The Anterolateral Ligament of the Knee. Dr. Matt Daggett, D.O./M.B.A.

Transcription

1 The Anterolateral Ligament of the Knee Dr. Matt Daggett, D.O./M.B.A.

2 Founded by Dr. Larry Lemak and Dr. James Andrews Epicenter of Sports Medicine: Over 300 publications Overhead athlete injuries Return to play ACL injuries

3 Shoulder Fellowship, Lyon France Dr. Gilles Walch Designer of Reverse TSA 400+publications Authority on Shoulder

4 Extended sports experience with Dr. Bertrand Sonnery-Cottet Anterolateral Ligament Biologic ACL Lower Extremity

5 YOU ARE CRAZY I VE NEVER SEEN IT FRANCE RUINED EVERYTHING YOU LEARNED MY ACLS DO GREAT!

6 CURRENT ISSUES WITH ACL RECONSTRUCTION Revision for Re-rupture:10% 20% in collegiate athletes with precollege ACL Return to play Rotational Control 20% continued rotational instability in double bundle

7 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%

8 RETURN TO PLAY High School/College Football: 63%/ 69% (MOON AJSM 2012) NFL 63% (ASMI) (55% at 2yrs) MLS:77%%: OJSM NBA:78% (Arthroscopy)

9 ACL MECHANISM

10 History Paul Ferdinand Segond 1879 Recherches cliniques et expérimentales sur les épanchements sanguins du genou par entorse fibreuse bande nacrée

11 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

12 TERRY-THE DEEP ITB

13 TERRY-THE DEEP ITB

14 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.

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16 Directly on LE Slightly Proximal and Posterior to LE Completely Proximal and Posterior to LE

17 Mid capsular / capsulo-osseous layer or Ligament? J. VINCENT, KSSTA 2012 C.HELITO, OJSM 2013 C. SCOTT, KSSTA 2014

18 Sectioning the anterolateral ligament did not increase tibiofemoral translation or rotation in an ACL-deficient cadaveric model. Yousif Al Saiegh et al. KSSTA 2015 ALL function: Controversy LCL ALL tibial insertion

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20 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

21 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

22 Introduction ALL function: AP translation control Tavlo, Ejaja et al. Scand J Med SCI Sports 2015 Spencer, Burkhart, et al AJSM 2015 Med Lat

23 Introduction Med Lat + Med Lat

24 Selective Sections The Involvement of the ALL in the rotational control of the Knee

25 Selective Sections 12 cadaver knees Selective section ACL, ALL, ITB Internal rotation at 20 and 90 + coupled axial rotation = simulated PS

26 Selective Sections Intact ACL ALL ITB SECTION 1

27 Selective Sections Intact ACL ALL ITB SECTION 2

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

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

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

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

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

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

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

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

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

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

38 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

39 Question? ALL Efficient close to flexion? Or close to extension?

40 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

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

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

43 ALL kinematic: basics

44 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

45 ALL Kinematic

46 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

47 History Paul Ferdinand Segond 1879 Recherches cliniques et expérimentales sur les épanchements sanguins du genou par entorse fibreuse bande nacrée

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50 ALL Reconstruction Basics Reconstruction 300 Load at failure. N / / /- 35 Single Double Native

51 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

52 Strong My Indications??? Pivot Shift ++ Chronic ACLs Lateral notch X-rays Segond facture ACL revision Relative Pain at ALL Female Pivoting Athletes ACCEPTED

53 ACL Graft Rupture primary ACL Reconstructions FU=33 months Graft Rupture = 2,8% years, Competitors, Sport Pivoting = 1071 Patients FU=33 months Graft Rupture = 4,20% ACL Contralateral rupture = 6 % BPTB = 6,95 % Graft rupture Mean delay 16,7 months Hamstring = 4,97 % ACL+ALL = 2,14 % ACCEPTED

54 RTP=84%

55 OTHER FACTOR: BIOLOGIC ACL

56 OTHER FACTOR: BIOLOGIC ACL

57 YOU ARE CRAZY I VE NEVER SEEN IT FRANCE RUINED EVERYTHING YOU LEARNED MY ACLS DO GREAT!

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59 Questions? 59