I'd like to thank John Kelly for this opportunity to talk to you about how I do ALO reconstruction. By the way, my disclosure is here. So we've heard some of the anatomy already, emphasis on the anterior ligament, but I also want to emphasize the importance of the deep IT band and particularly the capsulosteous fibers. So we've seen this picture already today. I want to point out that the original description with Stephen Kleiss was that the attachment was anterior and distal to the lateral epicondyle, and I think that has been called into question in other studies. My mentor, Dr. Houston, described the middle third of the capsular ligament, which is basically the exact same location as what was described by Stephen Kleiss. So the importance of the ALO, it's a capsular ligament. Kennedy did this study in 2015 showing us this. It tightens in internal rotation about 30 degrees, and its attachment is proximal and posterior to the lateral carotid ligament at the epicondyle. That's very important. It attaches halfway on the tibia between the center of the girdies and the anterior fibro head. It's a very weak ligament, maximum load only 175 newtons. So if you look at this dissection I did in the lab, you can see here when I internally rotate the tibia, this is the ALL, this capsular ligament. There's a lateral carotid ligament there, so it's a very thin capsular ligament. And Dr. Houston, again, in my training years ago, talked about the importance of the IT band. And he taught us it's like a bank curve, and the capsulaceous fibers serve as a sling around the lateral firmal condyle to help control the pivot shift as your knee goes into extension. In fact, in 1986, in this article, he described the anterolateral ligament of the knee. So he was well ahead of his time. So this is a dissection I did, and you can see here I've reflected the superficial portion of the IT band. Here's my hemostat. These are the capsulaceous fibers here that can hug the lateral firmal condyle. Now I put the two together. Here's the ALO in blue. Here's the lateral carotid ligament. And in blue is the capsulaceous fibers. And you can see the parallelism between the ALL and these capsulaceous fibers. So my approach for an anterolateral ligament reconstruction is to base both on the anatomy as well as the science. So I want to recreate both the path of the ALL as well as those deep IT band fibers. I want to do this minimally invasive, and I want to protect the lateral carotid ligament when I do this procedure. So I call this an anterolateral reconstruction. So here will be pictorial of the ALL. I'm going to place a graft here, and my landmark is the lateral gastroc tubercle, and I'm going to try to duplicate those deep IT band fibers at the same time. So we just have this study coming out in arthroscopy. We did a cutting study looking at the pivot shift and the importance of either the deep IT band or the ALL. And what we found in our study, we had six matched pairs of cadaveric knees, and we tested cutting them both sequentially. We found the deep IT band was more important for anterior translation at 0, 30, and 90, and particularly more important for interrotation at 0 degrees. So in our study, we found that this deep IT band was more important than the ALL for the pivot shift in that biomechanical study. So what I do is I check isometry, but I'm actually looking for a lengthening pattern of my graft and extension. I fix my, I use an allograft, I fix it proximal at the lateral gastroc tubercle. Importantly, I use an anchor that has a suture attached, and I use that suture to also placate the capsulaceous fibers back to that anchor. On the tibia, I use a forked anchor to fix my graft. I fix my grafts at 0 degrees, neutral rotation. I do not want to overtighten. So here's, I did one in the cadaver, and you can see here's my graft for the ALL reconstruction. Here's the lateral muscular septum, here's the gastroc tubercle, which is my landmark for the graft, and the ALL would be in blue, and the lateral precondyle is here. So this is a video. I do it after my ACL reconstruction when I felt it's necessary. So I make a small lateral incision, drill my guide pin, find my point on the tibia. Here's my check for my isometry. I just pass the suture around each pin deep to the IT band. I take the knee from 100 degrees of flexion into full extension, and if you watch, my hemostat moves up toward the hip. It lengthens. So I'm looking for a 2 to 3 degree lengthening pattern for my non-isometric position. I do that on purpose. So now I'm going to overdrill on the femoral side for my fixation of my allograft. Here's my suture anchor here, and again, I leave the suture that's in that anchor to use to later reattach the capsulaceous fibers separately. So once I have my femoral fixation in place, I drill my femoral side. This is usually a 7-millimeter hole here for my graft. I pass my graft deep to the IT band through this small incision here. So here's my forked anchor, knees in full extension, neutral rotation, get my fixation on my graft. So once that's completed, there's the graft here. Now I go back up here, and I take this suture, and I take those capsulaceous fibers that I carefully reflected on my initial exposure, and I reattach those with that suture, and then I close the IT band afterwards. So this is what a post-operative x-ray looks like. You can see where my anchor position is, posterior and proximal to the epicondyle. Again, this is the lateral gastro-tubicle, and there it is on the tibia. So as part of our study, we looked at doing this procedure and compared it to a modified LaMer. After we did an ACL reconstruction, this was done after the IT band and the ALL was cut. What we found is between the two procedures, no difference in inter-rotation. Anterior translation was a bit better for the ALL than the modified LaMer, but neither procedure over-constrained our ACL reconstruction. So we concluded that doing this procedure was, in the mechanical model that we studied, was equivalent to a modified LaMer. If you look at the LaMer procedure here, schematically, right where their femoral tunnel is, is right by the lateral gastro-tubicle, which is right here, which is my landmark. So we're basically in the same place. Of course, this begs the question, who needs a reconstruction? I think most patients do well with a primary ACL reconstruction, but I believe the ALL and IT band have some degree of injury. But being extra-articular, like on the medial side, I think it can heal most of our patients. For me, my indications, primarily, if I have a patient with hyperextension, more than 10 degrees, excessive laxity with their normal knee, or if they have physiologic postural laxity, excessive varus when they stand, especially a female soccer player, I'm thinking about doing an ALL at the time of my ACL reconstruction. Sugon fractures or a big impact of lateral thrombosulcus, suggestive of major rotational injury, may sway me that way. And revisions, because of the fact many of those patients have lost some meniscus and they're a little bit looser than normal, I typically do the ALL. This is what I'm looking for in the operating room. If I have this truly explosive pivot shift, this is a case where I'm going to add an ALL. So my technique, I've been doing the same way since 2014, tabulating my cases, 78 primary, 25 revision, using allograft and all. And notably, this represents only 18% of my total ACL cases that I add this extra ticker procedure. Clinically, what I'm seeing is a bit of a tenodesis effect, especially in the hyperextended patients. Average pre-op of 9 degrees, post-op of 3 degrees. So it seems like there is some degree of loss of hyperextension. So I do tell my patients and their families that might occur, and we've done pretty well so far. I've had one failure with one female soccer player. So in conclusion, I think ACL graft tears are still problematic, despite maybe better optimal ACL techniques these days. So I think we need to still consider doing something extra articular with this anterolateral reconstruction, especially for those at-risk knees. And I believe it's important to address not just the anterolateral ligament, but also the anatomy of the deep capsule osseous IT band fibers as important lateral stabilizers. Thank you.

anterolateral ligament reconstruction

deep IT band

capsulosteous fibers

ALO path recreation

ALO reconstruction technique