bony groove deep to the femoral origin of the FCL with the knee flexed to 45 and held in external rotation

Muller procedure:A strip of iliotibial band was detached proximally and fixed with 2 cancellous screws to a point anterior to the junction of the femoral shaft and lateral femoral condyle with the knee held in external rotation

Marcacci and Zaffagninitechnique:

• Solves both purposes: ACL & ALL reconstruction.

• Semitendinosus and gracilis tendons were harvested proximally, sutured together, and passed through a tibial ACL reconstruction tunnel.

• The graft exited the tibial tunnel intra-articularly and was passed through the posterior aspect of the femoral notch and over the top of the lateral femoral condyle.

• The graft was then passed deep to the iliotibial band and over the FCL and was fixed distal to the Gerdy tubercle. With the knee flexed to 90 and held in external rotation

Review of literature:• Various studies have reported following conclusions:

• In the ACL-deficient knee, LET procedures overconstrained the knee and restricted internal tibial rotation when compared with the native state.

• In addition, isolated LET procedures did not return normal anterior stability to the ACL-deficient knee but did significantly reduce anterior tibial translation and intra-articular graft forces during anteriorly directed loading.

Review of literature:• 2006, Zaffagnini et al. quantitatively assessed in vivo static and dynamic biomechanics

of the knee before and after ACL reconstruction, comparing the Marcacci technique with anatomic double-bundle technique.

• The Marcacci technique showed statistically better laxity reduction in varus/valgus stress test at full extension and in internal/external rotation at 90° of flexion.

• The lateral plasty better controlled the lateral compartment during drawer test and varus/valgus stress test both at 0° and 30° of flexion and both the compartments during internal/external rotation at 90° of flexion.

• On the other hand, pivot-shift phenomenon was better controlled by anatomic double-bundle reconstruction.

• The authors also concluded that patellar tendon and Marcacci techniques can be equivalent options for ACL reconstruction.

• In 2007, Monaco et al. compared lateral tenodesis (Arnold-Coker procedure) plus single bundle ACL reconstruction (Group A) with anatomic double bundle ACL reconstruction (Group B), in terms of internal tibial rotation.

• A computer navigation system was used to evaluate the global kinematic of the knee.

• No differences were found in terms of antero-posterior tibial displacement and external rotation; however a significant reduction in internal rotation of the tibia was found in group A compared with group B (P=0.0001)

Review of literature:

• In 2014, Monaco et al. evaluated the role of lateral tenodesis on the pivot shift effect.

• Twenty patients underwent anatomic single bundle ACL reconstruction with the addition of extra-articular reconstruction. showed that extra-articular reconstruction had little effect in reducing ATT at 30° of flexion, but it was more effective than intra-articular reconstruction in reducing ATR (Ax Tibial Rotn.)

• The authors concluded that anatomic ACL reconstruction and lateral tenodesis were synergic in controlling the pivot-shift phenomenon

Review of literature:

• The concept of anterolateral laxity & anterolateral tenodesis for ALL injuries is well known.

• Although isolated lateral plasties are obsolete, many surgeons are currently combining a lateral tenodesis with traditional ACL reconstruction.

• Whether or not these techniques produce better outcomes compared with isolated ACL reconstruction is still under debate.

• No randomized controlled trials are available comparing the traditional ACL reconstruction techniques isolated and combined with lateral plasties.

Conclusion: