Anterolateral Ligament 
Alan M. Hirahara, M.D., FRCS(C) 
Board Certified in Orthopaedic Surgery & Orthopaedic Sports Medic...
Anatomy of the ACL 
Double Bundle 
Courtesy of Steven Claes
Lachman Test 
Most sensitive test for ACL instability 
Diagnostic 95% of time
Pivot Shift 
• Anterolateral instability 
• Lateral tibial plateau 
subluxes in extension 
• Reduces in flexion by IT 
ban...
ACL Reconstruction 
Single-bundle ACLR Double-bundle ACLR
Outcome after ACL Reconstruction 
• Good control of AP laxity 
– Lachman benchmark for success of ACLR 
• Poor control of ...
Post-op: Pivot Shift 
Suomalainen et al., AJSM 2012
Pivot Shift 
• Most specific test for ACL injury 
• Correlates best with functional instability after ACL 
injury & recons...
Post-op Outcomes: Tibial Rotation 
• Claes et al, KSSTA, 2011 
– Tibial rotation excursion significantly different in ACL ...
How Can a Centrally Located Ligament 
Adequately Prevent Rotation? 
Courtesy of Steven Claes
The Anterolateral Ligament 
Steven Claes, J of Anatomy 2013 
ALL found in 97% of knees (n=41)
Mechanical Advantage 
• 
– Force on ACL = (Force on ALL) x (R / r) 
• For example, if R2 = 30 mm & R1 = 5 mm 
• Force on A...
Biomechanics of ALL 
• Claes et al., ISAKOS 2013, AAOS 2013 
– Selective cutting of ACL bundles / ALL 
– ALL important int...
Segond Sign 
• Lateral capsular sign 
• Avulsion fracture, 
indicating lateral capsular 
injury associated with ACL 
ruptu...
Segond Fracture 
• Paul Segond (1851 1912) 
– 
– Found in < 1% of other knee injuries 
– Proposed structures 
• Segond 
• ...
Paul Segond (1879) 
•
Segond Fracture 
Courtesy of Steven Claes
Segond Fracture 
Difference of 0.4 mm (p=0.70) 
Segond Fracture = Bony ALL Avulsion 
Courtesy of Steven Claes
Localization of ALL Injury 
• Claes et al. 
– ACLR Cohort (2005 -2011) (n=351) 
– ALL Lesion identified on MRI (n=206, 60%...
MRI of the Knee
MRI of the Knee 
LCL 
IT Band 
ALL
LCL 
• Leg position: 30o Flexion; Hip internally rotated 
• Tip: Find fibular head and follow to lateral epicondyle 
• MRI...
IT Band 
• Leg position: Extension; Hip internally rotated 
• Tip: Find tubercle and follow proximally 
• MRI equivalent: ...
Ultrasound Evaluation of ALL 
ALL
How to Find the ALL 
ALL Intact
Ultrasound Evaluation 
ALL Intact 
ALL 
ALL
Ultrasound Evalution 
Distal Tear 
ALL TEAR
Can the ALL Heal? 
Jan 30, 2014 Mar 11, 2014 
ALL TEAR HEALED
My Experience 
Since January 2014 
• 13 ACL + ALL Reconstructions 
• 1 ACL Recon + ALL Repair 
• 5 ACL Recon without ALL i...
ALL Reconstruction using Ultrasound 
& Internal Brace
MRI / Ultrasound ALL Recon 
6 months post-op
HiraharaMD.com
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Anterolateral Ligament (ALL)

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

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Anterolateral Ligament (ALL)

  1. 1. Anterolateral Ligament Alan M. Hirahara, M.D., FRCS(C) Board Certified in Orthopaedic Surgery & Orthopaedic Sports Medicine Specializing in arthroscopic shoulder surgery
  2. 2. Anatomy of the ACL Double Bundle Courtesy of Steven Claes
  3. 3. Lachman Test Most sensitive test for ACL instability Diagnostic 95% of time
  4. 4. Pivot Shift • Anterolateral instability • Lateral tibial plateau subluxes in extension • Reduces in flexion by IT band Combined internal rotatory & anterior translational instability
  5. 5. ACL Reconstruction Single-bundle ACLR Double-bundle ACLR
  6. 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. 7. Post-op: Pivot Shift Suomalainen et al., AJSM 2012
  8. 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. 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. 10. How Can a Centrally Located Ligament Adequately Prevent Rotation? Courtesy of Steven Claes
  11. 11. The Anterolateral Ligament Steven Claes, J of Anatomy 2013 ALL found in 97% of knees (n=41)
  12. 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. 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. 14. Segond Sign • Lateral capsular sign • Avulsion fracture, indicating lateral capsular injury associated with ACL rupture
  15. 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. 16. Paul Segond (1879) •
  17. 17. Segond Fracture Courtesy of Steven Claes
  18. 18. Segond Fracture Difference of 0.4 mm (p=0.70) Segond Fracture = Bony ALL Avulsion Courtesy of Steven Claes
  19. 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. 20. MRI of the Knee
  21. 21. MRI of the Knee LCL IT Band ALL
  22. 22. LCL • Leg position: 30o Flexion; Hip internally rotated • Tip: Find fibular head and follow to lateral epicondyle • MRI equivalent: Frontal plane
  23. 23. IT Band • Leg position: Extension; Hip internally rotated • Tip: Find tubercle and follow proximally • MRI equivalent: Frontal plane
  24. 24. Ultrasound Evaluation of ALL ALL
  25. 25. How to Find the ALL ALL Intact
  26. 26. Ultrasound Evaluation ALL Intact ALL ALL
  27. 27. Ultrasound Evalution Distal Tear ALL TEAR
  28. 28. Can the ALL Heal? Jan 30, 2014 Mar 11, 2014 ALL TEAR HEALED
  29. 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. 30. ALL Reconstruction using Ultrasound & Internal Brace
  31. 31. MRI / Ultrasound ALL Recon 6 months post-op
  32. 32. HiraharaMD.com

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