Is the ALL reconstruction new?

From the French corner came a solution to stabilize the rotation. The name for the operation was called the Lemaire plastic, named after a Lyon orthopedic surgeon. It was the forerunner of today's ALL reconstruction. So funny fact is that nothing was known about that ligament (ALL) at the time, but the vision, how to restore stability, was ahead of its time. However, the surgical techniques back then were not up to today's standards. The Lemaire plastic was a major surgery with a large skin incision. As a result, there was an increased risk of infection. Over the years, surgical techniques improved and anatomical placement of the anterior cruciate ligament partially solved the problem of rotational instability. The Lemaire plastic fell into oblivion.  

Although modern anterior cruciate ligament reconstruction is a successful surgery, a proportion of operated patients still continue to experience instability complaints. On physical examination, the knee is unstable in rotational movements, while the knee is stable in forward movements. Thus, forward, backward stability is restored (Lachman test). Due to rotational instability, a number of patients are not satisfied with the outcome of surgery. They continue to experience instability, mainly in high impact sports and sports with a lot of turning and turning (soccer, field hockey, rugby etc). For this group of patients, sports resumption is not possible or adapted as the risk of re-rupture is increased. The discovery of the ALL and its reconstruction may possibly provide the solution.

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What is the ALL?

It is a small band or reinforcement of the capsule on the outside of the knee (see photo). It runs from the femur to the tubercle of Gerdi. Because of this position, this ligament has great influence on stabilizing rotation. Supposedly, the ALL has even a greater stabilizing function of the rotation, than the posterior bundle of the anterior cruciate ligament (one of the two bundles of the anterior cruciate ligament).

​How do you know if the ALL is torn?

If you have a segond fracture (see photo) then you have a 100 percent chance of a torn anterior cruciate ligament, most likely the ALL is also damaged. A segond fracture is an avulsion fracture, where the attachment of the ALL is pulled away from the bone. If the x-ray does not show a segond fracture, then the ALL may still be torn. A reasonable to good diagnosis can be made with the physical examination. On the MRI, a ruptured ALL is difficult to image. The ALL can be properly assessed during surgery. For the physician, this is the optimal time to reassess the knee before anterior cruciate ligament reconstruction is performed. Thus, it is common for the orthopedic surgeon to decide only at that time whether ALL reconstruction is necessary.

Examining a ruptured ALL

Forward mobility (Lachman +), rotationally stable (Pivot -) → no ALL

Forward mobility (Lachman +), rotationally stable (Pivot -/+) → no ALL

Forward mobility (Lachman +), rotationally unstable (Pivot +) → ALL

(- = negative, -/+ = doubt, + positive)

A positive pivot shift is a good indication to do an ALL reconstruction in addition to an anterior cruciate ligament reconstruction. However, there are other situations to do an ALL reconstruction. More on this later.

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​The ALL reconstruction

There are many different surgical techniques to reconstruct the ALL or strengthen the outside of the knee. The Lemaire plastic is a technique in which a strip is taken from the tractus iliotibialis. This strip is passed under the outer ligament (lateral collateral ligament) and fixed in the thigh bone. This creates a connection between the tibia and femur and prevents internal rotation of the tibia. 

The other technique is an ALL reconstruction. The ALL reconstruction is a technique that uses a tendon or artificial ligament that is secured with a screw in the femur and a screw in the tibia.

Who is eligible for ALL reconstruction?

Patients who are at increased risk of or have re-torn their anterior cruciate ligament reconstruction are eligible for ALL reconstruction. Hypermobility, hyperextension of the knee (space overstretching) and a positive pivot shift test making the knee rotationally unstable are reasons to perform an ALL reconstruction. The physician, as mentioned, can assess this well. In high-risk sports, the physician may decide to add an ALL as a precaution. After a re-rupture, an ALL reconstruction is almost always done in addition to an anterior cruciate ligament reconstruction.

What does treatment look like after ALL reconstruction?

Post-treatment varies by physician. The doctor may choose to provide an extension lock brace. (foto brace) The brace can be adjusted to flex up to 70 degrees in the first two weeks after anterior cruciate ligament reconstruction. After two weeks, the brace is adjusted to 90 degrees of flexion. After six weeks, the brace is tapered off. A second option is to wear an extension lock brace for six weeks that is adjusted to 90 degrees of flexion. A third option is no brace and mobilize based on pain and response. 

Most patients have more pain initially after ALL reconstruction. This is due to the 8- to 10-centimeter skin incision on the moving part of the knee. The patients with a brace, complain more often of knee stiffness. In addition, a brace usually results in a disturbed gait pattern. As a result, regaining a symmetrical gait pattern takes longer. Another inconvenience is that the brace often slips off. Recently, new braces have come on the market that are more comfortable to wear. Furthermore, rehabilitation after ALL reconstruction follows the protocol of an anterior cruciate ligament reconstruction without ALL.

​The ALL combined with anterior cruciate ligament reconstruction.

Since ALL reconstruction has been added to the orthopedic surgeon's arsenal, there has been a marked decrease in the number of re-ruptures. The outlook is good and it remains to be seen how the longer-term effects will be in relation to osteoarthritis and other knee problems. 

Indication:

Not everyone needs this surgery and is especially recommended for patients at high risk of rupturing their anterior cruciate ligament again;

• Patients with hyperlaxity/hypermobility
• Patients under 30 years of age
• Revisions of a previously performed anterior cruciate ligament reconstruction
• Top athletes who play cap and spin sports such as soccer, field hockey, tennis and handball. 

Is there scientific evidence for the ALL

Recent well-conducted scientific research shows that ALL reconstruction reduces the risk of anterior cruciate ligament rupture in young patients who have undergone VKB reconstruction. The rate of re-rupture from anterior cruciate ligament reconstruction decreased by 70% from 11% to 4%.

Summary

An old technique in a new guise. It is a godsend for certain patient groups. Also in recent years, ALL reconstruction has proven its value in reducing the number of re-ruptures. However, it remains custom-made who does and does not need an ALL reconstruction. Therefore, be well advised by a kniespecialist. How the long-term effects will be will remain to be seen, but as mentioned, the outlook is good. 

This blog was created in collaboration with Aernout Zuiderbaan orthopedic surgeon in the Velsen Medical Clinic