Anterolateral ligament reconstruction in the setting of anterior cruciate ligament deficiency

OVERVIEW

Chapter synopsis

Anterolateral ligament reconstruction (ALLR) in the setting of anterior cruciate ligament reconstruction (ACLR) is a subject of debate. Recent studies showed good outcomes and low graft failure rates when ALLR was used in combination with ACLR. This chapter provides an overview of the ALL, its relevant clinical findings, surgical technique and outcomes.

Important points

Indications: A treatment algorithm recommended by the consensus of the Anterolateral Ligament Expert Group is presented in this chapter. It determines whether ALLR should be considered at the time of ACLR.
Contraindications: There are no absolute contraindications for this technique.
Patient presentation: There is no specific physical examination test to identify an injury to the anterolateral structures of the knee; however, the association between a high-grade pivot shift and ALL injury in ACL-injured knees has been clinically proven.
Surgical technique: ALLR is typically performed using a combined ACL and ALL graft and a single femoral tunnel. Techniques with separate graft and tunnels independent of the ACL reconstruction are also described.

Clinical/surgical pearls

ALL tunnel preparation must be done prior to arthroscopy for more precise identification of landmarks.
ALL graft should be passed beneath the iliotibial band (ITB) band.
ALL graft should be fixed in full extension to ensure neutral rotation and avoid overconstraint of the knee.

Clinical/surgical pitfalls

Attention should be paid to fascial attachments/bands while harvesting the semitendinosus and gracilis.
Identify the lateral collateral ligament (LCL) to avoid iatrogenic injury while drilling the outside-in femoral tunnel; a longitudinal incision is preferred to a stab incision for non-experienced surgeons.
The femoral interference screw shall not protrude over the lateral cortex or onto the intra-articular surface.

Video available

. Surgical technique for combined ACL + ALL reconstruction.

Introduction

Historically, the concept of combining a lateral extra-articular tenodesis (LET) procedure with an intra-articular reconstruction for the treatment of anterior cruciate ligament (ACL) injury was associated with improved knee kinematics. ^, However, these procedures (mostly non-anatomic) were almost completely abandoned after 1989 due to a failure of clinical studies to demonstrate a significant advantage of combined ACL reconstruction (ACLR) and LET over anterolateral ligament reconstruction (ACLR) alone, as well as concerns about postoperative stiffness and over-constraint. ^, Recently, there has been considerable interest in the clinical value of LET. Since the “rediscovery” of the ALL by Claes et al in 2013 ( Fig. 88.1 ), its existence has been highly debated and its indication in the setting of ACLR has heated up the literature. In 2019, an international consensus meeting acknowledged the ALL role as a knee stabilizer and defined its key anatomical parameters and indications. Meanwhile, multiple groups have published combined ACL and ALL reconstruction clinical outcomes, reporting significant advantages over isolated ACL reconstruction with respect to graft rupture rates, knee laxity parameters, meniscal repair protection, and functional outcomes (including return to sport). ^, ^, ^, The inherent advantages of ALLR are the simplicity of the technique, the fact that no additional graft is required when combined with ACLR, and that there is no added morbidity related to the site of ALLR, as graft passage is percutaneous. Therefore, ALLR can be beneficial not only in the setting of revision ACLR, but also in primary ACLR because the addition of ALLR can restore normal knee kinematics.

Fig 88.1, The anterolateral ligament dissected, with relationship to the lateral collateral ligament, the popliteofibular ligament, and the popliteus tendon. The femoral origin is just posterior and proximal to the lateral epicondyle. The tibial attachment is 21.6 mm posterior to Gerdy’s tubercle and 4 to 10 mm below the tibial joint line. LCL, Lateral collateral ligament.

This chapter details the surgical technique for combined ACLR and ALLR as well as isolated ALLR using hamstring tendon autografts.

Preoperative considerations

History

In the setting of ACL-injured knees, attention should be paid to patients at high risk of graft rupture, particularly young patients less than 25 years old involved in pivoting sports. The cause of the accident (traumatic or not) and mechanism of injury (hyperextension, twisting movement, valgus loading) must be highlighted, as internal tibial rotation may be associated with combined ALL injury. Prior knee surgeries must be noted, as these could influence graft choice.

Signs and symptoms

In acute ACL injured knees, any swelling or bruising on the anterolateral tibial plateau with pain on palpation, particularly if it is located between the fibular head and Gerdy’s tubercle, is suggestive of ALL injury. Symptoms and signs related to a Segond fracture may also be present.

Physical examination

Physical examination should include a full inspection of the knee with integrity assessment of all ligaments. Nevertheless, in acute ACL injured knees, the physical examination is frequently affected by pain and swelling. In the setting of an ACLR, a detailed examination under anesthesia is of great value. To date, there is no specific physical examination test that has been demonstrated to reliably identify an injury to the anterolateral structures of the knee. However, a significant association between a high-grade pivot shift and ALL injury in ACL-injured knees has been reported.

Imaging

The presence of a Segond fracture on a standard A/P radiograph of the knee can suggest combined ALL injury, as it demonstrates avulsion of the tibial insertion of the ALL ( Fig. 88.2 ). More frequently, coronal magnetic resonance imaging (MRI) views using T2-weighted and proton density fat-suppressed sequences can visualize ALL injury or bone edema on ALL femoral and tibial insertion sites, with better spatial resolution using three-dimensional (3D) MRI ( Fig. 88.3 ). Ultrasound imaging can also be useful in diagnosing ALL injury, particularly the distal (tibial) part.

$Fig 88.2, Anteroposterior radiograph of a left knee showing a Segond fracture.$

Fig 88.3, Injury classification of ALL (white arrowheads) on coronal MRI images: Type A, normal ALL, visualized as a clearly defined low-signal continuous band. Type B, abnormal ALL showing warping, thinning, or iso-signal changes. Type C, abnormal ALL showing no clear continuity.

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