Good morning, everybody. So these are my disclosures which are in the program. So why this renewed interest in the anterolateral complex? I think we all know that ACL graft rupture rates in young high-risk population up to 18 to 28 percent, as you heard earlier, a return to pre-injury level of sports after an isolated ACL reconstruction only about 50 to 65 percent of the time. So not ideal. Rate of residual pivot shift after a primary ACL up to 20 to 30 percent of the time, even with an anatomic single bundle technique. And even higher for our chronic and revision ACL reconstructions are those who have a high-grade preoperative pivot shift or knee hyperlaxity. So if we look at the anterolateral complex, the femoral origin is just proximal and posterior to the FCL. The tibial insertion is pretty consistently midway between the center of Gertie's tubercle and the anterior aspect of the fibular head and about one centimeter distal to the joint line. The lateral meniscus, as you've heard, obviously plays a role as well. And we also have our IT band and our Kaplan's fibers, the proximal and the distal fibers as seen there. Also I think radiographic anatomy is helpful. So intraoperative fluoro, Kennedy and LaPrade have shown the femoral and the tibial origin and insertion. And that can be helpful intraoperatively. I did want to give a shout out to Charlie Brown. He has a great chapter looking at intraoperative fluoroscopy when you're doing various ligament reconstructions. So he happens to be in the room if any of you have an interest in that. The ALL complex function. So the ALL is a capsular structure and is a secondary restraint to anterior tibial translation. Also tibial internal rotation at greater than 30 degrees flexion and is probably maximal around 60 degrees. The IT band and Kaplan's fibers also control tibial internal rotation but closer to extension. And then the lateral meniscus, as you heard, also has an additional role in controlling anterolateral rotatory instability. So there's increased length with flexion for at least the native anterolateral complex. So it's tightened flexion. So there's really some debate and still with regards to your knee flexion angle and your fixation angle. So what I'd say is that a proximal and posterior origin is more forgiving. And if you're doing an LAT and passing it deep to the FCL, that's also much more isometric and more forgiving. So there have been various reconstruction techniques for anterolateral ligament reconstruction using a free tendon graft. The majority of these have shown that the origin on the femur is proximal and posterior to the FCL. A couple of them showed that it was anterior. The tibia is pretty consistent and there's one technique that had a two-arm technique here. For the LAT, that's pretty straightforward. Basically you're identifying the IT band. You're taking a 1 by 8 centimeter posterior IT band slip and then you're routing that deep to the FCL. And then you can fix that proximally with various devices. So what about our indications in the literature? So if you look at reviews, you look at expert consensus, for a primary indication you're talking about a high-grade pivot shift, hyperlaxity, revision ACL, maybe a Sagan fracture, and going back to a pivoting sport. Your secondary indications might be your young athletes, medial meniscus repair, meniscal deficiency. I think posterior tibial slope greater than 12 degrees is becoming increasingly important. The lateral femoral notch sign and also in the chronic setting. So what about outcomes after these procedures? This is probably the best study we have. This is a randomized controlled study, probably most of you are familiar with, won the O'Donohue Award. It looked at hamstring tendon autograft in high-risk patients with and without an LAT. And impressively they found that if you added an LAT it decreased the relative risk of graft rupture by greater than 60%. They're currently doing another study looking at patella tendon and quad tendon, but we don't have data on that yet. If we look at ALL reconstruction, here's a review of five studies showing that two and a half to three times lower rate of graft failure with an ALL reconstruction, two times lower rate of medial meniscus repair failure with an ALL reconstruction as well, and that was with both BTB and hamstring tendon autograft. Revision ACL, this study showed a significant decrease in the pivot shift, greater return to sports with an ALL reconstruction. And then this study looking at chronic ACL deficiency, they had better results with an ALL for graft failure, pivot shift, and their patient-related outcome measures. So this came out last year. This is kind of the most recent systematic review. Looking at 11 studies, six of them were in ALL reconstruction, five in lateral extra-articular tenodesis. They had a significant reduction in graft rupture with lateral augmentation, rotational laxity was higher in an isolated ACL reconstruction, Lysholm scoring was better with a lateral augmentation, and there was a slightly increased return to sports with a lateral augmentation procedure. This is a great study, if you haven't read it, looking at the ACL graft risk calculator. Basically they developed an algorithm to predict risk based on graft choice and a number of other factors. This involved the MOON cohort and the Stability 1 cohorts. Those are the two cohorts that were evaluated. Graft failure was not a predictor of re-injury. Young age, high grade pivot, preoperative laxity, graft type, all were significant predictors of re-injury. And they found that a BTB or a hamstring plus an anterolateral complex procedure was protective against re-injury and really argued that an isolated hamstring tendon autograft might be avoided in our young active patients. So this is really the key in this study. So what about my experience in these high-risk patients? So this is a study that I did looking at kind of my early experience. I had 182 consecutive ACL reconstructions, and 41 of them were hypermobile based on Baten's criteria. At six-year follow-up, our graft failure rate was higher in these hyperlaxity patients. So 24 versus 7.7% failure. And then if you looked at ACL failure plus contralateral ACL injury, it was 34 versus 12%. And what we found was that heel height greater than 5 centimeters was predictive of the failures. And I think it's a good point to bring up. This was heel height and the contralateral knee, not the injured knee, because you have to be worried if your heel height's increased, it could be an FCL injury or posterolateral coronary injury. So this is really what I use as my evaluation in these hyperlaxed patients for our higher-risk patients. And then this study came out looking at hypermobile patients with and without an anterolateral ligament reconstruction. And with an ALL, they found that they had better KT1000 stability, better rotational control with a pivot shift, and a lower failure rate at 21.7% to 3%. So really their rate without the ALL was similar to what we saw in our study. So I performed about 160 ALL LAT reconstructions. I do about 200 ACLs a year. So I'd say 15% to 20% of the time now I'm adding an additional anterolateral complex procedure. We've looked at our numbers, 205 knees. The ALLs were with a tibialis anterior allograft. The LAT is obviously the IT band. If we look at our patient-related outcome measures in the primary group with 19-month follow-up, 101 knees, significant improvement in their outcome scores. And in the revision group, 104 knees at follow-up 22 months, again pretty significant improvement in their patient-related outcome measures. But most importantly, even though this is early follow-up, in the primary group we've had two graft failures, so a 2% revision rate compared to my 24% failure rate over six years in this hypermobility study and 22% failure rate in that Halido study that I mentioned. And in the revision group we've only had one graft failure. We'll have more. And that's a revision rate of 1%. And I'd say our improvement in patient-related outcome measures and our graft failure rate is equal to or at least better than the pooled high and low-risk ACL revision studies by Mars and Anand et al. So just a couple of case examples I wanted to go through. This is a 22-year-old college striker, had an ACL tear. Has been told she's hypermobile, has a high-grade Lachman, a high-grade pivot shift, a lot of hyperextension of the knee with a heel height of eight centimeters on the contralateral side, generalized hypermobility, and some increased posterior tibial slope. So here's just a video. So with an anterolateral ligament reconstruction, I initially did this with two incisions. Now I've gone to using just one smaller incision. You can do either. So in this example here, it's going to be two incisions. So one between Gertie's tubercle and the anterior aspect of the fibular head. I do a little various stress. You can feel the FCL. And then just proximal and posterior to that, I'll make another incision. Or you can just make one incision kind of between those two. Initially I'm going to take my graft. So this is a high-risk patient. I'm going to use a bone, patella tendon bone autograft. We're all familiar with that. I like to drill my femoral and tibial tunnels before doing the ALL reconstruction. You can see I use a two-incision technique. Obviously, you can use any technique you want. You don't want to pass your graft and then place the ALL because you potentially are drilling tunnels through your graft if you're in the wrong spot. So here you can see the position using intraoperative fluoro between Gertie's tubercle and the fibular head. So you have kind of palpation plus your intraoperative fluoro if you want. This is a semitendinosus allograft I use. I've actually switched to using a tibialis anterior allograft. It's a flatter graft. And when I've used that, it seems more like a capsular thickening to me. So I've switched to that. It's usually a six, sometimes up to seven millimeter, or a millimeter graft. It just kind of depends on the size of the patient. I'll basically size the graft the same size as the tunnel and then use a biocomposite screw or whatever screw you want to, usually the same or one millimeter greater size. So the tibial side is pretty easy. Now in this case, I passed the patella tendon graft, but now I would actually expose the femoral side and do whatever tunnel or fixation you want to use on the femur before you pass your ACL graft, just to make sure you don't have convergence. If you use a low anterior medial portal, you want to make sure you make your ALL tunnel on the femur anterior and proximal. So here you can see I'm using intraoperative fluoro again to verify, as well as doing a varistress to feel the FCL. You split the IT band. Here I'm just using an all suture anchor. You can drill a tunnel if you want to. And then once you place that anchor, then you just need to pass your graft from the distal incision to the proximal incision. If you're using a one incision technique, then it's pretty easy. You just pass it deep to the IT band. And then once you pass it, the big question is really, you know, what degree of knee flexion are you going to fix this in? I currently use 20 to 30 degrees, but you're going to hear a lot of people say they use 40 or 60 degrees. We really don't know. I think the key is just to make sure you have a good level of isometry throughout your range of motion. What I worry about is capturing that knee in extension, because I'm not sure that our reconstruction techniques actually reproduce the native anterolateral complex, which tightens up inflection and looses in extension. So just make sure you're not making them too tight in extension. But I use 20 to 30 degrees. Postoperatively, again, I use a two incision technique. There's no difference in your postoperative rehab for these patients, just standard ACL rehab. And then the last case I wanted to present was a 14-year-old, open growth plates, premenarchal, hypermobile, high-grade pivot shift. You can see the ACL tear, you can see open growth plates, you can see this femoral notch sign and tibial slope is a little bit elevated. So with his open growth plates, I'm going to use an LET. So here you can see the incision on the side that I'll use for the LET and now I'll also use that for the anterolateral ligament reconstruction. It's a little blurry at first but it'll get closer here. So you just make a lateral incision. You want to take either kind of the central to central posterior aspect of the IT band about one centimeter wide. Go up about eight centimeters. That's about the length that you need. Make sure you don't take the very posterior aspect because you want to keep Kaplan's fibers intact. So there's your graft and then you find the FCL here. If you're having a hard time finding it, just put the knee in a figure of four. Put a little varustress on. You can make capsular incisions in front or behind the FCL. This case was pretty easy to find. Now you're just going to pass this graft deep to the FCL. The nice thing about this technique is once you pass this deep to the FCL, you can fix this anywhere proximal on the posterior femur that you want to because it's very forgiving. But with open growth plate case, I still make it kind of more anatomic where I'm going just proximal and posterior as you can see there to the FCL. And if you look at this fluoro image, you can see where that suture anchors coming in tends to be just distal to the growth plate on the femur. So I aim it distally to kind of be within the epiphysis. And then at that point, all you have to do is put your knee in whatever degree flexion you choose. Again, I choose 20 to 30 degrees. And then you're going to suture that in. I wouldn't use a tunnel here, obviously, because you have an open growth plate. So at this point, I'm passing my hamstring graft. You can see I have an endobutton button type device on the femur. And then I'm going to fix that on the tibia as well. There's the graft. There's the x-ray showing that you have your fixation superior to the femoral thysis, distal to the tibial thysis. And then after you secure the ACL, now I've secured the lateral extra-articular tenodesis. Once you've done that, just check your isometry. And then you simply repair the IT band. I usually start proximally, work my way distally. And there's going to be about one to two centimeters maybe that you can't repair of the IT band. But you can repair the majority of that. So in summary, the interlateral ligament complex consists of the ALL, the IT band, and Kaplan's fibers and the lateral meniscus. ALL injuries are frequently associated with ACL tears. I think our current indications are clearest for a high-grade pivot shift, hyperlaxity, revision ACL, or if you're using a soft-tissue graft in a young, active patient. And I think longer-term follow-ups are required to really better define the role for and optimal techniques for these procedures. Thank you very much. So you could do an entire instructional course on just LET, ALL. I think there's a lot of topics you could talk about. Dr. Brown has been doing this for a while. And he's an expert on it. And he could probably render opinions on it. I think some of the key points to think about is if you're doing an interlateral complex reconstruction, either ALL or LET, what's your order of fixation? How do you do that in relation to the ACL? In terms of the timing? Yeah. Yeah. So I'm going to... So again, the key things are you just... There can be a little convergence, especially on the femoral side with your femoral tunnel for the ACL. So I actually like to drill my tunnels for the ACL. And then I like to fix the tibial side if I'm doing an ALL reconstruction. Because the graft's not going to go all the way over to the tibial tunnel. But your drill could potentially go through that tunnel. Once I fix the tibial side, then I prepare the femoral side with either... Whether you use a tunnel or whether you use a suture anchor. And then I'd put your camera up the tunnel while you're drilling for your femoral tunnel for the ALL, just so you can see that you're not getting that convergence. And then once I've prepared either the tunnel or the suture anchor on the femoral side, then I'll pass my graft, fix the graft in full extension, and then lastly fix the femoral side for the ALL. So ACL is fixed first. First. And then ALL is secured after. And historically, a lot of the studies said, well, you have to maximally externally rotate the knee when you're doing the fixation. Do you externally rotate the knee at all? I think the key is to have the knee in neutral rotation. And then again, the degree of flexion may not matter as much. But I think you want the foot in neutral rotation, not externally rotated. I think that's an important point. And if you look at the old techniques, they all maximally externally rotated. And that's where a lot of the over-constraint concerns come from, is with that maximal external rotation. Is there a contraindication or major contraindication for you for ALL reconstruction or LAT? So I didn't talk about, one of the concerns was sort of over-constraint of the lateral compartment when you do these procedures. And biomechanically, they've shown that. But clinically, we haven't really shown that. So from my standpoint, I don't, if I'm doing, like if you have a high-grade pivot shift, and then you have a lateral meniscus root tear, and you repair it, and that pivot shift goes away, then I don't think you have to do the anterolateral complex procedure. If somebody has a posterolateral corner injury, I think it'd be very rare for you to ever add an anterolateral complex procedure to that. So if you're doing some other big ligamentous procedure, I would see how the knee is feeling after you're reconstructing the posteromedial corner, posterolateral corner, because I think it's very rare in these multiligamentous knees to have to do an anterolateral complex procedure. So it's mostly with the isolated ACL and some meniscus work. Yeah, I think that's important. You don't want to be the early adopter and do ALLLET in every single patient. You can see from his data, 200 patients doing maybe 15 to 20%. I think that's where a lot of surgeons are when they're considering this in their practice. It's not 100%. If you do it in everyone that's got a return to pivoting sports, you're probably doing it in too many patients. I think the one patient I think about is we all get excited when we get in and we see an ACL-deficient knee and the menisci seem normal, and we think, wow, this is going to be easy. I think that's actually your patient where you might want to consider it, because usually if they have hyperlaxity, that knee will be more forgiving when they have the pivot shift and the menisci don't get injured. So that's the patient where I would really look hard for a high-grade pivot shift or hyperlaxity when you don't see any meniscus damage and it seems like it's an isolated ACL. Yeah, I think that's important. Any questions from the audience? How much tension are you fixing on your LAT graft or your ALO graft? Yeah, I don't know. I mean, I don't. That's a personal question. Yeah, same as with the ACL. I really don't know. I mean, I just put tension on it, and I hope that where I'm securing it and what position I have the knee in is going to make sure that's okay. So I am careful. What I do is when you use a suture anchor, for instance, I kind of bring it down to the point where the suture anchor is so I can kind of evaluate where that's going to be tight, and I'll hold it there kind of through a range of motion a little bit to see what the tension looks like, and I'll mark that spot, and that's where I'll put my sutures through. But I don't know. And it's not an isometric feel? I mean, once it's done, it's secure. You mentioned the right isometry. When you bring it through a range of motion, I'm assuming you're expecting to feel a little bit of an anisometry throughout it. It will lose tension, essentially an extension. No, so that's the interesting thing, right? So I would tell you my experience is that I'm excited when it's isometric throughout the whole range. More often with a LAT, I'll see that. With an ALL reconstruction, if anything, it's tight through like zero to 30, and actually as you flex more, it will actually loosen a little bit. So that's why I'm saying our reconstruction techniques aren't necessarily recreating what we've seen in the lab. So it's not the same. The tension's important to consider, though. We looked at that maybe five years ago in a two-part study and looked at 20, 40, and 80 newtons, and increased tension caused increased over-constraint. So typically now the statement is 20 newtons, and no one has a pressure or a force measuring device in the operating room. But generally, it's felt to be just light tension. Hold it so it's not loose, but don't try to constrain it. Yeah, I'd be a little more careful if somebody had some early lateral compartment degenerative change and you were using like tunnels on both sides with interference screws, then I'd be a little careful about how much tension you put on that one. With suture anchors, I don't worry about it. Yeah, you can use a staple, too. Staple is a pretty straightforward technique. You just want to make sure you're putting that higher on the flare, not as distal as what Dr. Larson was showing, because if you put it that distal, you're going to have prominence, and that's probably where patients or where the staple has gotten a bad report. But if you look at Elgato's study, they only removed maybe 10 of 300 or so, so it's a pretty low need for secondary surgery for moving the staple. That's cheap, simple to reproduce, and it gives good fixation. Chris, I have two questions for you. One is when do you use one or the other? So when do you use ALL and when do you use LET? And the second question is, one of the things that I've noticed in my patients is sometimes the ACL has no pain whatsoever, but the lateral side is the thing that hurts. I'm not sure if it's because I use a staple, but do you have any tips or tricks for that? Yeah, so number one, just my preference is I like the anterolateral reconstructions, so I'll use them the majority of the time. When I'll use an LET is if somebody doesn't want donor tissue or cadaveric tissue, or the case I showed you, if they have open growth plates, I don't want to drill a tunnel on the tibial side, so I think an LET is perfect in that case. So that's just my preference, but I think you can use an LET every time. It's fine. I like data to support one versus the other. As far as your second question, I have not, that's the one thing I've not seen is anybody really complaining of pain, clicking. I mean, it's been the surprise for me is that that's not been their complaint. I never use staples. I still suspect, even though some studies show some pain with a staple, some don't, I think using a lower profile fixation is helpful. I do think the staple can create some pain. We also looked at our recovery afterwards using biomechanic evaluation, and we haven't found that they recover more slowly. If anything, they're a little quicker with an ALL, which is kind of interesting. So I haven't shown that that slows down their recovery, range of motion or anything like you would with a root repair. Do you change your post-op protocol? Not at all. Not for an ALL or an LET. So weight bearing is tolerated and any change in range of motion? Not at all. I think that's important to consider, because that's convention, and you think about the collateral ligament, and most people will delay weight bearing, but in general, I haven't changed it, and I'm predominantly LET if I'm doing an antilateral complex, and I don't change the post-op protocol at all, assuming that they didn't have a root or something else with it. Right. All right. Any other questions from the audience? All right. As Dr. Cain comes up, I'm going to ask Dr. Brown a question. So there's, some say use a 10 millimeter graft, some say 15, some of the old biomechanical studies said 20. Do you have a graft width preference for an LET? Centimeter. I mean, that's the classic teaching, centimeter. So I don't think we know the answer to that, but officially, if you look at the mayor's description, it's low C, and all the other extra articulators, it's a centimeter. Yeah. Maybe in a big patient, you might go 12. Chris, what's yours? Same. I mean, I kind of go based on the size. I mean, I think if I was doing a big patient, I'd go bigger, but it's kind of like that central curve. Just the audience, anyone use a graft bigger than a 10 millimeter? Anybody? 12? 15? 10? 10 it is. Well, I think I'll just keep it going then, so Andy, thanks. I'm going to be talking about...

anterolateral complex

ACL reconstruction surgeries

tibial internal rotation

reconstruction techniques

graft failure rates

high-risk ACL patients