Abstract
Anterolateral rotatory instability (ALRI) occurs after injury to the anterior cruciate ligament (ACL) and the anterolateral structures of the knee. We present a technique for anterolateral extra-articular soft-tissue (ALES) reconstruction of the knee that can be used in revision ACL reconstruction cases, cases of persistent ALRI after adequate ACL reconstruction, and cases with severe ALRI after primary ACL rupture. The surgeon performs ALES reconstruction with a strip of iliotibial tract autograft while respecting the anatomic origin and insertion of the anterolateral ligament. The purpose of this reconstruction is to restore the normal anterolateral rotatory stability of the knee in ALES-deficient patients.
Anterolateral rotatory instability (ALRI) is a combined anterior translational and internal rotational movement of the tibia. This instability occurs after injury to the anterior cruciate ligament (ACL) and the anterolateral structures of the knee.1 Even the most recent ACL reconstruction techniques remain unable to fully restore normal knee joint biomechanics.2, 3 Persistent rotatory instability is related to poorer functional outcomes and to the progressive occurrence of osteoarthritis.4, 5 Injuries to the mid-third lateral capsular ligament, the lateral meniscus, the capsulo-osseous and deep layers of the iliotibial tract (ITT), and the biceps femoris muscle complex have been advocated to cause ALRI in combination with an ACL tear.6, 7 Failure to recognize and manage concomitant injuries at the time of primary ACL reconstruction might result in persistent postoperative instability and put the knee joint at risk of secondary damage, including failure of the primary ACL reconstruction. The anterolateral extra-articular structures of the knee have received much renewed attention.8, 9, 10, 11 The addition of an anterolateral extra-articular soft-tissue (ALES) reconstruction might be promising in restoring the grossly altered kinematics seen in knees with ALRI.
Surgical Technique
Patient Positioning
After the induction of general or epidural anesthesia, the patient is placed in the supine position with a nonsterile tourniquet placed on the upper thigh. The leg rests are removed, enabling the knee achieve at least 90° of flexion. The patient is then prepared and draped in the usual sterile fashion.
Access Route
An incision is made from the superior edge of the lateral femoral condyle to the proximal tibia midway between the proximal fibular head and Gerdy tubercle. The peroneal nerve is located distal to the surgical field and is not in danger throughout the procedure. After dissection of the skin and subcutaneous tissue, the central portion of the ITT is identified (Fig 1 A and B, Video 1).
Fig 1.
The lateral side of the right knee is shown with the patient in the supine position. (A) The anatomic landmarks of the proximal fibular head and Gerdy tubercle are indicated by the crescent and cross, respectively. The line with perpendicular dashes indicates the incision site. (B) The iliotibial tract is identified after dissection of the skin and subcutaneous tissue; the middle-third part of the iliotibial tract will be used to dissect a 5-mm × 12-mm graft. (C) The upper forceps (asterisk) show the proximal fixation point for the anterolateral soft-tissue reconstruction. The lower forceps (triangles) show the course of the lateral collateral ligament.
Graft Preparation
The central portion of the ITT is split sharply with a No. 20 blade along its fiber direction. A strip of 5-mm × 12-mm ITT is gently lifted from the central mid third of the ITT and is sharply dissected. The distal dissection is made about 4 fingerbreadths above the joint line of the knee, with preservation of the part of the ITT around the knee. Both the proximal and distal ends of the ITT autograft are then braided in ordinary fashion with nonabsorbable sutures.
Anterolateral Extra-articular Reconstruction
The proximal fixation point is identified by use of anatomic landmarks on the prominence of the lateral femoral epicondyle (Fig 1C). The femoral attachment sites of the lateral collateral ligament (LCL) and popliteus tendon (PT) are identified. Slightly anterior to the origin of the LCL and just proximal and posterior to the origin of the PT, a small stab incision is made in the ITT along its fiber direction. A pilot hole with a depth of 10-mm is drilled with a Kirschner wire before the self-punching suture anchor (PEEK [polyether ether ketone] SwiveLock SP Vented; Arthrex, Naples, FL), measuring 4.75-mm × 24.5-mm, is used to fixate the proximal part of the ITT autograft (Fig 2A). The pilot hole enables the surgeon to determine the direction of the fixation material. Subsequently, a small incision is made at the tibial attachment point, identified midway between the Gerdy tubercle and the tip of the fibular head at approximately 5 to 10 mm below the lateral tibial joint line. The graft is then tunneled under the ITT by using the incisions at the proximal and distal attachment sites for the ALES reconstruction (Fig 2B). The tibia is predrilled with a 7-mm drill to a depth of 30 mm, and the distal end of the ITT autograft is fixed onto the tibia with a suture anchor measuring 7-mm × 19.5-mm (BioComposite suture anchor for SwiveLock Tenodesis; Arthrex) (Figs 2 C and D and 3). Tibial graft fixation is performed with the knee in slight exorotation and 90° of flexion.
Fig 2.
Perioperative images of the right knee with the patient in the supine position. The iliotibial tract (ITT) autograft (5 mm × 12 mm) has been prepared with nonabsorbable sutures at both ends. The proximal fixation point is slightly anterior to the lateral collateral ligament and proximal and posterior to the popliteus tendon. (A) For the proximal fixation point, a 4.75-mm × 24.5-mm suture anchor (PEEK Self Punching Vented SwiveLock) is used. (B) Thereafter the graft is tunneled deep to the ITT. (C) The distal fixation point is located approximately 5 to 10 mm below the tibial joint line and midway between the fibular head and the Gerdy tubercle. (D) The distal fixation point is predrilled with a 7-mm drill before the graft will be tightly fixated with a 7-mm × 19.5-mm BioComposite suture anchor for SwiveLock Tenodesis. The ITT autograft is fixated with the knee in 90° of flexion and slight exorotation.
Fig 3.
Postoperative anteroposterior (A) and lateral (B) radiographs of the right knee showing the proximal self-punching anchor (lines with circles) and the distal fixation (lines with diamonds).
After reconstruction, the ITT is sutured with absorbable wire, the surgical site is closed in ordinary fashion, and a pressure bandage is placed on the mid calf to mid thigh for 24 hours. Postoperatively, the functional activity of the patient is determined by pain. With less pain, the patient is able to mobilize more, and vice versa.
Discussion
ACL tears are among the most common injuries of the knee; however, even the most recent reconstruction techniques remain unable to fully restore normal knee joint biomechanics.3, 12 This has stimulated further research on the extra-articular components and stabilizing contributions of the anterolateral region of the knee.9, 10, 13 Although some authors have named the identified structure the “anterolateral ligament,” inconsistency on the femoral attachment site is seen.8, 9, 10, 11 The tibial attachment site is consistently described to be halfway between the tip of the fibular head and the center of the Gerdy tubercle. Discrepancies exist on the association or attachment to the lateral meniscus.13
ALRI can be caused by ALES deficiency; it is most accurately shown by the jerk test but is also manifested by a positive anterior drawer test with the tibia in neutral rotation showing anterior subluxation of the lateral tibial plateau. The result of the adduction stress test performed with the knee at 30° of flexion, on the other hand, may be normal or mildly positive.1
ALES reconstruction can be performed in patients needing revision ACL reconstruction, patients with persistent ALRI after adequate ACL reconstruction, and sometimes, primary cases with excessive ALRI (i.e., preoperative grossly positive pivot-shift test results). In the case of a patient with continued symptoms of instability after ACL reconstruction and extensive rehabilitation with a physical therapist, the surgeon must be wary of the possible presence of ALES deficiency.
With our ALES reconstruction, close attention should be paid when the femoral fixation is being placed because the attachment site is in close relation to the LCL and PT. Care should be taken not to harm these adjacent structures (Table 1).
Table 1.
Tips and Pearls, Pitfalls, and Risks
| Tips and pearls |
| Dissect the iliotibial tract strip along its fibers through the lateral access route. |
| Drill a pilot hole to determine the direction of the femoral fixation material; predrill the tibial fixation point. |
| Identify the femoral and tibial anatomic landmarks: LCL, PT, fibular head and the Gerdy tubercle. |
| Tunnel the graft deep to the iliotibial tract. |
| Avoid protrusion of both the femoral and tibial anchors. |
| Perform fixation with the knee in 90° of flexion and slight exorotation. |
| Pitfalls and risks |
| The LCL and PT are in close relation to the femoral attachment point; caution should be taken not to damage these structures. |
| Protrusion of anchors can irritate surrounding soft tissue. |
| Discomfort at the surgical site of the iliotibial tract can last for up to 6 wk. |
| Complications |
| Alteration of kinematics. |
| Excessive constraint of tibial internal rotation. |
LCL, lateral collateral ligament; PT, popliteus tendon.
Performing ALES reconstruction to aid in restoring normal anterolateral rotatory stability of the knee is not new. Multiple authors have proposed various techniques for this purpose. In ALES reconstruction, a strip of the ITT is typically routed beneath the LCL and looped back to the Gerdy tubercle through a bone tunnel in the lateral femoral condyle,14, 15 through a suture fixation on the intermuscular septum,16 or through the over-the-top position after an intra-articular ACL reconstruction.17 However, results of additional ALES reconstruction with ACL reconstruction are mixed.18, 19, 20, 21 A possible explanation for these mixed results might be that the ALES reconstruction techniques were often used without simultaneous intra-articular ACL reconstruction, thereby leaving a major component of instability unaddressed.
Most authors agree that the lateral extra-articular structures' main function is to restrain anterolateral luxation of the tibia.8, 9, 22 Recently, Kittl et al.10 performed a biomechanical analysis of 8 cadaveric knees and measured the length changes of several combinations of tibiofemoral points (including several previously performed ALES reconstructions) at knee flexion angles between 0° and 90°. Their results suggested that graft placement proximal to the lateral femoral epicondyle tunneled deep to the LCL and connecting to the Gerdy tubercle was the most isometric. The concept of isometry indicates a transformation that is invariant with respect to distance; this is the distance between 2 moving points (e.g., where the points are on either side of a joint). Exact isometry rarely exists and has not been found in ACL or ALES reconstruction.10 Concomitant injuries of the knee should be treated simultaneously with primary ACL reconstruction, if possible, because persistent postoperative instability might be present and put the knee joint at risk of secondary damage, including failure of the primary ACL reconstruction.
The aim of this study was to present an ALES reconstruction technique that might be performed to solve persistent ALRI after ACL reconstruction or performed concomitantly with ACL reconstruction. However, it should be noted that multiple surgical factors need to be further investigated to achieve optimal extra-articular reconstruction in a predictable manner in the future. Only a few cadaveric studies have addressed the biomechanical behavior of the extra-articular structures' optimal insertion site for extra-articular reconstruction,9, 10, 13, 22 no in vivo information on ALES constructions exist, and the optimal flexion angle for fixation and pre-tensioning of the graft is unknown.
Acknowledgment
The authors thank G. Patho, medical photographer and film editor at the Medical Center Haaglanden, for his help in creation of the surgical video and figures, as well as editing.
Footnotes
The authors report that they have no conflicts of interest in the authorship and publication of this article.
Supplementary Data
Lateral extra-articular soft-tissue reconstruction of right knee. The patient is placed in the supine position with the knee able to flex over 90°. The incision is made from the lateral femoral condyle to midway between the fibular head and the Gerdy tubercle. Thereafter the iliotibial tract (ITT) is identified, and a strip measuring 5-mm × 12-mm is dissected from the middle third. The graft is proximally fixated slightly anterior to the origin of the lateral collateral ligament and proximal and posterior to the popliteus tendon. It is then tunneled deep to the ITT. Distally, it is fixated 5 to 10 mm below the tibial joint line, midway between the tip of the fibular head and the Gerdy tubercle, with the knee in 90° of flexion and slight exorotation. The defect in the ITT is sutured with absorbable sutures before the surgical site is closed.
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Associated Data
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Supplementary Materials
Lateral extra-articular soft-tissue reconstruction of right knee. The patient is placed in the supine position with the knee able to flex over 90°. The incision is made from the lateral femoral condyle to midway between the fibular head and the Gerdy tubercle. Thereafter the iliotibial tract (ITT) is identified, and a strip measuring 5-mm × 12-mm is dissected from the middle third. The graft is proximally fixated slightly anterior to the origin of the lateral collateral ligament and proximal and posterior to the popliteus tendon. It is then tunneled deep to the ITT. Distally, it is fixated 5 to 10 mm below the tibial joint line, midway between the tip of the fibular head and the Gerdy tubercle, with the knee in 90° of flexion and slight exorotation. The defect in the ITT is sutured with absorbable sutures before the surgical site is closed.