The Anterolateral Ligament- Is it the Whole Story? Andy Williams, Fortius Clinic, London

Transcription

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