Welcome to the Anterolateral Ligament Reconstruction section of this ANA-ACL Toolkit. My name is Adnan Saifner from Scottsdale, Arizona, and I'd also like to acknowledge my co-author for this presentation, Bertrand-Henri Cote from Lyon, France. An important introduction to this presentation is to quickly mention that there's a large number of comparative clinical studies demonstrating significant benefits, typically significantly reduced graft rupture rates, when an ALL reconstruction is added at the time of ACL reconstruction. This includes various high-risk categories, as demonstrated on the left, including young patients participating in high-risk sports, those with chronic injuries, hypolaxity, those undergoing revision ACL reconstruction. These benefits have been demonstrated at long-term follow-up, and also more recently we've demonstrated that even in lower-risk patients, for example, those over the age of 30, significant benefits with respect to graft rupture rates are still demonstrated. If you've decided to perform an ALL reconstruction on the basis of the evidence mentioned previously, it's important to perform this in an anatomical manner. The reason that's important is because we want to try to replicate normal knee kinematics. We don't want to over-constrain the knee, but we want a graft that's functional. So on the left-hand side, we can see an image courtesy of Stephen Kleiss, which shows the native anatomy of the ALL. This is a thin structure, which overlaps the lateral collateral ligament. On the femoral side, we can see that it has a footprint that's proximal and posterior to the lateral epicondyle. The structure then fans out and has a broader insertion on the tibial side. On the right-hand side image, you can see that we tried to replicate this in our surgical reconstruction. Important landmarks are marked here. These include the lateral epicondyle, the joint line, GERDI's tubercle, and the fibular head. Stab incisions are made just proximal to the lateral epicondyle, just posterior to GERDI's tubercle, and just anterior to the fibular head. There are two main ways of performing an ALL reconstruction. You could perform it in combination using a single femoral tunnel for your ACL reconstruction and ALL reconstruction, or you could perform it independently, meaning that you have separate femoral tunnels for your ALL and your ACL. This slide demonstrates the independent ALL reconstruction technique. On the left-hand side, you can see that an anchor has been used to fix a graft, typically a gracilis allograft, just proximal and posterior to the lateral epicondyle. This is shuttled underneath the iliotibial band through a tibial tunnel. That tibial tunnel is created by drilling two 15mm by 4mm sockets, which are then converted using a coracoid parser or a right-angle clamp into a single tunnel, and then the graft is shuttled through that from posterior to anterior, and then back underneath the iliotibial band, staying superficial to the lateral collateral ligament, back to the femoral footprint of the ALL, where it's fixed in full extension with suture fixation only. Here is a video demonstrating that technique. You can see that we're drilling some sockets in the tibia, and then converting those sockets into a single tunnel, which is U-shaped in configuration. The coracoid parser is used to create that tunnel, and also to pass this passing suture. Proximal and posterior to the lateral epicondyle, the graft is fixed with a suture anchor, and then that's shuttled through the tibial tunnel and back to itself at the femoral footprint, where it's fixed with the knee in full extension. We are now going to discuss combined ACL and ALL reconstruction using a single femoral tunnel rather than an independent technique. We're going to highlight some of the same steps used previously because there's considerable overlap between the independent and combined procedures. The main difference, obviously, for the combined procedure is the use of a single femoral tunnel. The main advantage of using a single femoral tunnel is to avoid tunnel collision. The image on the left demonstrates the overall appearance of a combined reconstruction. We have an ACL graft that's combined of a tripled semitendinosus and a single strand of gracilis. This is passed through a femoral tunnel, which exits proximal and posterior to the lateral epicondyle to replicate that femoral footprint of the anterolateral ligament. The rest of the procedure is similar to the independent technique because the graft is shuttled underneath iliotibial band, superficial to the LCL through a tibial tunnel, and back to itself where it's fixed in full extension. The landmarks for the procedure are exactly the same as for the independent ALL technique. My recommendation is that when you are starting this procedure, that instead of making a small percutaneous incision just proximal to the lateral epicondyle, that instead you make an incision of about two to three centimetres as demonstrated in the main picture here. The advantage of this is that it allows clear visualisation of the lateral collateral ligament which has been marked in surgical marking pen. You can see the proximity of our outside-in guide here, which is very close to the lateral collateral ligament, and we want to make sure that we avoid iatrogenic injury. It's important to use outside-in drilling here because intra-articularly we want to achieve an anatomical mid-AM bundle position, and extra-articularly it's important to be at that proximal posterior position to replicate the normal anatomy of the ALL. This cannot be achieved with other drilling techniques. Tibial tunnel creation for the ALL reconstruction remains the same as in the independent technique. Parts are drilled and converted to a single tibial tunnel using a coracoid parser or a right-angle clamp. A shuttling suture is placed and retrieved for use later in the procedure. The next step in the procedure is to harvest the graft. We typically use hamstring tendons when we perform a combined ACL and ALL reconstruction. The main reason for this is because when you harvest the semitendinosus and gracilis, you have sufficient graft to achieve an 8-10mm ACL section of the graft and enough length to perform a two-strand ALL reconstruction replicating the normal anatomy of the native anterolateral ligament. It's important to cut expansions carefully to avoid deviation of the harvester. Once the graft is harvested, we leave the tibial attachment of the semitendinosus attached. Here you can see we're whipstitching the end of the gracilis, but that's going to be detached at the next step. Image B shows that once you've harvested and attached the gracilis, it's then sutured to the semitendinosus at approximately 4 or 5cm from the tibial attachment of the tendons. The reason to do this is to provide enough length of gracilis to perform a two-strand ALL reconstruction. You can determine the precise measurement by measuring your tibial tunnel length, or you can use a general rule of thumb, which is a 4cm gap for female patients and 5cm for tall patients or male patients. Once you've sutured the gracilis to the semitendinosus, the semitendinosus is tripled, as seen in Image C. This is an example of graft preparation in a male patient. The gracilis is being detached. The two marks you see on the semitendinosus there are at 5 and 11cm. Our first tagging suture is placed at 5cm from the tibial attachment, and then a second tagging suture is placed at 11cm, giving an overall ACL part of this graft measuring 6cm in length. An additional suture is placed at this stage, which you'll see used for fixation of the ALL graft at the end of the procedure. Graft preparation proceeds by constructing a tripled semitendinosus section and a single strand of gracilis, leading to an overall four-strand ACL section of the graft, which typically measures 8-10mm in diameter. Multiple tagging sutures are placed to ensure that the graft is adequately fixed. The graft is then sized in order to subsequently drill tunnels. This slide summarizes the surgical procedure so far. On the left hand side we have an ALL tibial tunnel which has been created with the passing suture in place. We also have a graft prepared which is a tripled semitendinosus and single strand of gracilis forming a four strand ACL graft and a single strand of gracilis for the ALL graft. The next step is to drill the femoral and tibial tunnels. As mentioned previously it's important to use outside in femoral drilling techniques. Here a hook guide is used to place the intra-articular aperture of the tunnel in a mid-AM bundle position. Again it's important to place the external part of the guide proximal and posterior to the lateral epicondyle being mindful to avoid iatrogenic lateral collateral ligament injury. Once a guide wire is placed in a satisfactory position confirmed both intra-articularly and externally it's converted to a full tunnel based on the size of the graft. The tibial tunnel is created in a standard manner and then the graft is passed into the knee using a shuttling suture. Here you can see the gracilis part coming into the knee and that was the ACL part coming in. Here we can see that happening intra-articularly. The next step is to remove slack from the graft and fix it on the tibial side with an interference screw. This slide summarizes the surgical procedure so far. The graft has been passed through the tibial tunnel. It's fixed on the tibial side with an interference screw. The ACL graft is in situ and femoral fixation is performed in a similar manner to the tibial side. A nitinol wire is placed in the tunnel. The knee is placed in 30 degrees of flexion. A posterior drawer is applied and an interference screw is inserted. This leaves us with the additional length of the gracilis exteriorized and ready to perform the ALL reconstruction as demonstrated previously and summarized on the next slide. The ACL part of the graft has been fixed on both tibial and femoral sides. The additional length of gracilis is shuttled underneath the iliotibial band superficial to the lateral collateral ligament through the tibial tunnel from posterior to anterior back underneath the iliotibial band where it's fixed proximal and posterior to the lateral epicondyle using suture fixation with the knee in full extension. These steps are performed percutaneously. It's important to ensure that the graft is passed deep to the iliotibial band. The graft is going to be shuttled back to that proximal posterior position. The ethiobond suture seen there on the femoral side is the one that was placed during the graft preparation for the purposes of fixation. The knee is placed in extension, slack is removed from the graft and suture fixation is performed in this position. Excess length of the graft is truncated, therefore terminating the procedure. A further summary slide demonstrates the overall procedure. We have a combined ACL and ALL single femoral tunnel. The ACL portion of the graft comprises a tripled semitendinosus and additional length of gracilis. Fixation of the graft on the tibial and femoral sides is with an interference screw. The additional length of gracilis is shuttled underneath the iliotibial band superficial to the lateral collateral ligament through the tibial tunnel where there is no additional fixation. Back underneath the iliotibial band to a position proximal and posterior to the lateral epicondyle where it is fixed with sutures only. I wanted to share some tips and tricks. The first is in relation to graft harvest. It's important to make sure that you cut all expansions in relation to both semitendinosus and gracilis tendons before attempting harvest. If you don't do this, the harvester can be diverted and this can result in truncation of your graft. If you have a truncated graft, you should firstly consider whether you have adequate graft to perform a combined reconstruction. Obviously, the ACL part of the procedure is most important and if you are concerned about having enough graft, that should be the main focus. However, an easy solution to dealing with inadequate length for the technique that I've demonstrated so far is to change from a double limb ALL reconstruction to single limb. This requires fixation in the tibial tunnel with a suture anchor, for example, a 4.75mm screw-in type interference fixation. My second tip is in relation to creation of the ALL tibial tunnel. As you saw in the videos, a coracoid passer is a great tool for conversion of sockets into a single tunnel and also due to its cannulation for suture passage. However, if you don't have a coracoid passer, a good alternative is to use a right angle clamp. This can be placed into the sockets and rotated to convert the sockets to a single tibial tunnel. Again, one of the advantages of a coracoid passer is the ability to shut all sutures. However, again, if you don't have one, a good alternative is to use a No. 5 ethbon suture and needle, which has a favorable curvature to get through that tunnel. My third tip is to help you to avoid over-constraint and replicate normal biomechanics. The normal biomechanics of the anterolateral structures of the knee are that they are tight in extension but lacks inflection to allow physiological internal rotation. In order to avoid over-constraint, I recommend that you always fix the ALL in full knee extension. This allows you to replicate normal knee kinematics. Also, it's important to think of the fixation as a check rein, similar to an MPFL reconstruction. We don't want excessive tension. An additional key consideration is incorrect positioning, particularly on the femoral side. Incorrect positioning can lead to an ALL that's either too lax or one that over-constrains the knee. When you're starting off performing this procedure, before you drill your sockets or tunnels, you can use guide wires and a suture wrapped around them to confirm that you're replicating normal knee kinematics. Again, that means that the knee should allow physiological internal rotation inflection, but the anterolateral structures should be tight in extension. Here's an example of guide wires placed with a suture wrapped around them to help confirm normal non-isometry. You can see that the sutures were tight in extension, but inflection they slacken off and allow physiological internal rotation. My fourth tip is to avoid femoral hardware related complications. It's important to remember that the combined ACL and ALL femoral tunnel is more horizontal than a typical AM drilled tunnel. Therefore, it's important to use short screws. 20-23mm is typically recommended. Alternatively, you should measure your femoral tunnel length before placing a screw, because otherwise you can have prominence either intraticularly or externally. My final tip is to avoid tunnel collision. The most reliable way to avoid femoral tunnel collision between the ACL and the anterolateral ligament reconstruction is to perform a single femoral tunnel, as seen in our prior videos on combined ACL and ALL reconstruction. However, if you are performing an independent technique, then there's several strategies that you can use to reduce the risk of tunnel collision. The first is to use outside in femoral tunnel drilling for your ACL reconstruction. You can see in the image below a post-operative CT scan, which shows an outside in drilled femoral ACL tunnel in yellow, which is a safe distance away from our fixation for the anterolateral ligament reconstruction shown in red. Another alternative option to consider is to use cortical fixation for the ALL graft fixation, which avoids the need for a socket or tunnel on the femoral side, further reducing the risk of tunnel collision. Many thanks for listening to this presentation. If you have any questions, feel free to reach out to me at my email address on this slide.

Anterolateral Ligament

ACL reconstruction

graft rupture rates

knee kinematics

surgical techniques

anatomical precision

Anterolateral Ligament reconstruction

Anterior Cruciate Ligament reconstruction

clinical benefits

graft tension