history, need, how to reconstruct, when to reconstruct. References: *Bonasia, Davide Edoardo et al. "Anterolateral Ligament Of The Knee: Back To The Future In Anterior Cruciate Ligament Reconstruction". Orthopedic Reviews 7.2 (2015) Biomechanical Results of Lateral Extra-articular Tenodesis Procedures of the Knee: A Systematic Review. Erik L. Slette, B.A., Jacob D. Mikula, B.S., Jason M. Schon, B.S., Daniel C. Marchetti, B.A., Matthew M. Kheir, B.S., Travis Lee Turnbull, Ph.D., and Robert F. LaPrade, M.D., Ph.D.

1. Extra-Articular ACL – ALL
reconstruction
Presented by: Dr. Milind
Moderated by: Dr. Ajay

2. Introduction:
• Need - A subset of patients experienced some residual antero-
posterior and rotational instability after ACL reconstruction.*
• Anterolateral stabilizing structures in cases of anterior cruciate
ligament (ACL) injuries so came to be recognized.
• High incidence of ALL lesions in ACL-injured knees, with high-grade
pivot-shift (ROTATORY INSTABILITY), led us into the anatomy and
function of the ALL.
*Bonasia, Davide Edoardo et al. "Anterolateral Ligament Of The Knee: Back To The Future In Anterior
Cruciate Ligament Reconstruction". Orthopedic Reviews 7.2 (2015)

3. • Pivot shift test is considered most specific test for ACL injury
• Correlates best with functional instability after ACL injury and
reconstruction.
• However, some patients show a persistant pivot shift post ACL
reconstruction.
• Question arose: How can a centrally located ligament (ACL) restrict
Axial Rotation????
• Answer: ALL was the ligament responsible for rotatory stability.

5. • It was concluded that ALL is an important internal rotatory stabilzer
between 30-90 degree, while ACL limited only ATT.**
• Sectioning of AMB+ PLB – grade 1 pivot positive
• Sectioning of ALL- grade 2 and above pivot positive
• Ruptured ALL is a pre requisite for Grade 3 Pivot Positive in ACL deficient
knee.
**Claes et al. , ISAKOS 2013, AAOS 2013.

6. Recent studies:
• Monaco et. Al (2012) concluded:
• Cutting the PL bundle did not increase anterior translation and rotation of the
knee.
• Cutting the AM bundle significantly increased the anteroposterior (AP)
translation at 30° and 60° (P=0.01), but did not increase rotation of the knee.
• Cutting the ALL increased anterior translation at 60° (P=0.04) and internal
rotation at 30°, 45°, and 60° (P=0.03).
• The authors concluded that cutting the ALL increased tibial rotation and could
be related to the pivot shift phenomenon.
• Pearsons et al. (2015) concluded: ALL to be an important stabilizer of
internal rotation at flexion angles >35°.

7. Brief history:
• In 1879, Paul Segond described a pearly, resistant, fibrous band
inserting on the anterolateral aspect of the proximal tibia.
• Segond fracture: avulsion fracture of LCL attachment at tibial
insertion
• Later called by different names:
• Anterior Band of LCL – Irvine et. al
• Anterior oblique band- Campos et. al
• Antero lateral ligament – Vieria et. al

8. Anatomy of the ALL:
• Origin: Fan like; Femoral epicondyle, anterior-
superior to LCL and posterior and proximal to
insertion of popliteus tendon.
• Insertion: thick capsular fold; midway between
the fibular head and the gerdy’s tubercle.

9. Diagnosis:
• MRI is the modality of choice. (3.0 T study
with 0.4 mm slice thickness and fat
suppression images)*
• Identification of ALL is easier at the
meniscal and tibial attachment, due to the
ALL’s close relationship with the insertion
of the LCL and popliteus tendon
proximally.
• Somewhat ill defined and sheet-like,
inseparable from the adjacent LCL
proximally and iliotibial band distally.
*Gossner J. The anterolateral ligament of the knee. Visibility on magnetic resonance imaging. Rev Bras Ortop 2014;9:98-9.

10. Treatment & indications of repair:
• Recommendation to add a lateral plasty to traditional ACL reconstruction
only in selected cases of:
• Marked rotational instability;
• In cases of high level athletes & contact athletes;
• In selected case of revision ACL surgery.
• Post ACL reconstruction- Symptomatic patients with clinical rotatory instability.
• *Bonasia, Davide Edoardo et al. "Anterolateral Ligament Of The Knee: Back To The Future In Anterior Cruciate Ligament
Reconstruction". Orthopedic Reviews 7.2 (2015)
• *Monaco E, Maestri B, Conteduca F, et al. Extra-articular ACL reconstruction and pivot shift: in vivo dynamic evaluation with navigation. Am
j Sports Med 2014;42:1669-74.
• *Saragaglia D, Pison A, Refaie R. Lateral tenodesis combined with anterior cruciate ligament reconstruction using a unique semitendinosus
and gracilis transplant. Int Orthop 2013;37:1575-81.

11. Techniques of repair:
• Main concept is reconstruction of ALL using either ITB, PTB graft, ST
&/or Gracilis graft.
• Peripheral location of the ALL is the main contributor to
Rotational/Axial stability in comparison to centrally located PL bundle.
• Various surgical procedures for lateral extra articular tenodesis have
been devised since 1967 when Lemaire described it first.

12. Lemaire’s Procedure:
• A strip of iliotibial band was
detached proximally
• Passed deep to the FCL, through a
femoral tunnel at the attachment
point of lateral gastrocnemius.
• The graft is passed deep to the
FCL a second time and fixed with
sutures to the iliotibial band with
the knee flexed to 30 degree and
held in external rotation

13. MacIntosh
procedure(1976):
• A strip of iliotibial band was detached
proximally and passed deep to the
FCL, through an osteoperiosteal
tunnel posterior to the FCL femoral
attachment.
• The graft was then looped through
the lateral intermuscular septum and
sutured back onto itself at the Gerdy
tubercle with the knee flexed to 90
and held in external rotation

14. Losee technique(1978)
A strip of iliotibial band was detached
proximally and passed through a femoral
tunnel that originated at the
attachment point of the lateral gastrocnemius
and ended anterodistal to the FCL femoral
insertion site.
The graft was then sutured at the Gerdy
tubercle with the knee flexed to 30 and held
in external rotation

15. Arnold & Coker (1979)
• A strip of iliotibial band was
detached proximally, passed
beneath the FCL and popliteus
tendon, and sutured to the
Gerdy tubercle with the knee
flexed to 90-100 and held in
external rotation

16. Ellison (1979):
• A distally detached strip of
iliotibial band with a bone flake
was passed deep to the FCL and
anchored in a bone trough
slightly anterior to its original
harvest site at the Gerdy
tubercle with the knee flexed to
90 and held in external rotation.
• The capsular structures were
reefed deep to the FCL

17. Wilson & Scranton:
• A strip of iliotibial band was
detached proximally, passed
deep to the FCL and lateral
gastrocnemius tendon, and
sutured back onto itself with
the knee flexed to 60 and held
in external rotation.
• This extra-articular
reconstruction was used in
conjunction with an intra-
articular ACL semitendinosus
graft reconstruction

18. Zarins and Rowe
technique:
The semitendinosus tendon was detached proximally and
passed through an obliquely oriented tibial tunnel,
across the knee joint, and over the lateral femoral condyle.
After passing over the lateral femoral condyle,
the graft was passed deep to the FCL and sutured onto the
iliotibial band. Similarly, the iliotibial band was
passed deep to the FCL and over the superior aspect of the
lateral femoral condyle.
After passing over the lateral femoral condyle, the graft
was passed across the knee joint, through the same
obliquely oriented tibial tunnel as the semitendinosus
tendon, and fixed with sutures to the semitendinosus
tendon with the knee flexed to 60 and held in external
rotation

19. Andrews procedure:
Two strips of iliotibial band were detached
proximally and sutured at their proximal
ends.
Then, the sutures were passed through 2
parallel tunnels, which originated at the
lateral femoral condyle and exited at the
medial femoral condyle.
After passing through the tunnels in the
lateral-to-medial direction, the suture were
tied together over the adductor tubercle. The
grafts were fixed with the knee flexed to 90
and held in external rotation.

20. Benam procedure:
• The lateral one-third of the
patellar tendon was harvested
proximally with a patellar bone
block, passed deep to the FCL,
and fixed with a staple within a
bony groove deep to the femoral
origin of the FCL with the knee
flexed to 45 and held in external
rotation

21. Muller procedure:
A strip of iliotibial band was
detached proximally and fixed with
2 cancellous screws to a point
anterior to the junction of the
femoral shaft and lateral femoral
condyle with the knee held in
external rotation

22. Marcacci and Zaffagnini
technique:
• Solves both purposes: ACL & ALL
reconstruction.
• Semitendinosus and gracilis tendons
were harvested proximally, sutured
together, and passed through a tibial
ACL reconstruction tunnel.
• The graft exited the tibial tunnel
intra-articularly and was passed
through the posterior aspect of the
femoral notch and over the top of
the lateral femoral condyle.
• The graft was then passed deep to
the iliotibial band and over the FCL
and was fixed distal to the Gerdy
tubercle. With the knee flexed to 90
and held in external rotation

23. Review of literature:
• Various studies have reported following conclusions:
• In the ACL-deficient knee, LET procedures overconstrained the knee
and restricted internal tibial rotation when compared with the native
state.
• In addition, isolated LET procedures did not return normal anterior
stability to the ACL-deficient knee but did significantly reduce anterior
tibial translation and intra-articular graft forces during anteriorly
directed loading.

24. Review of literature:
• 2006, Zaffagnini et al. quantitatively assessed in vivo static and dynamic
biomechanics of the knee before and after ACL reconstruction, comparing the
Marcacci technique with anatomic double-bundle technique.
• The Marcacci technique showed statistically better laxity reduction in
varus/valgus stress test at full extension and in internal/external rotation at 90° of
flexion.
• The lateral plasty better controlled the lateral compartment during drawer test
and varus/valgus stress test both at 0° and 30° of flexion and both the
compartments during internal/external rotation at 90° of flexion.
• On the other hand, pivot-shift phenomenon was better controlled by anatomic
double-bundle reconstruction.
• The authors also concluded that patellar tendon and Marcacci techniques can be
equivalent options for ACL reconstruction.

25. • In 2007, Monaco et al. compared lateral tenodesis (Arnold-Coker
procedure) plus single bundle ACL reconstruction (Group A) with
anatomic double bundle ACL reconstruction (Group B), in terms of
internal tibial rotation.
• A computer navigation system was used to evaluate the global
kinematic of the knee.
• No differences were found in terms of antero-posterior tibial
displacement and external rotation; however a significant reduction
in internal rotation of the tibia was found in group A compared with
group B (P=0.0001)
Review of literature:

26. • In 2014, Monaco et al. evaluated the role of lateral tenodesis on the
pivot shift effect.
• Twenty patients underwent anatomic single bundle ACL
reconstruction with the addition of extra-articular reconstruction.
showed that extra-articular reconstruction had little effect in reducing
ATT at 30° of flexion, but it was more effective than intra-articular
reconstruction in reducing ATR (Ax Tibial Rotn.)
• The authors concluded that anatomic ACL reconstruction and lateral
tenodesis were synergic in controlling the pivot-shift phenomenon
Review of literature:

27. • The concept of anterolateral laxity & anterolateral tenodesis for ALL
injuries is well known.
• Although isolated lateral plasties are obsolete, many surgeons are
currently combining a lateral tenodesis with traditional ACL
reconstruction.
• Whether or not these techniques produce better outcomes compared
with isolated ACL reconstruction is still under debate.
• No randomized controlled trials are available comparing the
traditional ACL reconstruction techniques isolated and combined with
lateral plasties.
Conclusion: