All right, thank you very much for this opportunity. Once I can get this figured out here, is it the button click here? There we go. My disclosures can be found online. Just like to shout out some acknowledgments to my partner, Volker and Michael both contributed some slides and I've learned a lot about this topic from Volker in particular, he's become a good friend and is very knowledgeable about this particular topic in particular. So why are we even talking about this? Obviously this particular ligament and its quote unquote rediscovery has been in the mainstream of news and has popularized a lot of this. I even had patients reach out to me and talk to me about this with ACL reconstruction. But this breaking news of this rediscovery is obviously nothing new. It's been mentioned previously that this description of lateral ligaments or lateral complex is nothing new. It's been reported as long as our literature goes back and looking at structures around the knee. Certainly, it was popularized in particular by Dr. Sagan. He associated this with lateral structure ruptures with ACL injuries. Interesting enough for me in my practice, I don't really often see Sagan fracture or avulsions. But when you do see them, it's quite obvious. I don't necessarily know what that means. You have to have to do an ALL. Volker says that they've only had three cases over three years and I had our fellows look open. We've only had four over the last three years. So it's surprisingly not that common. As mentioned, Dr. Freddy is a big proponent of this and he describes this injury pattern, not necessarily the fracture, but the lateral sided capsular injury is upwards of 90% of all ACLs. I have not seen a paper that collaborates that. I think that's a little high. What we're really talking about is the pivot shift and these unstable knees to rotation. So dealing with that is not a new concept. LaMer and then Andrew's procedure, this has been a common thing in practice to stabilize knees even without ACL reconstructions and it actually works. The issue with extra articular reconstruction is it works and produces stability. The fact is that it does also produce some stiffness and some over constrainment of the joints that does lead to arthritis. The bad news is it does produce some motion loss, some arthritic progression, typically as mentioned on the lateral side of the telepharmic compartments, but it controls stability. So what about this rediscovery and this is sort of the article that's brought it back to the fruition, I suppose. The reality is is there's a lot of anatomic descriptions that have a lot of variability. So I'm not totally sure what we're reconstructing if we're trying to take an anatomic directed approach to this. The issue with this is there's a lot of discrepancies, not only on the origin, but also on the insertion. So I think that if we're going to do this anatomically, we've got to be really clear about what we're anatomically reconstructing. So the biomechanics, sure there is biomechanics. The issue with this biomechanics is the effects of both the ALL and the illitibia band with rotation really didn't become significant until the knee was into greater than 90 degrees of flexion. The other issue is is it's much higher pivot shifts once both the ALL and illitibia band, not just the capsule, but and the illitibia band are violated. That suggests that there's maybe more going on than just this capsular ligament or structure. So Volcker's done a lot with this and we think that the strain that we see out there is really just not one particular ligament, but a whole capsular area. So how are you going to reconstruct just that one area? Where is the evidence? There's been actually surprisingly a lot published in the recent literature. There's conflicting reports over anatomy, prevalence, biomechanics, and the treatment options. So I would just say buyer beware. ALL restraints internal rotation of the tibia is what it's supposed to do, but the DELs and the details. And we need to be careful about the promotion of these techniques with new devices, new techniques, and industry bias. So let's take a look at the facts, and the facts are fiction. So there's animal studies, developmental studies, not really clean appearance on MRI, histology hasn't borne out, the tensiles testing is not as clear, the robotic and pivot shift testing hasn't borne out as much. One concept is maybe this whole lateral side is a functional unit to include an issue or band across the inferior border of the iliotibia band, a proponent from Pittsburgh, which I think is interesting. This is probably most likely an extension of sort of what's called Kaplan's fibers, which has been well described and basically extends from the proximal femur all the way down to Gary's tubercle. If you go deep to that, you can see the capsular layer that we're talking about with this ALL. Medical outcomes, the early data says there's really not that much difference that it supports and solidifies the constructs that we do, whether it's soft tissue or BTB grafts. But what's the risk and what's the reward? So this is another systematic review that really only two studies showed over-constraint, but they did show over-constraint, and two utilized the distal anterior tunnel and did not over-constraint. So I think the devil is in the details with this. So a recent roundtable discussion was had with a bunch of experts, and they say that the rotary instability is multi-factorial, there's debate over whether it exists and what the real anatomy is, that the concern with over-constraint I think is real and certainly dependent upon the technique that one is to use. So a summary for me is the anatomy is probably real but inconsistent. Maybe it's just the tip of the iceberg and there's more to this on the lateral side that we really appreciate, or maybe we've forgotten from old literature, that the middle third capsule ligament is really only found in about 30%. The biomechanics, it's a real native structure but works in multiple planes. It's weak. Strain behavior is not fully understand. Clinically, the early results show that maybe there's a benefit, but the long-term, we don't really know. We don't want to over-constraint the knee and cause further problems. Cost and bias, there's certainly additional cost to the procedure, extra implants, and then potential for surgeon bias with additional billing codes. Thank you.

rediscovery

anterolateral ligament

knee

ACL injuries

ALL injuries