Presentation on the Anterolateral Ligament (ALL) with information on diagnosis with ultrasound and treatment using an ultrasound guided, percutaneous, reconstruction and an internal brace

1. Anterolateral Ligament
Alan M. Hirahara, M.D., FRCS(C)
Board Certified in Orthopaedic Surgery & Orthopaedic Sports Medicine
Specializing in arthroscopic shoulder surgery

2. Anatomy of the ACL
Double Bundle
Courtesy of Steven Claes

3. Lachman Test
Most sensitive test for ACL instability
Diagnostic 95% of time

4. Pivot Shift
• Anterolateral instability
• Lateral tibial plateau
subluxes in extension
• Reduces in flexion by IT
band
Combined internal rotatory
& anterior translational
instability

5. ACL Reconstruction
Single-bundle ACLR Double-bundle ACLR

6. Outcome after ACL Reconstruction
• Good control of AP laxity
– Lachman benchmark for success of ACLR
• Poor control of rotational laxity
– Pivot-Shift difficult and non-standardized
• Return to pre-injury of sports level +/- 60%
Courtesy of Steven Claes

7. Post-op: Pivot Shift
Suomalainen et al., AJSM 2012

8. Pivot Shift
• Most specific test for ACL injury
• Correlates best with functional instability after ACL
injury & reconstruction
• However,
– Some ACL-deficient knees do not show a pivot shift
– Some ACLR patients have persistent (+) pivot shift
Courtesy of Steven Claes

9. Post-op Outcomes: Tibial Rotation
• Claes et al, KSSTA, 2011
– Tibial rotation excursion significantly different in ACL
intact & deficient knees
– No difference in deficient/reconstructed knees
– No difference between SB vs DB reconstructed knees

10. How Can a Centrally Located Ligament
Adequately Prevent Rotation?
Courtesy of Steven Claes

11. The Anterolateral Ligament
Steven Claes, J of Anatomy 2013
ALL found in 97% of knees (n=41)

12. Mechanical Advantage
•
– Force on ACL = (Force on ALL) x (R / r)
• For example, if R2 = 30 mm & R1 = 5 mm
• Force on ACL = 6x the force seen by the ALL

13. Biomechanics of ALL
• Claes et al., ISAKOS 2013, 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

14. Segond Sign
• Lateral capsular sign
• Avulsion fracture,
indicating lateral capsular
injury associated with ACL
rupture

15. Segond Fracture
• Paul Segond (1851 1912)
–
– Found in < 1% of other knee injuries
– Proposed structures
• Segond
• IT Band
• Hughston, Goldman, Johnson
• Campos
• - Neyret
Courtesy of Steven Claes

16. Paul Segond (1879)
•

17. Segond Fracture
Courtesy of Steven Claes

18. Segond Fracture
Difference of 0.4 mm (p=0.70)
Segond Fracture = Bony ALL Avulsion
Courtesy of Steven Claes

19. Localization of ALL Injury
• Claes et al.
– ACLR Cohort (2005 -2011) (n=351)
– ALL Lesion identified on MRI (n=206, 60%)
– ALL Lesion in 79% of ACL injuries (n=162)
• Proximal injuries 20% (n=33)
• Distal / Midsubstance injuries 78% (n=126)
• Segond 2% (n=3)

20. MRI of the Knee

21. MRI of the Knee
LCL
IT Band
ALL

22. LCL
• Leg position: 30o Flexion; Hip internally rotated
• Tip: Find fibular head and follow to lateral epicondyle
• MRI equivalent: Frontal plane

23. IT Band
• Leg position: Extension; Hip internally rotated
• Tip: Find tubercle and follow proximally
• MRI equivalent: Frontal plane

24. Ultrasound Evaluation of ALL
ALL

25. How to Find the ALL
ALL Intact

26. Ultrasound Evaluation
ALL Intact
ALL
ALL

27. Ultrasound Evalution
Distal Tear
ALL TEAR

28. Can the ALL Heal?
Jan 30, 2014 Mar 11, 2014
ALL TEAR HEALED

29. My Experience
Since January 2014
• 13 ACL + ALL Reconstructions
• 1 ACL Recon + ALL Repair
• 5 ACL Recon without ALL injury
• 4 ACL Recon with healing of ALL
• 3 ALL Recon only
– With previous ACL Recon
• 60%
– Needed ALL surgery with ACL
• 22%
– No ALL tear with ACL rupture
• 18%
– ALL showed evidence of healing
* All reconstructions and repairs augmented with Internal Brace

30. ALL Reconstruction using Ultrasound
& Internal Brace

31. MRI / Ultrasound ALL Recon
6 months post-op

32. HiraharaMD.com