Ligament rupture
anterolateral (LAL)

Role of the Anterolateral Ligament (ALL) in Knee Stability

Tibial Rotation Control
The LAL plays a crucial role in controlling internal rotation of the tibia relative to the femur.
This means that it helps prevent the tibia from rotating excessively inward, which is especially important during pivoting movements.

ACL Stability Support
The ALL works synergistically with the anterior cruciate ligament (ACL) to stabilize the knee during rotation and flexion movements. In the event of an ACL rupture, the ALL can partially compensate for the loss of stability, although to a limited extent.

Prevention of Anterior Tibia Translation
In addition to the ACL, the ALL helps prevent excessive anterior translation of the tibia, thereby contributing to anteroposterior stability of the knee.

Clinical Importance

Associated Lesions
ALL injuries are often associated with ACL tears, particularly during trauma involving pivoting or twisting movements.
Recognition of these lesions is important for complete and optimal management of knee stability.

Diagnosis and Treatment
Diagnosis of ALL lesions can be made by clinical examinations, magnetic resonance imaging (MRI), and sometimes arthroscopic evaluation.
Treatment of ALL injuries may include conservative approaches such as physical therapy or, in some cases, surgical procedures to repair or reconstruct the ligament, often in addition to ACL reconstruction.

The anterolateral ligament is an important structure of the knee, playing a key role in stabilizing internal rotation and contributing to overall knee stability. Its understanding is essential for the diagnosis and treatment of complex knee injuries, including those involving the ACL.

What are the mechanisms of LAL rupture?

Rupture of the anterolateral ligament (ALL) of the knee can occur as a result of a variety of traumatic mechanisms that result in excessive force or stress on this ligament. The main mechanisms that can lead to a rupture of the ALL include:

Knee Hyperextension
Forced hyperextension of the knee, often seen in backward falls with the knee extended, can stretch or rupture the ALL.

Side Impact
A direct impact to the outer side of the knee, such as in a sports collision or accident, can cause the ALL to rupture by putting excessive stress on it.

Knee Twist
A sudden twist of the knee, such as during rapid changes of direction in pivoting sports, can put stress on the ALL and cause it to rupture.

Sports Accidents
Sports with a high risk of knee injuries, such as football, skiing, or basketball, can expose the knee to dynamic forces that can rupture the ALL.

Direct Trauma
A direct blow to the knee, such as from a car accident or a fall on the knee, can damage the ALL.
Associated with an ACL Rupture:

Often, a rupture of the ALL occurs in association with a rupture of the anterior cruciate ligament (ACL), particularly in violent trauma where multiple ligamentous structures of the knee are affected simultaneously.
These traumatic mechanisms may vary depending on the physical activity, the type of accident or the nature of the impact suffered by the knee. Rupture of the ALL can lead to lateral instability of the knee, compromising its ability to support twisting movements and may require surgery to restore stability and joint function.

Non-Surgical Treatments

Functional rehabilitation
Physiotherapy : A structured rehabilitation program can help strengthen the muscles around the knee, especially the quadriceps and hamstrings, to compensate for the loss of stability.

Proprioception Exercises : Exercises to improve balance and coordination are essential to stabilize the joint.

Use of Splints or Knee Braces :

A knee brace or brace can be used to stabilize the knee during physical activities and reduce the risk of excessive movement or twisting.

Pain and Inflammation Management :

Nonsteroidal anti-inflammatory drugs (NSAIDs) and pain relievers may be prescribed to manage pain and reduce inflammation.

Surgical Treatments

Surgery may be considered if the ALL rupture causes significant knee instability or if associated injuries, such as an ACL rupture, require intervention. Possible surgical options include:

LAL reconstruction

Anterolateral ligament (ALL) reconstruction is a surgical procedure to restore lateral and rotational stability of the knee after a rupture of this ligament.
It is often performed in addition to anterior cruciate ligament (ACL) reconstruction when both ligaments are damaged.

Indications for ALL Reconstruction
Rotational Instability:

ALL reconstruction is indicated in cases of persistent rotational instability of the knee, often felt as a “drop” or “pivot-shift” during specific movements.

Concomitant ACL rupture:

It is often performed in combination with ACL reconstruction when both ligaments are torn.

Failure of Conservative Treatment:

When non-surgical methods, such as rehabilitation and the use of knee braces, are not enough to stabilize the knee.

Objectives of the LAL Reconstruction
– Restore Rotational Stability: Prevent the tibia from rotating excessively relative to the femur.
– Improve Overall Knee Function: Reduce pain, improve mobility and allow a return to normal and sporting activities.
– Prevent Secondary Injury: Reduce the risk of further damage to knee structures, such as the menisci and cartilage.

Stages of LAL Reconstruction
Preparation for Surgery:

The patient is placed under general or spinal anesthesia.
The knee is cleaned and prepared for surgery.

Surgical Access:

One or more incisions are made to access the ALL site and for insertion of the arthroscope if necessary.

Graft collection:

A graft is taken either from the patient's hamstring tendons (semitendinosus and gracilis) (autograft) or from a donor (allograft).

Preparation of the Insertion Site:

The ligament attachment points on the femur and tibia are prepared. This often involves creating bone tunnels to allow for graft fixation.
Fixing the graft:

The graft is passed through the created bone tunnels and secured using devices such as screws, buttons or staples to ensure a secure fixation.
The graft tension is adjusted to mimic the natural tension of the ALL and restore knee stability.

Stability Check:

Knee stability is checked by motion tests to ensure that the graft is correctly positioned and fixed.

Closing the Incisions:

The incisions are closed with sutures or adhesive bandages.

Postoperative rehabilitation

Initial Phase:

The knee is protected with a splint, and the use of crutches is recommended to limit the load on the joint.
Managing pain and swelling with medication, ice, and leg elevation.
Rehabilitation Program:

A progressive physiotherapy program is essential to restore mobility, strengthen muscles and improve proprioception.
Rehabilitation exercises are tailored to each phase of healing, ranging from passive mobilization to advanced functional rehabilitation.
Gradual Return to Activities:

Return to daily and sporting activities is gradual, generally between 6 and 12 months after surgery, depending on the patient's progress and the advice of the surgeon and physiotherapist.

Expected Results
Improved Stability: The majority of patients regain significant rotational and anteroposterior stability of the knee.
Recovery of Function: Patients can expect improvement in overall knee function, reducing pain and improving mobility.
Return to Activities: Most patients can return to normal activities and sports, although recovery time varies from individual to individual.

Anterior-lateral ligament reconstruction is an effective procedure for treating knee rotational instabilities, especially when performed in combination with ACL reconstruction. With proper rehabilitation and careful medical follow-up, patients can expect to regain good knee stability and function, allowing them to return to their daily activities and sports.

Anterolateral ligament repair is a surgical treatment option for recent ALL tears, aiming to preserve the patient's natural ligament.
This approach may offer advantages in terms of tissue preservation and recovery, although it is not suitable for all types of injuries.
Careful evaluation by an orthopedic surgeon is essential to determine the best approach for each patient, and rigorous rehabilitation is crucial to optimize postoperative outcomes.

Joint LCA-LAL Reconstruction

Joint reconstruction of the anterior cruciate ligament (ACL) and anterolateral ligament (ALL) is a complex surgical procedure aimed at restoring knee stability when there are tears of both ligaments.
This technique is often used to treat severe and recurrent rotational instabilities, especially in patients who have suffered significant knee trauma.

Indications for Joint ACL-ALL Reconstruction
Severe Rotational Instability:

Joint reconstruction is indicated in cases of persistent rotational instability of the knee, often felt as a “pivot shift” or “unhooking” during specific movements.
Concomitant ACL and ALL ruptures
When both ligaments are damaged, joint reconstruction may be necessary to restore overall knee stability.

Failure of Previous Treatments
If previous surgical procedures, such as isolated ACL reconstruction, have failed to stabilize the knee.

Objectives of the Joint LCA-LAL Reconstruction
Restore Antero-Posterior Stability: Prevent the tibia from sliding forward relative to the femur.
Restore Rotational Stability: Prevent the tibia from rotating excessively relative to the femur.
Improve Overall Knee Function: Reduce pain, improve mobility and allow a return to normal activities and sports.
Prevent Secondary Injury: Reduce the risk of further damage to knee structures, such as the menisci and cartilage.
Stages of Joint LCA-LAL Reconstruction

Preparation for Surgery
The patient is placed under general or regional anesthesia.
The knee is cleaned and prepared for surgery.

Surgical Access
One or more incisions are made to access the ACL and ALL sites.

An arthroscopy is often used to visualize the inside of the joint and guide the procedure.

Graft collection:

Grafts are harvested, often from the patient's own hamstring tendons (semitendinosus and gracilis) (autograft) or from a donor (allograft).
In some cases, a synthetic graft may be used.

ACL reconstruction:

The ACL insertion site on the femur and tibia is prepared by drilling bone tunnels.
The ACL graft is passed through these tunnels and secured using devices such as screws, buttons, or staples.

LAL reconstruction

The LAL insertion site is prepared in a similar manner, by drilling tunnels or using bone anchors.
The LAL graft is passed through these tunnels and fixed with appropriate fixation devices.

Stability Check

The stability of the reconstructed ligaments is checked by motion tests to ensure that they are correctly positioned and fixed.

Closing the Incisions

The incisions are closed with sutures or adhesive bandages.

Postoperative rehabilitation

Initial Phase

The knee is protected with a splint, and the use of crutches is recommended to limit the load on the joint.
Managing pain and swelling with medication, ice, and leg elevation.
Rehabilitation Program:

Physical therapy begins quickly to restore mobility, strengthen muscles and improve proprioception.
The rehabilitation exercises are progressive and adapted to the different phases of healing.
Gradual Return to Activities:

Return to daily and sporting activities is gradual, generally between 6 and 12 months after surgery, depending on the patient's progress and the advice of the physiotherapist and surgeon.

Expected Results
Improved Stability: The majority of patients regain significant rotational and anteroposterior stability of the knee.
Recovery of Function: Patients can expect improvement in overall knee function, reducing pain and improving mobility.
Return to Activities: Most patients can return to normal activities and sports, although recovery time varies from individual to individual.

Joint reconstruction of the anterior cruciate ligament and anterolateral ligament is an effective procedure for treating complex knee instabilities.
It aims to restore rotational and anteroposterior stability, improve overall knee function, and allow a return to normal and sporting activities. Appropriate rehabilitation and rigorous medical monitoring are essential to optimize results and ensure complete recovery.