The Antero-lateral ligament "the whole story"

Anterolateral Ligament
of the knee
The whole story
Dr. Mohamed A. Abdel-Salam
M.D. Orthopedic Surgery

The problem with ACL reconstruction??
• ACL reconstruction , with graft
either hamstrings or BTB , can
restore abnormal anteroposterior
translation of the tibia.
• Lachman test is the benchmark for
success of ACL reconstruction
However
• Poor control of rotational laxity
• Return to pre-injury of sports level +/-
60%

• Pivot shift is the most specific test for ACL
injury
• Correlates best with functional instability
after ACL injury and reconstruction
However:
• Some ACL deficient knees don’t show a Pivot Shift !!!
• Some ACL reconstructed knees show a persistent + Pivot Shift

• Is it a technique problem ?
• Does improvement of femoral tunnel placement
from trans-tibial to more the anatomical Antero-
medial portal improve the rotational stability of
the knee ?
• A more horizontal placement of the femoral tunnel ,close to 10 o΄clock ,
which is anatomically closer to the insertion of the p/l bundle , can
improve rotational stability , however without full restoration

• Does the anatomical double-bundle
reconstruction decrease the
translation and rotation of the tibia
during pivot-shift??
• Several Meta-analysis
studies,No significant
difference or major clinical
advantage in terms of use the
technically demanding
double bundle technique

• How a centrally located
ligament control rotation
??

• The Answer of all these questions is the :
Anterolateral ligament

The Anterolateral ligament
Found in 97% of the knees

• Function of the Anterolateral ligament:
Claes et al.,AAOS 2013 – Selective cutting of ACL bundles / ALL
ALL important internal rotatory stabilizer between 30-90o,
while ACL is NOT –
Sectioning of ALL -> Grade 1+ Pivot shift – Cutting AMB+PLB -> Grade 1 Pivot shift –
Ruptured ALL is prerequisite for Grade 3 Pivot shift in ACL deficient knee
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.

This anterolateral ligament can explain:
• Why the pivot shift gets worse over time after untreated ACL injury.
• Why reconstructed ACL’s can still show a residual pivot.

Diagnosis of ALL tear :
• Clinically :
Grade 2/3 pivot shift
Marked rotational instability
• Radiologically :
Segond fracture
MRI: Best in T2 coronal image
Recent studies have shown
the prevalence of MRI signs of
ALL injury can reach 44 % in
ACL injured knee

• Various surgical procedures for lateral extra articular tenodesis
have been devised since 1967 when Lemaire described it first.
• The main concept is reconstruction of ALL thus restoring the
rotational stability using either ITB, PTB graft, ST &/or
Gracilis graft.

Modified Lemaire’s procedure for Extra-
articular tenodesis
From January 2017 2016 to August 2018
84 ACL reconstructions were performed
Extra-articular tenodesis was Added to the ACL reconstruction in 36 patients
43%
The indications for Adding Extra-articular tenodesis were :
Revision ACL Reconstruction:
When no other significant pathology needs to be addressed
Primary ACL Reconstruction :
Grade 2/3 pivot shift
Patient younger than 20 years
Elite professional athletes
Pivoting sports
Ligamentous laxity
Increase tibial slope more than 12 degrees
Another indication was added : when graft size is 7mm or less

articular tenodesis

articular tenodesis
Post Operative Protocol:

•No re-rupture or re-operation
•Pivot shift is negative in all patients
•8 patients have difficulty in the terminal 10
degrees of flexion
•3 patients are disappointed from the scar
•5 patients were able to return to their same
professional sport activity 9-12 months post
operatively

Take Home Messages
• ACL reconstruction techniques may fail
to restore full knee rotational stability
• Pivot shift test grade 1+ or more points
to an Anterolateral ligament tear
• A lateral placed tendon may provide
better rotational control due to
enhanced Biomechanical advantage
• Modified Lemaire’s lateral extra-
articular tenodesis may help to reduce
anterolateral rotational instability and
graft failure.

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The Antero-lateral ligament "the whole story"

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