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A modern day discovery – the anterolateral ligament of the knee

The first question most footballers or skiers ask after suffering serious knee damage is whether they will ever be able to kick a ball or parallel down a black slope again?

For many years the truthful answer has been “probably not” or at least “not as well as you used to”.

But thanks to three years of brilliant anatomical research by Dr Steven Claes, a knee specialist working in Belgium, there is now a new ray of hope.

He, like many other surgeons over the years, had wondered why in a significant number of individuals who injured their Anterior cruciate ligament (ACL) have a very characteristic finding on their X-ray. This showed a tiny fracture on the outer side of the knee where a small piece of bone would often be seen. This has been known as the Segond fracture and was first described by Paul Segond towards the end of the last century. But what we haven’t until now known is what has caused that flake of bone to pull off.

This troubled Steven!

Through some intensive work, minutely examining over 50 damaged knees over a 3 year period, Steven eventually, and some might say unbelievably, discovered a tiny ligament that no one had noticed before and therefore had never thought about repairing.

Hidden inside other tissue encountered on the side of the knee joint is the Anterolateral Ligament.  Just 4mm wide, 2mm thick and 4cm long, it is very difficult to identify.

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Following lengthy discussions and experimentation with Steven and Professor Johan Bellmans, my team and I here at the Basingstoke Hospital have devised a new procedure that has radically altered the traditional approach to Anterior Crucial Ligament (ACL) surgery.

In the past, when faced with a serious tear of the ACL, some patients become so unstable that we need to effectively do 2 ACL operations, one inside the knee, the traditional operation that people are familiar with, and the other on the outer side of the knee. We called this other operation an extra articular tenodesis procedure. This is based on the work of Macintosh who first described the surgery in 1979.  This entails a new ligament being fixed to the outside of the knee to prevent painful rotation and act as an external support. This operation provided a reasonable degree of relief to the patient but in essence presented a non-anatomical solution that was itself subject to a level of degradation over time.

Basically it did not reflect what was there before and therefore could not deliver the same mechanical properties.

As a result of Steven’s research we can now replace the Anterolateral Ligament with a true representation of how the joint was meant to be designed – an anatomical solution for the problem.

The first operation of its kind was only performed here at Basingstoke in December 2012.

We were able to use tissue donated from the patient’s hamstring to reconstruct this small ligament which we then attached to respective elements of the knee joint to replicate the original Anterolateral Ligament.

Using keyhole surgery the operation is far less invasive and as it is based on the body’s original anatomy it would appear to stop the unnatural painful pivoting of the joint which can be experienced by the traditional non anatomical solution.

So far our results have been very promising but as with all things to do with new innovations in medicine it will probably take another 20 to 30 years of study before we could say for certain that patients should start booking skiing holidays again!

HampshireKnee

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