Knee surgery success may hinge on ALL attention

While anterior cruciate ligament (ACL) reconstruction surgery is a widely proven procedure, a Western orthopaedic surgeon says re-injury rates in young patients after such procedures are unacceptably high for those returning to pivoting sports like basketball, volleyball and soccer.

“Seeing your patients get back to the top level of their sport, which right now is at about 60 per cent of those with ACL injuries getting back to pre-injury level, we’d like to get that up to 90 per cent if we could, and that’s what’s exciting,” said Dr. Al Getgood, a Schulich School of Medicine & Dentistry professor and Fowler Kennedy Sport Medicine Clinic orthopaedic surgeon, specializing in disorders of the knee and shoulder.

In an attempt to address this concern, there has been renewed interest in the anterolateral ligament (ALL) of the knee, recently focused on by orthopaedic surgeons Drs. Steven Claes and Johan Bellemans of University Hospitals Leuven in Belgium, with whom Getgood is collaborating.

Only recently, Getgood said, has the function of the ALL – and its role in ACL injuries and reconstruction – been clarified. Along with colleagues at Western’s Interdisciplinary Development Initiative in Bone & Joint Health, Getgood is trying to further understand the function of the ALL.

While ACL reconstruction is pretty much the ‘go-to’ procedure in dealing with knee injuries, addressing the ALL and its role could further reduce the occurrence of re-injury. Right now, Getgood said such injuries come with a 20 per cent chance of re-injury following surgery in the younger age group (under 20 years old).

“If we can drop that down to 10 per cent, it would be wonderful,” he said. “The thing is, it’s really easy to think we do a good job until you critically look the literature.”

A recent paper published in the Journal of Anatomy by Claes and Bellemans is the first to study the origin and structure of the ALL. While ALL reconstruction is being performed in Belgium and France, a fuller understanding of the ligament is needed.

Getgood has had patients he worried may have a higher risk of re-injuring the knee. So, while performing a standard ACL reconstruction, an extra-articular procedure was done at the same time.

“My research group at Fowler Kennedy and Western has been working on further dissection and histological analysis of the ligament as well as performing MRI (magnetic resonance imaging) and micro CT (computed tomography) in collaboration with the Robarts Research Institute to better characterize the tissue,” he said. “Furthermore, our future biomechanical studies will tell us the best way to reconstruct the ligament.”

In the New Year, Getgood is leading a multi-centre randomized study through a $200,000 grant award from the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine and the Orthopaedic Research and Education Foundation. The study will involve six centres in Canada and Europe, with Fowler Kennedy as the lead centre, studying whether or not the addition of an ALL reconstruction to standard ACL reconstruction will help to reduce graft failure after ACL surgery.

“So much of what we do is based on experience,” Getgood said. “So, for the patients who I do my extra-articular on, I feel the knee is a lot more stable than those who aren’t done. But that’s a completely biased opinion because I’m a proponent of this particular procedure.”

Getgood hopes the study will shed light on the pros and cons of this procedure. He understands it could show no clinical benefit and doctors are simply putting patients through more surgery and potential complications than necessary

But, he admits, this could also lead to massive changes in the way surgeons think about ACL reconstruction.

“Reconstructing the anterolateral ligament could – theoretically – produce improved outcomes following surgery and reduce failures,” Getgood said. “It is the hope this new procedure will help reduce failure rates and improve the function and quality of life of so many of the young active people that we see with this injury.”