The Anterolateral Ligament- Is it the Whole Story? Andy Williams, Fortius Clinic, London
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1 The Anterolateral Ligament- Is it the Whole Story? Andy Williams, Fortius Clinic, London 1
2 Disclosures Alex Dodds and Christoph Kittl, Fellows Smith and Nephew Research Grant 2
3 3 Disclosures
4 4 Disclosures
5 ACL Deficiency ATT
6 ACL Deficiency ATT
7 ACL Deficiency ATT
8 ACL Deficiency ATT
9 ACL Deficiency ATT
10 ACL Deficiency ATT
11 Dynamic M.R.I. GE 0.5T Signa SP
12 Weight-Bearing MRI
13
14 ACL Deficient Knees What happens in the Lachmann test?
15 ACL Deficient Knees What happens in the Lachmann test? Predominantly lateral translation Logan et al, AJSM 2003
16 Impact of Cruciate Ligament Deficiency ACL deficiency PCL deficiency 3 AJSM articles: Logan et al 2004 PCL Intact ACL Intact
17 Impact of Cruciate Ligament Deficiency ACL deficiency altered LATERAL kinematics PCL deficiency altered MEDIAL kinematics 3 AJSM articles: Logan et al 2004 PCL Intact & Deficient ACL Intact & Deficient
18 ACL Deficiency Pivot Shift
19 ACL Deficiency Pivot Shift Due to coupled ATT and IR
20 The Pivot Shift is the cause of symptoms in ACLD is the focus of treatment - laxity does not correlate well with success - pivot shift does correlate with success 20
21 Note in cadaveric studies - Isolated ACL tears can NO Pivot Shift - Lateral soft tissue lesions (ACL intact) can Pivot Shift 21
22 ACL Rupture = a Lateral Compartment Injury The Ségond fracture is pathognomonic of ACL rupture
23 ACL Rupture = a Lateral Compartment Injury
24 ACL Rupture = a Lateral Compartment Injury
25 And yet. State of the art ACLR involves - obsessive reconstruction of the ACL alone - anatomic surgery
26 And yet. State of the art ACLR involves - obsessive reconstruction of the ACL alone - anatomic surgery Whilst leaving the lateral injury
27 And yet. State of the art ACLR involves - obsessive reconstruction of the ACL alone - anatomic surgery Whilst leaving the lateral injury Anatomic surgery must deal with all lesions
28 Clearly this interested others! Lyon, France - Philippe Neyret - KSSTA Vincent et al 2011 Leuven, Belgium - J of Anatomy Claes et al 2013 London- Imperial College - BJJ, Dodds et al 2014
29 Anatomy 40 cadaveric knees ITB exposed, elevated from posterior to anterior Different to standard surgical approach
30 Anatomy 40 cadaveric knees ITB exposed, elevated from posterior to anterior
31 Anatomy 40 cadaveric knees ITB exposed, elevated from posterior to anterior
32 Anatomy 40 cadaveric knees 33 (83%) with Oblique Lateral Ligament
33 Anatomy 40 cadaveric knees 33 (83%) with Antero-Lateral Ligament
34 Anatomy 40 cadaveric knees 33 (83%) with Antero-Lateral Ligament
35 Anatomy 40 cadaveric knees 33 (83%) with Antero-Lateral Ligament
36 Anatomy 40 cadaveric knees 33 (83%) with Antero-Lateral Ligament
37 Anatomy 40 cadaveric knees 33 (83%) with Antero-Lateral Ligament
38 Anatomy Av length 60mm
39 Anatomy Tibial attachment 50% between Gerdy s tubercle & Fibular head
40 Anatomy Tibial attachment At site of Ségond fracture?
41 Anatomy Femoral attachment 10mm from LCL attachment
42
43 The Greatest Breakthrough in Modern Medicine?
44 The Greatest Breakthrough in Modern Medicine? Twitter Mentions November 2013 Blue = ALL Orange = New body part
45 Previously Unclear Anatomy Terminology Anterolateral Ligament Anterior Oblique Band Capsulo-osseous layer of iliotibial tract Author Vieira et al,vincent et al Campos et al Terry et al Capsular portion of Lateral Collateral Ligament Goldman et al Lateral Capsular Ligament Midthird Lateral Capsular Ligament Dietz GW et al, Hughston et al,, LaPrade et al, Sanchez et al
46 Is the A.L.L. the Whole Story?- I.T.B. Role Proximal insertion Supracondylar insertion Retrograde insertion ITB dissected / flapped down 04/04/2014 Christoph Kittl Fib G
47 Is the A.L.L. the Whole Story? Proximal insertion Supracondylar insertion Retrograde insertion ITB dissected / flapped down 04/04/2014 Christoph Kittl Fib G
48 The Role of ITB 48 Courtesy Christoph Kittl
49 Extra-Articular Tenodesis David Dandy footballers- great results Peter Myers we need to work out when to use it 1996 Works Protect intra-articular ACL graft during healing Extra restraint on return to activity Almost 100% of my revision ACLs
50 Extra-Articular Tenodesis
51 Extra-Articular Tenodesis ACL
52 Extra-Articular Tenodesis ACL provides Big resistance to ATT
53 Extra-Articular Tenodesis ACL provides Big resistance to ATT small resistance to IR (Ed Wojtys et al)
54 Extra-Articular Tenodesis Lateral tenodesis
55 Extra-Articular Tenodesis Lateral tenodesis Biomechanically very effective vs IR
56 Development- due diligence Biomechanical testing of O.L.L. Finesse a lateral procedure Assess lateral compartment consequences
57 Additional Extra-Articular Procedures
58 Additional Extra-Articular Procedures
59 Additional Extra-Articular Procedures
60 Additional Extra-Articular Procedures
61 Additional Extra-Articular Procedures
62 Additional Extra-Articular Procedures
63 Additional Extra-Articular Procedures
64 Additional Extra-Articular Procedures
65 Additional Extra-Articular Procedures
66 Additional Extra-Articular Procedures
67 Additional Extra-Articular Procedures
68 Additional Extra-Articular Procedures
69 Additional Extra-Articular Procedures
70 Additional Extra-Articular Procedures
71 My practise Never on own Must rule out PLRI? In cases of compromised ACR revision cases vulnerable primary cases
72 Results October 2009 April 13: 61 cases Revision ACR: 91 (67 tenodesis = 74%) Primary ACR: 407 (22 tenodesis = 5.4%) No failures one known ACL graft failed but asymptomatic 2 deep wound infections? Lateral OA
73 73 Investigating Surgical Techniques
74 74 Investigating Surgical Techniques
75 Investigating Surgical Techniques Tight in flexion Loose in extension 75
76 Investigating Surgical Techniques Imperial ALL Tightens in extension 76
77 Investigating Surgical Techniques DEEP TO LCL Good Eg McIntosh, Lemaire 77
78 Acknowledgements Alex Dodds Christoph Kittl Andrew Amis Imperial College, London
79 79 Disclosures
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