Knee Preservation Foundation

ALL, Segond fracture & grade III pivot shift – towards clarity

In the same way as we have a posterolateral corner of the knee I’m sure we are now moving into an era where we’re going to talk about the anterolateral corner of the knee.

The important structures in this corner include the anterolateral ligament at the front of the triangle, with the back of the triangle being the lateral collateral ligament and the inferior part being the capsule. 

The relationship of the ALL to the Segond Fracture

Sceptics continue to ask how is it possible to find a new ligament? Nonetheless our fraternity did not appreciate the medial patellofemoral ligament (MPFL) until 2000 - and since 2000 surgeons have developed surgical techniques for MPFL reconstruction and helped a lot of patellar patients. But we have at last come to appreciate the relationship of the ALL to a condition that we have known for a long time - and that is the 'Segond fracture' - that subtle avulsion fracture on the lateral aspect of the tibial plateau so often associated with ACL injury. You can see the little flake of bone on the lateral aspect of the X-ray (to the left of the first picture).

Paul Segond - who was actually a gynaecologist - in 1879 dissected the tissue out that was attached to that bony fragment and presented his findings at that time in one of the French scientific journals, but the true importance failed to be understood. The photo on the right shows how they re-created Segond's discoveries in LaPrade’s laboratory in Vail with an experimental dissection.

But Steven Claes’ work in the last few years (ref 2, 4) really has led the way on the anatomy, and his paper which was published in the Journal of Anatomy in 2013 has already become a classic. Some great evidence is emerging from his work with Rob LaPrade from the Steadman Hawkins Philippon Institute in Vail, Colorado - where they’ve repeated the anatomical and biomechanical studies.

When I was in Warsaw in 2013 a very senior Consultant Radiologist  said that she had been seeing this injury for many, many years and she was just waiting and wondering why surgeons hadn’t picked it up because she could clearly see a structure that was being injured on a regular basis. So, who get’s it?

Well we know all about extraarticular structures and we’ve had extraarticular reconstructions for many, many years and there are many good papers. Werner Muller was a leading European surgeon who realised the importance of these, and was really one of the first people to really think about structures on the lateral side such as the ALL. Jack Hughston - another father figure of sports knee surgery - also realised their importance and developed his own techniques for tightening these structures. And then the procedure that we’ve all been doing for many years is the MacIintosh – which involves a big incision, taking a strip out of the existing ITB to tether the side of the knee - and I just was never happy with that as a reconstruction.

References

1. Behavior of the anterolateral structures of the knee during internal rotation. Lutz C, Sonnery-Cottet B, Niglis L, Freychet B, Clavert P, Imbert P.Orthop Traumatol Surg Res. 2015 Sep;101(5):523-8.

2. Anatomy of the anterolateral ligament of the knee. Claes S, Vereecke E, Maes M, Victor J, Verdonk P, Bellemans J.J Anat. 2013 Oct;223(4):321-8. (FULL PAPER - FREE)

3. Arthroscopic Identification of the Anterolateral Ligament of the Knee. Sonnery-Cottet B, Archbold P, Rezende FC, Neto AM, Fayard JM, Thaunat M1. Arthrosc Tech. 2014 Jun 9;3(3):389-92. (FULL PAPER - FREE)

4. The Segond fracture: a bony injury of the anterolateral ligament of the knee. Claes S, Luyckx T, Vereecke E, Bellemans J.Arthroscopy. 2014 Nov;30(11):1475-82.​

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After ACL reconstruction, 63% of patients return to their pre-injury levels of sport - which means that 40% don’t and that's not good. The anterolateral ligament (ALL) could be key to improving those numbers.

Take a look at this cadaveric video of rotational stability of the knee before and after one cuts the reconstructed ALL. It shows clearly how much the rotation increases -

The 2015 study by Lutz, Sonnery-Cottet et al. describes two distinct anterolateral tissue layers that are tightened when going from neutral rotation of the tibia to internal rotation (ref 1):

  • a superficial plane represented by the iliotibial tract and its deep Kaplan fibres
  • a deep plane represented by a 'triangular capsular complex' integrating the ALL

Bertrand's insights into the anatomy of the ALL have added considerably to our understanding, and especially the matter of the ligament naturally being tight in extension and loose in flexion, and how this should be replicated in ALL repair (ref 3).

I think the indications for ALL reconstructions are large pivot shifts where the knee is very unstable – that’s what the video shows – all revision ACL surgeries, athletes, and poorly compliant patients.

Bertrand Sonnery-Cottet’s results are really amazing with a 2 year follow up of 92 cases combined ACL and ALL with only 1 failure.

Leave a Comment:

4 comments
Nishith Shah says May 25, 2016

INteresting article. Comparison with MPFL is good. Cant understand why Modified Brostrum has given very good results without ALL reconstruction in Grade 2+ PLC injuries. I have been doing Brostrum for more than 18 years in Indian patients who are used to sit on the ground. Hardly has seen failure or continuous problems. Pivot shift is eliminated also

Reply
    Adrian wilson says May 28, 2016

    Thanks Nishith
    Steven Claes was debating the all at the recent esska meeting in Barcelona and was asked why this ligament isn’t as visible as the anatomical images indicate it might be and he made a very good comparison with the inferior Gleno humeral ligament of the shoulder. Which of course is a very important structure functionally but not overly obvious as a discrete anatomical structure.
    What we can say about the all is
    It exists anatomically
    It has the function of a ligament restricting movement
    It has the histologiacl properties of a ligament
    It carries out an import at role in controlling rotation

    I take your point that there are many ways to carry out extra articular reconstructions and your method of choice for the PLC is giving you good results.

    What I believe is that we mustn’t confuse posterolateral instability with Anterolateral instability.

    We wouldn’t suggest an all recon to treat a Plc injury. In this situation of course you need to carry out a Plc recon and in most instances I think a modified Larsen works well. And this can be done through a very minimal invasive approach. For chronic Plc instability which includes Tripple varus then I would advocate a Laprade anatomic recon

    The all comes into its own when there is no Plc injury and significant grade 3 Acl deficiency

    Hope that makes sense

    Reply
Phil Harris says May 26, 2016

Thanks Adrian. Great info and insight that is defiantly thought provoking. Through many years of assessing knees and potential ACL injuries I have perhaps only seen a couple with TOP of the anterior lateral corner. I would expect there to be TOP here with an ALL avulsion in addition to a significant pivot shift. Is non tenderness of this injury potentially a reason why it’s not normally picked up or is it down to lack of anatomical knowledge of the ligament and its attachment resulting in “joint line tenderness” being miss interpreted. I will certainly look out for it more in the future.
Thanks again
Phil Harris
Harris Mind & Body
MSK & Sports Injury Physiotherspist

Reply
    Adrian wilson says May 28, 2016

    Thanks phil
    I think we are constantly learning and improving our knowledge
    Actually if you ask most surgeons with experience we have seen a haematoma in the ALL territory very frequently following Acl injury
    The bony Segond is unusual and is indicative of an Acl injury but only present in 2% of Acl injured knees.
    In the radiological papers on the ALL if the surgeon or radiologist know where to look this structure can be indentified.
    Since Steven Claes brought the all to light in 2013 there have been 86 published articles. ! That’s more than anything else.
    The need for an extra articular is unquestionable.
    Non anatomic all procedures have been routine for many years for knee surgeons. Perhaps not so much in the uk but the French and Central Europeans have made it routine.
    Anatomic all makes a lot more sense.
    The hope is that we can improve our results in Acl surgery which currently aren’t as good as we would like !!!
    Best
    Adrian

    Reply
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