All right, so great talk, Seth. My name is Mike Alea. I'm from NYU in Manhattan. It's great to be here. It's great to be at a real meeting, although it's early. I'm kind of regretting that it's a live meeting right now, but that's quite all right. So we're going to talk a little bit about anterolateral ligament reconstruction versus IT band tinnitus, et cetera. Our disclosures can be found on the website. So Jim Lubowitz a few years ago published this nice little editorial about the hammer and nail phenomenon, meaning if you've got a hammer, then everything becomes a nail. If you have one tool, then you want to use it for everything. So I'd like to first caution you all, saying that ALL and LETs are great surgeries when done for the right indications for the right times, but it's not our bailout. It's not our golden rule. It's not our everything needs an LET. So I'm going to start by cautioning you that although we have this hammer, not everything should be a nail. And in my own experience, I probably use it about maybe 3% to 5% of the time when I'm doing an ACL reconstruction. That's a primary. When it comes to revisions, it's sort of like a sine curve for me. It's like I do a lot, then I do a little, then I do a lot. If you look at how I did things from 2015 to the present, like 20%, 80%, et cetera, 2020 was erased from my memory. I don't even know what I did in 2020. So if you ask me, I have no idea. But if you want to go back in time, we obviously have known that the lateral structures have played a very important role in stability, specifically rotational stability. So go back to 1879, Paul Sagan. You go back to the 1930s, 1940s, Immanuel Kaplan talking about the iliotibial tract and its role in rotational stability with the Kaplan fibers. Then you fast forward to 2013 when this all took control again in the New York Times published article about the new ligament. And you talk about the work done by Claes and his colleagues over in Belgium. But what we do know, despite all the things that happened over the past 150 years at the time, is that the anterolateral structures are incredibly important. And there's a lot of them. There's anterolateral ligament. There is the non-ALL capsule that people talk about. Your iliotibial band obviously has a very significant role in terms of rotational stability. The lateral meniscus, particularly the lateral meniscus root posteriorly, never, ever neglect that. And then the Kaplan fibers that have been so elegantly described. And can adding one structure really be the game changer and solve everything? Obviously I think the answer is no to that. But there's a great deal of promise for extra-articular tenodesis. So we know that the extra-articular lateral structures are very, very important for rotational control of the knee. And that's been really described very nicely by Bertrand Sonnery-Cotet and his colleagues down in France. We found out that the ACL obviously needs to be incompetent to get a pivot shift. And the pivot shift becomes more and more pronounced as the lateral structures get damaged. We also know from Frank Noyes and his colleagues that there's a much higher pivot shift once the ALL and the IT band are both violated. So if you have an ALL with an IT band injury, whether it be superficial or a stretch injury, a creep, et cetera, then the pivot shift becomes a little bit more prominent. But what we have to define as surgeons looking for a reason to do ALL reconstruction or IT band tenodesis is defining our at-risk knee for failure. So what Seth had pointed out is obviously correct. Your high-risk athletes, your young, pivoting, female contact athletes less than 20 years old because we know that they have a tremendously higher rate of failure than, let's say, me, who just does Peloton at a very poor rate. When you talk about ALL augmentation, we know from the French that the results are very good. I'm not going to inundate you all with numbers here, but we know that the re-rupture rate and the clinical instability rate when you add an ALL reconstruction to a hamstring autograft obviously is much improved than just doing an anti-recruciate ligament reconstruction in and of itself. We also know from some work that we've done over at NYU, my colleagues and I, we found that augmentation procedures can certainly result in clinical improvements in the pivot shift as well as a better return to play. So your high-risk elite athlete that you're going to add an ALL or extra-articular augmentation to, these patients might have or probably will have a better chance of returning to full sport and full participation. And we know from ALL's tremendous work, probably one of the best studies that have been published in quite some time from Canada, the stability trial. If you've not read it, I obviously strongly encourage you to read it. It's a great study, level one, 600 patients plus using hamstring autograft, plus or minus lateral extra-articular tenodesis. And as Seth pointed out earlier today, this results in improved re-rupture rates, improved clinical stability rates. So it's very important that we have this in our armamentarium. Now we're looking at the stability two trial now, which is looking more in terms of BTB and quad, plus or minus LET. But those results obviously have not been borne out yet. And my anticipation is that this will take quite some time to get these results. But I'm obviously very optimistic about it. When it comes to revisions, again, we don't have a lot of data out there. But the data that we do have do support the use of both ALL reconstruction and lateral extra-articular tenodesis with IT band. They've both showed improved pivot shift, improved clinical stability rates, lower re-rupture rates, et cetera. So even for revisions, I strongly suggest that we have it in our armamentarium. Now when we talk about technical pearls in terms of ALL reconstructions, just show of hands, how many surgeons in the room do an ALL reconstruction as opposed to an LET? So we got a fair amount that do the ALL reconstruction. How many do LET with IT band? Yeah, so about half and half, kind of what I figured. So technical pearls that I've done with ALL reconstructions, I used to do this percutaneously. But then I would get a few x-rays, haven't been completely satisfied with my position, although it's been shown that you can get good position. I like to use anatomy now as my guide. I make an incision. It doesn't have to be a big incision, maybe 4 centimeters, 5 centimeters. You can easily undermine the skin and get to where you need to be. The attachment site is just proximal and posterior to the attachment site on the fibular collateral ligament, approximately. That's been described by some good studies about 5 millimeters away. The distal attachment should be about halfway between GERDI's tubercle and the fibular head, about 1 centimeter distal to the joint line. You want to put it under the superficial iliotibial band, not over it. But you do want to put it superficial to the fibular collateral ligament. So as opposed to LETs that we might do a modified Lemaire technique for an ALL reconstruction, at this point the recommendation is to put it over the fibular collateral ligament. And then it's dealer's choice in terms of fixation. You can use screws, you can use interference fixation, buttons, whatever have you. But the one thing that's very important is to avoid over-constraint. We're not trying to make this the tightest thing known to man. We're simply trying to make a check rein to give you one extra thing that's going to improve the stability in your patients. So in terms of LET, there's obviously tons and tons of options that are out there. I would probably say that the most common one right now is the modified Lemaire technique, taking a small strip of the iliotibial band, weaving that under the FCL, and placing it just proximal and posterior to the attachment on the fibular collateral ligament proximally. And we have found out that the technique may matter. This is another paper that we worked on showing that when you pile all the different types of extra-articular tenodesis out there, only three really stood out as ones that really improve stability. The modified Lemaire, the anterolateral ligament reconstruction, as well as the Cocker-Arnold technique. But I don't think many are probably using the Cocker-Arnold. But these are the three that stand out in terms of returning to stability. But we also have to remember that the pivot shift is very much multifactorial. You have to think about your lateral capsule, your lateral meniscus, your IT band, tibial slope, and other structures inside the knee as well. Because if we think that one structure is going to completely eliminate the pivot shift, then we have to think again, because there's obviously many structures out there that are going to give you a high-grade pivot separate from your lateral capsule. And adding an LET to a malaligned, meniscus-deficient knee is certainly not the answer if you are overlooking the other pathology in the knee. So again, as surgeons, if you've got a lateral root tear, you've got to fix that. You might not need to add an LET if there's a big pivot, because the pivot might be coming from the lateral meniscus root tear. If the tibial slope is 20 degrees, then again, the LET might help you, but it might not, because you're missing other pathology that might be the true underlying root cause of recurrent instability in that patient's knee. So in terms of my indications to augment, any patient with a large pivot on a primary is immediately getting a thought of an LET. It doesn't mean I'm doing it, but I'm going to start thinking about it. Patients with hyperlaxity or recruvotum that is symmetric, I tend to choose doing an LET. If there is asymmetric recruvotum, then you have to start thinking about other injuries like the posterolateral corner, etc. Patients that are elite young athletes that are going back to pivoting or contact or high-level athletics should be considered. Any revision in my mind gets consideration, and I mean consideration. I don't mean I'm doing it, I mean consideration. There really should be other minimal causes of failure. Again, if you've got a completely meniscus deficient knee on the medial or lateral side or 10 degrees of varus malalignment, again, adding an LET is probably not going to give you that much benefit. So again, it really does not substitute for meniscal deficiency, slope issues, coronal malalignment, etc. So I tend to caution everybody, make sure you get your alignment films on all revisions, make sure you have a thorough and proper workup, look at bone loss, etc. So my preferred technique at this point in my career is to do an IT banditine lesis. It's a very straightforward procedure. This incision doesn't need to be this large. This is early on. We would take pictures of these, and you can do this easily through a 4cm incision, undermine the skin. It's not a very difficult procedure to do. But once you develop your skin flaps, anterior and posterior, you just basically take a posteriorly located strip. I tend to use the posterior border of the IT band as my landmark. I don't like going too anterior because then you start making it more non-anatomic, it starts to kink around the LCL in a way that when you're bending the knee and ranging it, it doesn't really seem anatomic. Our ligaments are not supposed to really kink around each other. So you have to think about that. You want it to really go in the same direction throughout its entire course. So taking a posteriorly located strip of the IT band is obviously very, very important in my opinion. Then you get a nice strip of tissue like this. It's usually like 5 or 6mm, and you could easily put a whip stitch in the end of it. I would caution everybody, especially people that train residents and fellows in the room, as you start going more distal and start peeling it off closer to the GERDES tubercle, it becomes a little bit thinner. So I have had one case where a resident was just peeling that off and then just sectioned the entire IT band off. So we wound up getting a free graft. And obviously that resident is going to Stedman-Philippon next year for his fellowship. So you have to caution them and make sure they don't cut any grafts on him. But in terms of fixation options, again it's dealer's choice, but you really want it to be just proximal and posterior to the fibular collateral ligament attachment site. Remember a lot of times the knee is bent at 90 degrees when you're doing this. So really know where you are with regard to space and time, because you might think you're posterior and proximal, but you actually might be a little bit anterior. Really pay attention to the attachment site on the LCL, and if you can see it, then you're even better off. Otherwise some pointers in terms of doing these procedures, whether you're doing an ALL reconstruction or a lateral extraticular tenodesis. In my opinion, I like to be as isometric as possible. Obviously ligaments in our native state are not isometric, but again we're not reproducing our native state anatomy. We're attempting to reproduce it, but we're not reproducing it completely. So in my opinion, to have a nice tense structure throughout an entire range of motion where it's not getting tight in flexion, not getting over tight in extension, is very, very important. Obviously you want to avoid the LCL attachment site on the femur so you don't cause iatrogenic lateral instability, and you want to avoid the ACL tunnel. So we've got lots of papers out there showing that you want to aim your tunnel about 20 degrees proximal and about 20 degrees anterior so that you can avoid your ACL tunnel. Some people out there like to do a certain technique where if they really worry about convergence, what they'll do is they'll look up the ACL tunnel that's already drilled as they're passing the guide wire for the ALL reconstruction or the IT band. That way if you're really worried about convergence, you can actually just watch you reaming through your LAT tunnel before you pass your ACL graft. I like to position my graft posterior because again, I think that the kinking is really not anatomic, and I don't like the graft kinking around the FCL as you pass it underneath that ligament. And again, really don't over tension this. This is designed to be a check grain. If we over tension a lateral compartment with meniscus deficiency or cartilage defects, then we might speed up the development of osteoarthritis, particularly in the lateral compartment. So be cognizant of what the pathology inside the knee is. Again, don't be fooled into thinking you're too proximal or too posterior. You can go as proximal and posterior as you want as long as that ligament is lined correctly. It doesn't matter if you go a little more proximal, a little more posterior, you just want to make sure it's isometric as possible. It's easy to pass the graft underneath the FCL when the knee is in 90 degrees of flexion. I find it's a little easier to do it when the FCL is a little bit lax at 90 degrees. So it makes my life easier when the knee is bent to 90 when I'm passing it underneath that ligament. We usually fix it at about 30 degrees, but again, the key is really to not over tension. And when you're starting these procedures, don't be incision gun shy. Develop your exposure. Don't be fearful of it. Make sure you got the right strip. Make sure you put it in the right place, and then you should be totally fine. Complications with these procedures, thankfully, they're few and far between, but they can exist. Obviously, Leprod has shown in some good studies that you can have over-constraint if you tighten it too much or at the wrong angle. Hematomas might be a little more prevalent as well if you're doing an IT band tenodesis. You can get hardware complications, tunnel convergence, tunnel malposition, et cetera, as well as iatrogenic LCL injury. This is a nice x-ray that came in to see me in the office that had an ALL reconstruction on top of an ACL, and you could see where the tunnel was placed. One would say it's a little bit non-anatomic, and this was the percutaneous technique. So again, you know, if you're just starting out, make an incision, because if you know where you have to be and you make an incision and you see it, you're going to avoid problems like that, and we obviously don't want to see that when it comes into our office. So in summary, augmentation procedures obviously show a lot of promise in ACL revisions and ACL primary surgeries, but again, although it might be of help, it's not going to be the entire solving of the puzzle. Use it wisely, use it cautiously, use it well, and I think you'll be happy with your results. So thank you all for your attention.

anterolateral ligament reconstruction

iliotibial band tenodesis

knee stability

pivot shift

ACL surgery