Reconstrução do ligamento anterolateral do joelho associada à reconstrução do ligamento cruzado anterior, em pacientes com instabilidade rotatória acentuada.
Tenodese extrarticular / Reforço extrarticular do ligamento cruzado anterior
5. Reconstrução do LAL
Claes et al. 2013
LCA - Restrição AP em todos os ângulos de flexão e
rotação interna < 35º
LAL – Rotação interna > 35º
6. Reconstrução do LAL
2 feixes
Meniscofemoral
Meniscotibial
Tensão em RI
Entre 30º e 90º
A rotura aumenta a
instabilidade rotatória
Pivot Shift
Steven Claes et al. J Anat 2013
9. Reconstrução do LAL
Sem relação com o TIT
Não é alternativa para reconstrução do CPL
Claes et al. 2013
Bonasia et al. 2015
10. Reconstrução do LAL
Helito et al 2015
Melhor visualizado em imagem
coronal
3.0 T / 0,4mm
Identificado em 33.3%
Carpenter 2009
Estudo com RM tri.
- Reconstrução do LCA foi incapaz
de restaurar estabilidade rotatória
- Falha no diagnóstico da lesão do
LAL
Bonasia et al 2015
11. Reconstrução do LAL
1. Instabilidade rotatória acentuada
Pivot-shift III
2. Revisão de LCA
3. Atletas de alta performance
Indicação Cirúrgica
Hewison et al. Arthroscopy 2015
14. Reconstrução do LAL
Técnica Cirúrgica
Adrian Wilson. 2013
Reconstrução individual – LCA All-inside (Graflink®) + LAL com âncoras de biotenodese (Swivelock®)
Vantagens – Mesmos enxertos utilizados para a reconstrução do LCA
21. Reconstrução do LAL
Conclusão
• Indicação em joelhos com instabilidade rotatória
- Pivot Shift 3
• Diminui a instabilidade residual
• Avaliar a Fraturas de Segond com rotura do LCA
+ LAL
Lateral view of a typical right knee during dissection. With the ITB reflected, the ALL fibers are clearly distinguishable from the thin anterolateral joint capsule anterior to it. ALL, anterolateral ligament; LCL, lateral collateral ligament; LFE, lateral femoral epicondyle; BFT, biceps femoris tendon; FH,
fibular head; JC, joint capsule.
the major origin of the ALL was located on the prominence of the lateral femoral epicondyle,
anterior to the socket from which the LCL originated, and proximal and posterior to the insertion of the popliteus tendon
The ACL is the primary restraint during anterior drawer at all flexion angles and during internal rotation at flexion angles less than 35°
ALL, anterolateral ligament; *(asterisk), meniscofemoral portion of the ALL; •(dot), meniscotibial portion of the ALL; ITB, iliotibial band; LCL, lateral collateral ligament; LIGA, lateral inferior geniculate
artery and veins; LFC, lateral femoral condyle; LFE, lateral femoral epicondyle; LM, lateral meniscus.
(A) Schematic drawing; (B) coronal MRI slice; (C) anatomical photo of the ALL of the knee. In these three images,arrow 1 (green) represents the femoral portion, arrow 2 (red) the meniscal portion and arrow 3 (blue) the tibial portion. P,tendon of the popliteal muscle; FEM, lateral femoral condyle; TIB, lateral tibial plateau
T2-weighted coronal MRI slice with fat saturation showing: (A) femoral portion; (B) meniscal portion; and (C) tibialportion of the ALL of the knee
The intra-capsular course of the ALL is appreciated, as well as the triple layered anatomy of the lateral knee. ALL, anterolateral ligament; ITB, iliotibial band; LCL, lateral collateral ligament; GT, Gerdy’s tubercle; LIGA, lateral inferior geniculate artery; PN, peroneal nerve; PCL, posterior cruciate ligament; ACL, anterior cruciate ligament; LM, lateral meniscus; MM, medial meniscus; MCL, medial collateral ligament.
A) Anteroposterior knee radiograph, showing Segond fracture (white
circle). B) Coronal magnetic resonance imaging (MRI) showing sequelae of Segond fracture
(white circle). C) Sagittal T1 MRI showing sequelae of Segond fracture (white circle).
D) Coronal fat suppression MRI showing anterolateral ligament rupture (black arrows).
- In a study using three-dimensional MRI, Carpenter showed that knees that had undergone ACL reconstruction presented greater internal rotation in going from extension to flexionthan did knees with a native ACL. This situation showed thatthis reconstruction alone did not fully restore the kinematicsof the knee. The greater internal rotation in flexion may havebeen due to an undiagnosed and untreated ALL injury.
Relative to the Blumensaat line (x-axis), the ALL distance was at a point 47.5% 6 4.3% and 3.7 6 1.1 mm relative to the y-axis (Figure 5). All of the ligament origins on the y-axis were below the Blumensaat linet. The tibial attachment, the femoral attachment was posterior to the Gerdy tubercle and anterior to the fibular head, approximately 4 to 7 mm distal to the lateral tibial plateau cartilage.
Tibial graft fi xation is performed with knee flexion between 60 and 90. No use of any type of drain or immobilization after reconstruction.
Tibial graft fi xation is performed with knee flexion between 60 and 90. No use of any type of drain or immobilization after reconstruction.
Pode-se utilizar o Graft Link para reconstruções independes com os enxertos. Como opção pode-se utilizar âncoras de biotenodese (Swivelock, Arhrex ®)