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Kang JH, Moon SG, Lee DW. Magnetic Resonance Imaging Features of Anterolateral Ligament in Young Adults without Anterior Cruciate Ligament Injury: Preliminary Evaluation. Diagnostics (Basel) 2024; 14:1226. [PMID: 38928641 PMCID: PMC11202545 DOI: 10.3390/diagnostics14121226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Revised: 06/01/2024] [Accepted: 06/08/2024] [Indexed: 06/28/2024] Open
Abstract
This study aimed to characterize the Magnetic Resonance Imaging (MRI) features of the Anterolateral Ligament (ALL) in young adults without Anterior Cruciate Ligament (ACL) injury and evaluate its visibility using MRI. In this retrospective analysis, MRI scans of 66 young adults without ACL injuries were assessed by two radiologists. The ALL was examined from its bone-to-bone attachment between the lateral femoral epicondyle and the lateral tibia. The visibility of the ALL was classified as normal, probably normal, abnormal, or non-visualized, based on ligament continuity and thickness relative to the Meniscotibial Ligament (MTL). A continuous structure with thickness equal to or greater than the MTL was considered normal; continuous but wavy and thin features were categorized as probably normal; discontinuity and angulation were deemed abnormal. The proximal attachment of the ALL was categorized as anterior, central, or posterior to the Fibular Collateral Ligament (FCL), while the distal attachment was noted as either at the same location or distal to the MTL. The ALL was identified in 87.9-95.5% of knees and was non-visualized in 4.5-12.1% of cases. Continuous ligamentous structures were observed in 63.7-71.2% of knees (normal in 30.3-37.9%; probably normal in 27.3-40.9%), whereas 19.7-30.3% exhibited abnormal features. Inter-observer agreement was moderate to substantial (κ = 0.66, 0.56), and intra-observer agreement was substantial to excellent (κ = 0.82, 0.66). Among the 58 visible ALLs, proximal attachments were predominantly anterior (63.8%) or central (32.8%) to the FCL, with a minority posterior (1.7%). In total, 4 of the 19 central insertions were incorporated into the FCL mid-substance, and one case was blended into the meniscofemoral ligament. Distal attachments were equally distributed between the same location (50%) and distal to the MTL (50%) (mean 3.7 mm distal). In conclusion, MRI was feasible for detecting the ALL in most young adults without ACL injury, revealing continuous ligament structures in about two-thirds of cases. Approximately 40% of cases exhibited a thickness equal to or greater than the MTL, with the majority of proximal attachments located anterior to the FCL and distal attachments evenly divided between the same insertion and distal to the MTL.
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Affiliation(s)
- Ji-Hee Kang
- Department of Radiology, Konkuk University Medical Center, Seoul 05030, Republic of Korea;
| | - Sung-Gyu Moon
- Department of Radiology, Konkuk University Medical Center, Seoul 05030, Republic of Korea;
| | - Dhong-Won Lee
- Department of Orthopedic Surgery, Konkuk University Medical Center, Seoul 05030, Republic of Korea;
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Totlis T, Tishukov M, Piagkou M, Vasiliadis AV, Tsiouris C, Domashenko P, Tsakotos G, Natsis K. The Anterolateral Ligament of the Knee Is a Nonisometric Thin Ligament With High Prevalence and Almost Constant Attachment to the Lateral Meniscus: A Systematic Review With Meta-analysis. Arthroscopy 2024; 40:1288-1299. [PMID: 37832743 DOI: 10.1016/j.arthro.2023.09.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 09/23/2023] [Accepted: 09/28/2023] [Indexed: 10/15/2023]
Abstract
PURPOSE To provide comprehensive information about the anterolateral ligament (ALL) prevalence, morphometry, isometry, insertions, histology, and its relationship with the lateral meniscus (LM). METHODS The study was performed, according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Eligible cadaveric studies investigating the frequency of the ALL presence, and anatomical features were identified through an online search of the PubMed, Scopus, and Cochrane Central databases from inception to June 2022. Statistical analysis was conducted with the open-source R programming language using the "meta" package. The Higgins I2 statistic was used for quantifying heterogeneity. RESULTS Thirty-three studies (1,478 cadaveric knees) were included. The ALL had a 79% prevalence. It was attached to the LM periphery in 97% of studies. Most studies reported a femoral insertion of the ALL, just proximal and posterior to the lateral epicondyle. Tibial attachment is constant at the midpoint between Gerdy's tubercle and fibular head. The mean ALL thickness at the joint line was 1.6 [1.2; 2.0] mm. The ALL length was found to significantly change across the knee flexion (P < .01). It was increased from 0° to 60° and decreased after 60° flexion. Seven histological studies demonstrated a typical ligamentous microstructure. CONCLUSION The ALL is a thin ligament, distinct to the knee capsule, which may be found in 79% of the knees having an almost constant attachment to the LM. The ALL is not isometric. It becomes tense during internal rotation and between 30° and 60° knee flexion. Pooled results should be interpreted with caution due to the high heterogeneity among the included studies. CLINICAL RELEVANCE This study sheds light on controversial issues and provides comprehensive and accurate information about the essential anatomical knowledge on ALL, which may contribute to optimizing ALL reconstruction surgical techniques and biomechanical settings.
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Affiliation(s)
- Trifon Totlis
- Department of Anatomy and Surgical Anatomy, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece; Thessaloniki Minimally Invasive Surgery (TheMIS) Orthopaedic Center, St. Luke's Hospital, Thessaloniki, Greece.
| | - Maksim Tishukov
- Department of Anatomy and Surgical Anatomy, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Maria Piagkou
- Department of Anatomy, School of Medicine, Faculty of Health Sciences, National and Kapodistrian University of Athens, Athens, Greece
| | - Angelo V Vasiliadis
- Sports Trauma and Orthopaedics Department, St. Luke's Hospital, Thessaloniki, Greece
| | - Christos Tsiouris
- Department of Anatomy, School of Medicine, Faculty of Health Sciences, National and Kapodistrian University of Athens, Athens, Greece
| | - Philip Domashenko
- Department of Anatomy and Surgical Anatomy, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Georgios Tsakotos
- Department of Anatomy, School of Medicine, Faculty of Health Sciences, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos Natsis
- Department of Anatomy and Surgical Anatomy, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Wei X, Wang Z, Lu Y, Sun J, Riehl J. Surgical Treatment for Avulsion Fractures of the Anterolateral Ligament Associated with Periarticular Fractures of the Knee. J Knee Surg 2023; 36:397-403. [PMID: 34507364 DOI: 10.1055/s-0041-1735311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The existence and anatomy of the anterolateral ligament (ALL) of the knee are a somewhat controversial topic in orthopaedic surgery. The fixation of the avulsion fracture of the ALL (Segond fracture), associated with periarticular knee fractures, is rarely given much consideration while the major fracture fragments are reconstructed. This study aims to confirm the existence of ALL and evaluate the clinical outcomes of surgical management for avulsion fractures, involving its insertion, when associated with periarticular knee fractures. Twenty-three patients (16 males and 7 females) with avulsion fractures of the ALL associated with periarticular knee fractures were fixed with a spider plate, cannulated screw, or suture anchor. Eight patients were diagnosed with distal femoral fracture, 10 with tibial plateau fracture, and 5 with tibial eminence avulsion fracture. All patients underwent X-rays at follow-up. Clinical and functional outcomes were assessed with the pivot-shift test, objective and subjective International Knee Documentation Committee (IKDC) score, Lysholm score, and Tegner activity scale. The ALL was found and identified as a distinct ligamentous structure in all patients. Prior to Segond repair, patients had significantly more instability, as determined by pivot-shift test, than seen postoperatively (p < 0.0001). At final follow-up, the mean subjective IKDC score was 83.2 ± 10.3. Fourteen patients were graded A, 6 were graded B, and 3 was graded C on the IKDC objective score. The mean Lysholm score was 85.4 ± 12.2. The mean Tegner score was 7.5 ± 1.2. This study confirmed that the ALL is a distinct structure in the anterolateral portion of the knee. The fixation of the avulsion fracture of the ALL associated with periarticular knee fractures can be an effective procedure without specific complications. Long-term and comparative follow-up studies are necessary to confirm the effects.
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Affiliation(s)
- Xuelei Wei
- Department of Orthopaedic Trauma, Tianjin Hospital, Tianjin, China
| | - Zengliang Wang
- Department of Sports Medicine, Tianjin Hospital, Tianjin, China
| | - Yandong Lu
- Department of Orthopaedic Trauma, Tianjin Hospital, Tianjin, China
| | - Jie Sun
- Department of Orthopaedic Trauma, Tianjin Hospital, Tianjin, China
| | - John Riehl
- Department of Orthopaedic Trauma, Pikeville Medical Center, Pikeville, Kentucky
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Park JG, Han SB, Rhim HC, Jeon OH, Jang KM. Anatomy of the anterolateral ligament of the knee joint. World J Clin Cases 2022; 10:7215-7223. [PMID: 36158026 PMCID: PMC9353924 DOI: 10.12998/wjcc.v10.i21.7215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 04/26/2022] [Accepted: 06/03/2022] [Indexed: 02/06/2023] Open
Abstract
Despite remarkable improvements in clinical outcomes after anterior cruciate ligament reconstruction, the residual rotational instability of knee joints remains a major concern. The anterolateral ligament (ALL) has recently gained attention as a distinct ligamentous structure on the anterolateral aspect of the knee joint. Numerous studies investigated the anatomy, function, and biomechanics of ALL to establish its potential role as a stabilizer for anterolateral rotational instability. However, controversies regarding its existence, prevalence, and femoral and tibial insertions need to be addressed. According to a recent consensus, ALL exists as a distinct ligamentous structure on the anterolateral aspect of the knee joint, with some anatomic variations. The aim of this article was to review the updated anatomy of ALL and present the most accepted findings among the existing controversies. Generally, ALL originates slightly proximal and posterior to the lateral epicondyle of the distal femur and has an anteroinferior course toward the tibial insertion between the tip of the fibular head and Gerdy’s tubercle below the lateral tibial plateau.
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Affiliation(s)
- Jun-Gu Park
- Department of Orthopaedic Surgery, Anam Hospital, Korea University College of Medicine, Seoul 02841, South Korea
| | - Seung-Beom Han
- Department of Orthopaedic Surgery, Anam Hospital, Korea University College of Medicine, Seoul 02841, South Korea
| | - Hye Chang Rhim
- Department of Medicine, MetroWest Medical Center/Tufts University School of Medicine, Framingham, MA 02111, United States
| | - Ok Hee Jeon
- Department of Biomedical Sciences, Korea University College of Medicine, Seoul 02841, South Korea
| | - Ki-Mo Jang
- Department of Orthopaedic Surgery, Anam Hospital, Korea University College of Medicine, Seoul 02841, South Korea
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Key Surgically Relevant Anatomy of the Medial and Lateral Aspects of the Knee. OPER TECHN SPORT MED 2022. [DOI: 10.1016/j.otsm.2022.150908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Knee Injuries in the Elite American Football Player: A Descriptive Pictorial Imaging and Mechanism of Injury Review. J Comput Assist Tomogr 2022; 46:197-211. [PMID: 35081603 DOI: 10.1097/rct.0000000000001259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Musculoskeletal injuries are common in American football, with an incidence ranging from approximately 10 to 35 per 1000 playing hours. Injuries occur more commonly in games than in practice. Although several studies have analyzed specific injury types in football, this review aims to describe the most common knee injuries sustained by American football players and to review the existing literature pertaining to the radiologic findings used in the diagnosis of these injuries.
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Anterolateral ligament reconstruction improves the clinical and functional outcomes of anterior cruciate ligament reconstruction in athletes. Knee Surg Sports Traumatol Arthrosc 2021; 29:1173-1180. [PMID: 32617609 DOI: 10.1007/s00167-020-06119-w] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 06/24/2020] [Indexed: 12/22/2022]
Abstract
PURPOSE To compare the outcomes of anterior cruciate ligament (ACL) reconstruction with those of combined ACL and anterolateral ligament (ALL) reconstruction in ACL-deficient knees. The objective of this study was to improve knowledge regarding the treatment of ACL-deficient knees with combined ACL and ALL reconstruction. Combined ACL and ALL reconstruction has been hypothesized to result in better clinical and functional outcomes than isolated ACL reconstruction (ACLR). METHODS One-hundred and seven adult male athletes with ACL tears and high-grade pivot shifts were randomized into two groups. Those in group A (n = 54) underwent ACLR, while those in group B (n = 53) underwent combined ACL and ALL reconstruction. The median age was 26 (18-40) and 24 (18-33) years in groups A and B, respectively, and the median follow-up was 60 (55-65) months. Physical examination findings, instrumented knee laxity tested using a KT-1000 arthrometer, and International Knee Documentation Committee Scale (IKDC) scores were used to evaluate the outcomes. RESULTS One-hundred and two patients were available for follow-up: 52 in group A and 50 in group B. Postoperatively, the pivot shift was normal in 43 (82.7%) and 48 (96%) patients in groups A and B, respectively (p < 0.001). The median instrumented knee laxity was 2.5 ± 0.7 (1.2-6.1) mm in patients in group A and 1.2 ± 0.7 (1.2-3.2) mm in patients in group B (p < 0.001). Additionally, 44 (84.6%) patients in group A had normal IKDC scores and 3 (5.8%) had nearly normal scores, while 48 (96.0%) patients in group B had normal IKDC scores and 2 (4%) had nearly normal scores (p < 0.001). CONCLUSION Combined ACL and ALL reconstruction, compared with isolated ACLR resulted in favourable clinical and functional outcomes, as demonstrated by decreased rotational instability and instrumented knee laxity, a lower graft rupture rate and better postoperative IKDC scores. LEVEL OF EVIDENCE 1.
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Delpupo FVB, de Fúcio Lizardo JH, Baptista JDS. The anterolateral ligament of the knee is not a solid structure in human fetuses. Surg Radiol Anat 2021; 43:1117-1122. [PMID: 33416973 DOI: 10.1007/s00276-020-02665-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 12/19/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE The purpose of this study was to investigate if the anterolateral ligament of the knee (ALL) is present in the human fetus and describe its topography along with other structures of the region. METHODS Forty human fetuses knee joints, at mean age 34 weeks (± 2.57 weeks), fixed in 10% formalin, were submitted to cross-sectional dissection and mesoscopic analysis. RESULTS The ALL was not identified, although the usual topography of the region was identified in all specimens: skin, subcutaneous tissue, iliotibial tract (ITT), fibular collateral ligament, popliteal muscle tendon, lateral meniscus, patellar ligament, infrapatellar fat pad, lateral patellar retinaculum, knee joint capsule, lateral inferior genicular vessels, and the biceps femoris tendon. The ITT reveals anterior (n = 12) and lateral thickening (n = 17) in some specimens. This thickening was found in both knees of the same subject in 6/20 specimens. CONCLUSION The anterolateral ligament of the knee is not a congenital or solid structure. Our results suggest that the ALL may be a deep layer of the ITT or part of the knee joint capsule, or its identification is evaluator dependent.
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Affiliation(s)
- Fernanda Vieira Botelho Delpupo
- Laboratory of Applied Morphology-LEMA, Universidade Federal Do Espirito Santo, Av. Marechal Campos, 1468, Maruipe, Vitoria, Espirito Santo, 29043-900, Brazil
| | - Juliana Hott de Fúcio Lizardo
- Laboratory of Applied Morphology-LEMA, Universidade Federal Do Espirito Santo, Av. Marechal Campos, 1468, Maruipe, Vitoria, Espirito Santo, 29043-900, Brazil
| | - Josemberg da Silva Baptista
- Laboratory of Applied Morphology-LEMA, Universidade Federal Do Espirito Santo, Av. Marechal Campos, 1468, Maruipe, Vitoria, Espirito Santo, 29043-900, Brazil.
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Lôbo CFT, Helito PVP, Bordalo-Rodrigues M, Helito CP. Computed tomography (CT), X-ray, and MRI evaluation of two anterolateral knee reconstruction techniques: lateral extra-articular tenodesis (LET) and the anterolateral ligament (ALL) reconstruction. Skeletal Radiol 2020; 49:1037-1049. [PMID: 32147757 DOI: 10.1007/s00256-020-03402-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 02/08/2020] [Accepted: 02/17/2020] [Indexed: 02/02/2023]
Abstract
The anterolateral ligament (ALL) and capsule of the knee are anatomical structures involved in rotational stability and pivot-shift control. As such, it has been demonstrated that the extra-articular anterolateral procedures improve clinical outcome when performed as an augmentation of the anterior cruciate ligament (ACL) reconstruction in specific groups of patients. This review describes the postoperative imaging findings of two techniques used to perform these procedures, using magnetic resonance imaging (MRI), computed tomography (CT), and radiography. The first technique described is the lateral extra-articular tenodesis (LET), which uses a strip of the iliotibial band that is harvested, passed underneath the lateral collateral ligament (LCL) and fixed posterior, and proximal to the lateral femoral epicondyle (LFE), preserving ITB insertion on Gerdy's tubercle. The second technique described is the ALL reconstruction, a procedure that attempts to recreate the anatomy of the ALL, using most often a gracilis autograft. In this procedure, femoral fixation is performed proximal and posterior to the LFE, and tibial fixation is slightly distal to the joint line, halfway from Gerdy's tubercle to the fibular head. The main objective of this review is to provide an overview of the postoperative imaging aspects of these two procedures with MRI, CT, and radiography and to describe possible complications. As they become more common, it is important for the radiologist and the orthopedic surgeon to understand their particularities in combination with the already well-known ACL reconstruction.
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Affiliation(s)
- Carlos Felipe Teixeira Lôbo
- Grupo de Radiologia Musculo-esquelética, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil.
| | - Paulo Victor Partezani Helito
- Grupo de Radiologia Musculo-esquelética, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
- Hospital Sírio Libanês, São Paulo, Brazil
| | - Marcelo Bordalo-Rodrigues
- Grupo de Radiologia Musculo-esquelética, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
- Hospital Sírio Libanês, São Paulo, Brazil
| | - Camilo Partezani Helito
- Hospital Sírio Libanês, São Paulo, Brazil
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
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Zhu Y, Qiu X, Yu T, Zhang C, Zhao X, Duan F, Hao D. Feasibility of three-dimensional constructive interference in steady state sequences for evaluating the anterolateral ligament. Clin Radiol 2019; 74:978.e9-978.e14. [PMID: 31582170 DOI: 10.1016/j.crad.2019.08.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 08/20/2019] [Indexed: 11/24/2022]
Abstract
AIM The purpose of the study was to determine the feasibility of three-dimensional (3D) constructive interference in steady state (CISS) sequences for evaluating the anterolateral ligament (ALL). MATERIALS AND METHODS Magnetic resonance imaging (MRI) of the right knee joint in 30 healthy volunteers was performed using a 3 T MRI machine. Axial T2-weighted imaging with fat saturation (T2WI-FS), coronal proton-density-weighted imaging with fat saturation (PDWI-FS), and 3D-CISS were included in the protocol. Multiplanar reconstruction (MPR) and rotating stretched curved planar reconstructions (CPRs) of the ALL at 30°, 60°, 90°, 120°, and 150° were generated from the 3D-CISS images. The visibility of the femoral part, meniscal part, tibial part, meniscal insertion, femoral footprint, and tibial footprint of the ALL on the imaging of all sequences was recorded. RESULTS Based on the CPR of 3D-CISS MRI, the presence of tibial and femoral footprints of the ALL was rated superior to MPR and PDWI-FS (96.67% and 96.67%, respectively; p<0.017). Rotating CPR of 3D-CISS MRI imaging was rated superior to PDWI-FS with respect to the tibial part, meniscal part, and meniscal insertion of the ALL (96.67%, 83.33%, and 83.33%, respectively; p<0.05). Rotating CPR of 3D-CISS MRI was rated superior to PDWI-FS with respect to the femoral part of the ALL, but the difference was not statistically significant (p=0.095). The angle between the ALL and lateral collateral ligament (LCL) on the oblique sagittal image was 18.34±1.88°. CONCLUSIONS The MRI 3D-CISS sequences significantly enhanced the ability to identify the ALL compared to the 2D MRI sequences.
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Affiliation(s)
- Y Zhu
- Department of Radiology, The Affiliated Hospital of Qingdao University, Qingdao, 266003, China
| | - X Qiu
- Department of Radiology, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China.
| | - T Yu
- Department of Sport Medicine, The Affiliated Hospital of Qingdao University, Qingdao, 266003, China.
| | - C Zhang
- Department of Radiology, The Affiliated Hospital of Qingdao University, Qingdao, 266003, China
| | - X Zhao
- Department of Radiology, The Affiliated Hospital of Qingdao University, Qingdao, 266003, China
| | - F Duan
- Department of Radiology, The Affiliated Hospital of Qingdao University, Qingdao, 266003, China
| | - D Hao
- Department of Radiology, The Affiliated Hospital of Qingdao University, Qingdao, 266003, China.
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The Accessory Iliotibial Band–Meniscal Ligament of the Knee: Association With Lesions of the Lateral Meniscus. AJR Am J Roentgenol 2019; 213:912-917. [DOI: 10.2214/ajr.18.21071] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Ariel de Lima D, Helito CP, Lacerda de Lima L, Dias Leite JA, Costa Cavalcante ML. Study of the Nerve Endings and Mechanoreceptors of the Anterolateral Ligament of the Knee. Arthroscopy 2019; 35:2918-2927. [PMID: 31604514 DOI: 10.1016/j.arthro.2019.05.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 05/05/2019] [Accepted: 05/10/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To describe the morphology and distribution of the anterolateral ligament of the knee (ALL) nerve endings, aiming to understand the interaction between the proprioceptive system and knee mechanics. METHODS Twenty ALLs were obtained from fresh frozen cadavers. The ligaments were measured, weighed, and cut. Sections (10 μm) were prepared in hematoxylin and eosin-stained slides to analyze tissue integrity, and 50-μm sections were subjected to immunofluorescence with the protein gene product 9.5 as primary antibody and Alexa Fluor 488 as secondary antibody, followed by microscopic analysis. RESULTS The ALL was identified in 100% of the dissections, exhibiting a mean (± standard deviation) length of 4.0 ± 0.4 cm, a mean width of 5.5 ± 0.8 mm, and a mean weight of 0.9 ± 0.2 g. The histological sections in hematoxylin and eosin showed dense, well-organized collagen and the presence of vascular tissue. All the specimens analyzed contained type I (Ruffini-like) mechanoreceptors and free nerve endings (type IV), varying from parallel to intertwined fibers. Unclassified nerve endings with different irregular shapes were also found. The neural elements occupied 0.6% ± 0.3% of the ligament area, and most were observed near the origin of ALL insertions. CONCLUSION The ALL exhibits a peripheral nerve structure, primarily type I and IV mechanoreceptors. These findings suggest that the ALL is important for the proprioception and anterolateral stabilization of the knee. CLINICAL RELEVANCE It is important to understand ALL innervation and infer how an injury could compromise the proprioceptive role of the lateral compartment, as the ligaments contribute dynamically to stability through proprioceptive control of muscle forces. The findings confirm that the ALL is highly innervated by mechanoreceptors and may have a proprioceptive role in conjunction with the lateral collateral ligament in the lateral region of the knee.
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Affiliation(s)
| | - Camilo Partezani Helito
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brasil; Hospital Sírio Libanês, São Paulo, Brasil
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Helito CP, Sobrado MF, Giglio PN, Bonadio MB, Pécora JR, Camanho GL, Demange MK. Combined Reconstruction of the Anterolateral Ligament in Patients With Anterior Cruciate Ligament Injury and Ligamentous Hyperlaxity Leads to Better Clinical Stability and a Lower Failure Rate Than Isolated Anterior Cruciate Ligament Reconstruction. Arthroscopy 2019; 35:2648-2654. [PMID: 31421960 DOI: 10.1016/j.arthro.2019.03.059] [Citation(s) in RCA: 87] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Revised: 03/27/2019] [Accepted: 03/30/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare functional outcomes, residual instability, and rupture rates in patients with ligamentous hyperlaxity undergoing isolated anterior cruciate ligament (ACL) reconstruction or combined ACL and anterolateral ligament (ALL) reconstruction. METHODS Two groups of patients were evaluated and compared retrospectively. Both groups consisted of patients with ACL injuries and associated ligamentous hyperlaxity, defined based on the modified Beighton scale with a minimum score of 5. Group 1 patients underwent anatomical ACL reconstruction, and group 2 patients underwent anatomical ACL reconstruction combined with ALL reconstruction. Group 1 consisted of historical controls. The presence of associated meniscal injury, subjective International Knee Documentation Committee and Lysholm functional scores, KT-1000 measurements, the presence of a residual pivot-shift, and the graft rupture rate were evaluated. The study was performed at University of São Paulo in Brazil. RESULTS Ninety patients undergoing ACL reconstruction with ligamentous hyperlaxity were evaluated. The mean follow up was 29.6 ± 6.2 months for group 1 and 28.1 ± 4.2 months for group 2 (P = .51). No significant differences were found between the groups regarding Beighton scale, gender, the duration of injury before reconstruction, follow-up time, preoperative instability, or associated meniscal injuries. The mean age was 29.9 ± 8.1 years in group 1 and 27.0 ± 9.1 years in group 2 (P = .017). In the final evaluation, group 2 patients showed better anteroposterior clinical stability as evaluated by KT-1000 arthrometry (P = .02), better rotational stability as evaluated by the pivot-shift test (P = .03) and a lower reconstruction failure rate (21.7% [group 1] vs 3.3% [group 2]; P = .03). Clinical evaluations of postoperative functional scales showed no differences between the 2 groups (P = .27 for International Knee Documentation Committee; P = .41 for Lysholm). CONCLUSIONS Combined ACL and ALL reconstruction in patients with ligamentous hyperlaxity resulted in a lower failure rate and improved knee stability parameters compared to isolated ACL reconstruction. No differences were found in the functional scales. LEVEL OF EVIDENCE Level III, case control study.
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Affiliation(s)
- Camilo Partezani Helito
- Hospital Sírio-Libanês, São Paulo, Brazil; Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil.
| | - Marcel Faraco Sobrado
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Pedro Nogueira Giglio
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Marcelo Batista Bonadio
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - José Ricardo Pécora
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Gilberto Luis Camanho
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Marco Kawamura Demange
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
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Correlation Analysis of the Anterolateral Ligament Length with the Anterior Cruciate Ligament Length and Patient's Height: An Anatomical Study. Sci Rep 2019; 9:9802. [PMID: 31278337 PMCID: PMC6611776 DOI: 10.1038/s41598-019-46351-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 06/21/2019] [Indexed: 01/23/2023] Open
Abstract
The aim of this study was to evaluate the anatomical characteristics of the anterolateral ligament of the knee (ALL) with the focus on potential gender differences. The ALL length and the length of the lateral collateral ligament (LCL) were taken in extension. The length of the anterior cruciate ligament (ACL) was measured at 120° flexion. We correlated the length of the ALL with the LCL and ACL with respect to potential gender differences. The ALL was significantly (p = 0.044) shorter in females (mean length: 32.8 mm) compared to males (mean length: 35.7 mm). The length of the ALL correlated significantly positively with the lengths of the ACL (p < 0.001) and the LCL (p < 0.001). There was no significant correlation with the total leg length (TLL) (p = 0.888) and body size (p = 0.046). Furthermore, TLL and donor size correlated significantly positively (p < 0.001). The ALL length correlated significantly positively with the ACL and the LCL length. The ALL length did neither correlate with the TLL nor the donor size. This fact may contribute to planning of graft harvesting in the upcoming techniques for ALL reconstruction.
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Helito CP. Editorial Commentary: Extension of Knowledge-and the Knee! New Biomechanical Study Suggests the Clinical Practice of Anterolateral Ligament Fixation Near Extension. Arthroscopy 2019; 35:2160-2163. [PMID: 31272637 DOI: 10.1016/j.arthro.2019.03.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Accepted: 03/18/2019] [Indexed: 02/02/2023]
Abstract
The knee anterolateral ligament (ALL) is one of the most hotly debated topics in sports medicine in the last decade. Once one aspect of discussion regarding the ALL reaches a consensus, attention immediately turns to the next one. This has already happened with the existence of the ALL itself, its anatomic features, the ability to visualize the ALL with magnetic resonance imaging, and many other topics. In the end, the most important aspect must be clinical outcomes, and existing studies are trying to find the optimum surgical technique to best restore knee stability and reduce failure rates. It appears that, when doing an anatomic ALL reconstruction, fixation must be performed in full extension. The literature regarding ALL reconstruction shows promising results, with a strong tendency to present better knee stability, improved functional scores, and lower failure rates.
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Brockmeyer M, Orth P, Höfer D, Seil R, Paulsen F, Menger MD, Kohn D, Tschernig T. The anatomy of the anterolateral structures of the knee - A histologic and macroscopic approach. Knee 2019; 26:636-646. [PMID: 30910626 DOI: 10.1016/j.knee.2019.02.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 02/27/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND The anatomy of the anterolateral structures of the knee is complex and still controversial. The aim of our study was to analyze this anatomy by histologic and macroscopic evaluation, with a particular emphasis on the anterolateral ligament (ALL). MATERIAL AND METHODS Twenty-three cadaveric knee joints were dissected followed by a qualitative and quantitative anatomic analysis of the anterolateral knee structures. Histology and comparison of different anterolateral structures was performed in addition. RESULTS The ALL was identified in all of the dissected cadaveric knee specimens. It runs in an oblique course from its proximo-dorsal insertion at the distal femur into a ventro-distal direction to the anterolateral tibia. The femoral insertion site was found to be posterior and slightly proximal to the lateral femoral epicondyle and the femoral attachment of the lateral collateral ligament (LCL). The femoral insertion of the ALL overlapped the LCL in all dissected knees. The tibial insertion site was midway between Gerdy's tubercle (GT) and the tip of the fibular head (FH). In 15 of the dissected 23 knee joints, thin attachments to the lateral meniscus were observed. Histology confirmed differences in the composition of the anterolateral knee joint capsule, the ALL and the iliotibial band (ITB). CONCLUSIONS The ALL occurs as a regular separate anterolateral ligamentous structure. It is distinguishable from the ITB and the anterolateral joint capsule in both embalmed and non-embalmed specimens. Histology of the ALL indicates typical ligamentous tissue which clearly differs from the anterolateral knee joint capsule and the thicker ITB. LEVEL OF EVIDENCE Level II, descriptive anatomic study.
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Affiliation(s)
- Matthias Brockmeyer
- Saarland University Medical Center, Department of Orthopaedics and Orthopaedic Surgery, Kirrberger Straße, Geb. 37, 66421 Homburg, Saar, Germany.
| | - Patrick Orth
- Saarland University Medical Center, Department of Orthopaedics and Orthopaedic Surgery, Kirrberger Straße, Geb. 37, 66421 Homburg, Saar, Germany; Saarland University Medical Center, Center of Experimental Orthopaedics, Kirrberger Straße, Geb. 37, 66421 Homburg, Saar, Germany
| | - Denis Höfer
- Saarland University Medical Center, Institute of Anatomy and Cell Biology, Kirrberger Straße, Geb. 61, 66421 Homburg, Saar, Germany
| | - Romain Seil
- Department of Orthopaedic Surgery, Centre Hospitalier de Luxembourg-Clinique d'Eich, 78 Rue d'Eich, 1460, Luxembourg, Luxembourg; Sports medicine Research Laboratory, Luxembourg Institute of Health, 78 Rue d'Eich, 1460 Luxembourg, Luxembourg
| | - Friedrich Paulsen
- Friedrich Alexander University Erlangen-Nürnberg, Department of Functional and Clinical Anatomy, Universitätsstr. 19, 91054 Erlangen, Germany
| | - Michael D Menger
- Saarland University Medical Center, Institute for Clinical & Experimental Surgery, Saarland University, 66421 Homburg/Saar, Germany
| | - Dieter Kohn
- Saarland University Medical Center, Department of Orthopaedics and Orthopaedic Surgery, Kirrberger Straße, Geb. 37, 66421 Homburg, Saar, Germany
| | - Thomas Tschernig
- Saarland University Medical Center, Institute of Anatomy and Cell Biology, Kirrberger Straße, Geb. 61, 66421 Homburg, Saar, Germany
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17
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Ariel de Lima D, Helito CP, Daggett M, Neto FMM, de Lima LL, Leite JAD, Cavalcante MLC. Anterolateral ligament of the knee: a step-by-step dissection. BMC Musculoskelet Disord 2019; 20:142. [PMID: 30947710 PMCID: PMC6449941 DOI: 10.1186/s12891-019-2517-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 03/18/2019] [Indexed: 02/06/2023] Open
Abstract
Background The number of studies and clinical interest in the anterolateral ligament of the knee (ALL) has grown in recent years. A meticulous and accurate ALL dissection is vital in anatomic and biomechanical studies, and a standardized technique is not yet established. As such, the aim of this study was to describe a step-by-step ALL dissection technique that could help authors consistently identify the ALL. Methods Twenty knees from frozen adult cadavers, with no preference for sex or age, were included in the study. All the cadavers were dissected using the same technique to determine the incidence of the ALL. Results A transverse incision is performed in the iliotibial band (ITB), around 10 cm proximal to the topography of the lateral epicondyle of the femur. Next, the ITB undergoes anterograde blunt dissection until its insertion at Gerdy’s tubercle in the tibia. Maintaining biceps femoris insertion, a dissection is performed anteriorly to it, until the lateral collateral ligament (LCL) is found. Using the LCL, internal rotation and 30 to 60° flexion as references, the ALL can be located in the anterolateral topography of the knee, with its origin near the lateral epicondyle (proximal and posterior) and insertion between Gerdy’s tubercle and the fibula (4.0 mm to 7.0 mm below the tibial plateau), expanding to the lateral meniscus (between the body and anterior horn), exhibiting a mean length of 4.0 ± 0.4 cm and mean width of 5.5 ± 0.8 mm. Conclusions The present article describes an effective and reproducible ALL dissection technique that made it was possible to identify the ligament in 100% of the cases in the present study. Electronic supplementary material The online version of this article (10.1186/s12891-019-2517-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Diego Ariel de Lima
- UFERSA. Universidade Federal Rural do Semi-Árido, Av João da Escóssia, 1300, Mossoró, RN, CEP: 59607-330, Brazil.
| | - Camilo Partezani Helito
- USP. Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.,Hospital Sírio Libanês, São Paulo, Brazil
| | - Matthew Daggett
- Kansas City University of Medicine and Biosciences, Kansas City, MO, USA
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Weber AE, Zuke W, Mayer EN, Forsythe B, Getgood A, Verma NN, Bach BR, Bedi A, Cole BJ. Lateral Augmentation Procedures in Anterior Cruciate Ligament Reconstruction: Anatomic, Biomechanical, Imaging, and Clinical Evidence. Am J Sports Med 2019; 47:740-752. [PMID: 29401410 DOI: 10.1177/0363546517751140] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND There has been an increasing interest in lateral-based soft tissue reconstructive techniques as augments to anterior cruciate ligament reconstruction (ACLR). The objective of these procedures is to minimize anterolateral rotational instability of the knee after surgery. Despite the relatively rapid increase in surgical application of these techniques, many clinical questions remain. PURPOSE To provide a comprehensive update on the current state of these lateral-based augmentation procedures by reviewing the origins of the surgical techniques, the biomechanical data to support their use, and the clinical results to date. STUDY DESIGN Systematic review. METHODS A systematic search of the literature was conducted via the Medline, EMBASE, Scopus, SportDiscus, and CINAHL databases. The search was designed to encompass the literature on lateral extra-articular tenodesis (LET) procedures and the anterolateral ligament (ALL) reconstruction. Titles and abstracts were reviewed for relevance and sorted into the following categories: anatomy, biomechanics, imaging/diagnostics, surgical techniques, and clinical outcomes. RESULTS The search identified 4016 articles. After review for relevance, 31, 53, 27, 35, 45, and 78 articles described the anatomy, biomechanics, imaging/diagnostics, surgical techniques, and clinical outcomes of either LET procedures or the ALL reconstruction, respectively. A multitude of investigations were available, revealing controversy in addition to consensus in several categories. The level of evidence obtained from this search was not adequate for systematic review or meta-analysis; thus, a current concepts review of the anatomy, biomechanics, imaging, surgical techniques, and clinical outcomes was performed. CONCLUSION Histologically, the ALL appears to be a distinct structure that can be identified with advanced imaging techniques. Biomechanical evidence suggests that the anterolateral structures of the knee, including the ALL, contribute to minimizing anterolateral rotational instability. Cadaveric studies of combined ACLR-LET procedures demonstrated overconstraint of the knee; however, these findings have yet to be reproduced in the clinical literature. The current indications for LET augmentation in the setting of ACLR and the effect on knee kinematic and joint preservation should be the subject of future research.
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Affiliation(s)
- Alexander E Weber
- Department of Orthopaedic Surgery, University of Southern California, Los Angeles, California, USA
| | - William Zuke
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, USA
| | - Erik N Mayer
- Department of Orthopaedic Surgery, University of Southern California, Los Angeles, California, USA
| | - Brian Forsythe
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, USA
| | - Alan Getgood
- Fowler Kennedy Sports Clinic, Western University, London, Ontario, Canada
| | - Nikhil N Verma
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, USA
| | - Bernard R Bach
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, USA
| | - Asheesh Bedi
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Brian J Cole
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, USA
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Anatomy of the Anterolateral Ligament of the Knee: A Systematic Review. Arthroscopy 2019; 35:670-681. [PMID: 30612770 DOI: 10.1016/j.arthro.2018.09.006] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 09/02/2018] [Accepted: 09/03/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To conduct a systematic literature review to search for studies on the anatomy of the anterolateral ligament (ALL) of the knee, presenting the most accepted findings, as well as the evolution of anatomic information on this structure. METHODS We reviewed the PubMed, MEDLINE, and ClinicalKey databases for anatomic studies on the ALL, involving cadaveric, histologic, and biochemical dissection and/or anatomic imaging. The primary data researched were the presence of the ligament; measures of length, width, and thickness; ligament path; insertions; number of bands; histologic assessment; and innervation. RESULTS We identified 53 studies. The ALL was found in 82.87% of adult dissections (more easily visualized in fresh cadavers), 74.07% of fetal dissections, and 84.80% of magnetic resonance imaging (MRI) studies. In 29 articles, the ALL was found in 100% of cases. There are 3 ALL insertion points: femoral, tibial, and meniscal. Histologic sections showed dense, well-organized collagen fibers, with an average of 121 fibroblasts/mm2 in adults, in addition to the presence of vascular and nervous tissue. MRI was shown to be a good examination tool to visualize the ALL, primarily in the coronal plane and with T2-weighted images. CONCLUSIONS The ALL is a distinct structure in the anterolateral portion of the knee. It exhibits typical ligament characteristics and can be visualized on imaging examinations, especially MRI. It has a femoral attachment near the lateral epicondyle, with a trend in recent years showing it to be located posterior and proximal to it, following an anteroinferior trajectory, with an insertion into the lateral meniscus and proximal tibia at the midpoint between the fibular head and Gerdy tubercle. Among the studies, the length of the ALL varied from 30.41 to 59.0 mm, the width ranged between 4.0 and 7.0 mm, and the thickness ranged between 1.0 and 2.0 mm. CLINICAL RELEVANCE During the past few years, much controversy has been raised about the correct anatomy of the ALL. The main clinical relevance of this study is not only to end the discussion about the ALL's existence but also to clarify and synthesize the main evidence on the ALL's anatomy, mainly the currently most accepted attachments according to the recent literature, to enable more precise development of biomechanical settings and surgical techniques.
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20
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Abstract
Despite several previous articles in the literature, never before have so many studies with regard to anterolateral knee structures been performed. The anterolateral knee complex consists briefly of the iliotibial band, with its proximal and distal attachments, the joint capsule, and the anterolateral ligament (ALL). The recently introduced ALL has several different descriptions, making it difficult to build a consensus with regard to its anatomy. An extensive description of these structures, particularly the iliotibial band and the ALL, with regard to anatomy and imaging, will be provided in this article.
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Affiliation(s)
- Camilo P. Helito
- Hospital Sírio-Libanês
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo
| | - Paulo V.P. Helito
- Hospital Sírio-Libanês
- Grupo de Radiologia Musculo-esquelética, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo-SP, Brazil
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21
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Burkhart TA, Matthew M, McGuffin WS, Blokker A, Holdsworth D, Degen RM, Getgood A. There Are No Kinematic Differences Between Inframeniscal and Suprameniscal Anterolateral Ligament Injury in the Anterior Cruciate Ligament-Deficient Knee. Am J Sports Med 2018; 46:3391-3399. [PMID: 30388039 DOI: 10.1177/0363546518803359] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Previous research demonstrated that the attachment of the anterolateral ligament (ALL) to the lateral meniscus is stiffer and stronger in its tibial attachment than its femoral attachment. How this relates to anterolateral knee stability and lateral meniscal function is unknown. HYPOTHESIS/PURPOSE The hypothesis was that the ALL acts as a peripheral anchor to the lateral meniscus, aiding in anterolateral rotatory stability, and that the inframeniscal fibers of the ALL will provide greater anterolateral rotatory stability because of their greater tensile properties. The purpose was therefore to compare the difference in kinematics of the anterior cruciate ligament (ACL)-deficient knee between the infra- and suprameniscal ALL-sectioned states. STUDY DESIGN Controlled laboratory study. METHODS Eight paired fresh-frozen cadaveric knees were tested in a 5-degree of freedom loading jig under the following loading conditions: 5-N·m internal rotation at 15° incremental angles of flexion and combined 5-N·m internal rotation moment, 10-N·m valgus moment, and 88-N anterior translation force representing a pivot shift test at 0°, 15°, and 30° of flexion. The knees were tested under intact, ACL-deficient, and ACL-/ALL-deficient conditions, with the pairs of knees being randomized to either supra- or inframeniscal ALL sectioning. Resultant joint kinematics and tibiofemoral translations were measured and compared with a 2-way mixed repeated measures analysis of variance. RESULTS Internal rotation increased by 3° after sectioning of the ACL at 0° of knee flexion ( P = .035). At 45° of knee flexion, internal rotation increased significantly by 2° between the ACL-deficient and the ACL-/ALL-deficient conditions ( P = .049). Secondary kinematics of valgus and anterior translation were observed in response to the 5-N·m load after ACL and ALL sectioning. Analysis of the pivot shift showed increases in tibiofemoral translation after sectioning of the ACL, with further translations after sectioning of the ALL. No differences were observed between supra- and inframeniscal ALL sectioning under any of the loading conditions. CONCLUSION An injury to the ALL, coexisting with ACL deficiency, results in only minor increases in knee joint patholaxity. No differences in pivot-shift kinematics or tibiofemoral rotations were observed between the supra- and inframeniscal sectioning of the ALL in the ACL-deficient knee. CLINICAL RELEVANCE Tears of the midbody and/or posterior root attachment of the lateral meniscus are often observed at the time of ACL reconstruction. Increased anterolateral rotatory laxity has been observed in both lateral meniscus- and ALL-deficient states in combination with an ACL injury. While no significant functional relationship was found between the ALL and lateral meniscus, ALL sectioning did result in increased knee joint patholaxity, as demonstrated by composite tibiofemoral rotations.
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Affiliation(s)
- Timothy A Burkhart
- Lawson Health Research Institute/Department of Mechanical and Materials Engineering, Western University, London, Ontario, Canada
| | - Manoj Matthew
- Fowler Kennedy Sports Medicine Clinic, Western University, London, Ontario, Canada
| | - W Scott McGuffin
- Fowler Kennedy Sports Medicine Clinic, Western University, London, Ontario, Canada
| | - Alexandra Blokker
- Department of Mechanical and Materials Engineering, Western University, London, Ontario, Canada
| | - David Holdsworth
- Department of Medical Biophysics, Western University, London, Ontario, Canada
| | - Ryan M Degen
- Fowler Kennedy Sports Medicine Clinic/Department of Surgery, Western University, London, Ontario, Canada
| | - Alan Getgood
- Fowler Kennedy Sports Medicine Clinic/Department of Surgery, Western University, London, Ontario, Canada
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22
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Ariel de Lima D, Helito CP, Lima FRAD, Leite JAD. Indicações cirúrgicas para reconstrução do ligamento cruzado anterior combinada com tenodese extra‐articular lateral ou reconstrução do ligamento anterolateral. Rev Bras Ortop 2018. [DOI: 10.1016/j.rbo.2017.06.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
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23
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Ariel de Lima D, Helito CP, Lima FRAD, Leite JAD. Surgical indications for anterior cruciate ligament reconstruction combined with extra-articular lateral tenodesis or anterolateral ligament reconstruction. Rev Bras Ortop 2018; 53:661-667. [PMID: 30377597 PMCID: PMC6204529 DOI: 10.1016/j.rboe.2018.09.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Accepted: 06/08/2017] [Indexed: 01/13/2023] Open
Abstract
Recently described in the medical literature, the anterolateral ligament of the knee is already considered an important stabilizer against the anterolateral tibial rotation, affecting the pivot shift in the failure of the anterior cruciate ligament and behaving as an important secondary rotational stabilizer. The mechanism of anterolateral ligament injury combined with anterior cruciate ligament injury is similar to the mechanism of anterior cruciate ligament injury alone. Thus, the main objective of the joint reconstruction of anterior cruciate ligament and anterolateral ligament would be increased rotational control and prevention of anterior cruciate ligament re-rupture. In view of this importance, the aim of the present study is to summarize the evidence on the main surgical indications described for anterior cruciate ligament reconstruction combined with lateral extra-articular tenodesis or anterolateral ligament reconstruction. A review of the literature was conducted in April 2017, through a search of the PubMed, MEDLINE, Cochrane, and Google Scholar databases, with no date limits. After reviewing the main articles in the subject, it was concluded that the main surgical indications described for anterior cruciate reconstruction combined with extra-articular lateral tenodesis or anterolateral ligament reconstruction are: anterior cruciate ligament revision, physical examination with pivotal shift grade 2 or 3, practice of sport with pivot mechanism and/or high level mechanism, ligament laxity and Segond fracture; Secondly, the following may also be indications: chronic anterior cruciate ligament injury, age less than 25 years old, and radiological sign of lateral femoral condyle depression. However, it is worth mentioning that more studies are still needed to prove these trends.
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Affiliation(s)
- Diego Ariel de Lima
- Departamento de Ortopedia e Traumatologia, Universidade Federal do Ceará, Fortaleza, CE, Brazil
- Universidade do Estado do Rio Grande do Norte (UERN), Mossoró, RN, Brazil
| | - Camilo Partezani Helito
- Instituto de Ortopedia e Traumatologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
- Hospital Sírio Libanês, São Paulo, SP, Brazil
| | | | - José Alberto Dias Leite
- Departamento de Ortopedia e Traumatologia, Universidade Federal do Ceará, Fortaleza, CE, Brazil
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Olewnik Ł, Gonera B, Kurtys K, Podgórski M, Polguj M, Sibiński M, Topol M. The Anterolateral Ligament of the Knee: A Proposed Classification System. Clin Anat 2018; 31:966-973. [PMID: 30144325 DOI: 10.1002/ca.23267] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 08/08/2018] [Accepted: 08/17/2018] [Indexed: 12/30/2022]
Abstract
The anterolateral ligament (ALL) is a potential stabilizer of the knee and cooperates with the anterior cruciate ligament (ACL). It originates on the lateral epicondyle of the femur, to which it is mainly posterior and proximal; insertion is posterior to Gerdy's tubercle. Its anatomical characteristics vary. Recent publications have focused on morphological variations concerning mainly the femoral and tibial attachments, and on morphometric measurements. Histological and cystochemical examinations have also been performed. Classical anatomical dissection was performed on 111 lower limbs (25 isolated and 86 paired) fixed in 10% formalin. The knee region was dissected using traditional techniques and the morphological features of the ALL were assessed: morphometric measurements and the types of ALL. The ALL was present in 70 individuals (37 woman and 33 men). In 30 cases, it was absent symmetrically, and in 11, it was present on just one side (P = 0.0011). The ALL was morphologically very variable. In type I (the most common form - 64.3%), a single band traveled parallel to the fibular collateral ligament (FCL); in type II the band crossed it. In type III, the origin was located on the lateral epicondyle of the femur and also on the lateral-posterior surface of the joint capsule, and the insertion was in the deep fascia of the leg: this type could be called a capsule. Type IV was characterized by a double ALL, type IIb by ligaments that bifurcated, and type V by the ALL starting directly from the FCL rather than the femoral epicondyle. The ALL is characterized by high morphological variability, both in its femoral and in its tibial attachments and in its course. Clin. Anat. 31:966-973, 2018. © 2018 Wiley Periodicals, Inc.
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Affiliation(s)
- Łukasz Olewnik
- Department of Normal and Clinical Anatomy, Interfaculty Chair of Anatomy and Histology, Medical University of Lodz, Poland
| | - Bartosz Gonera
- Department of Normal and Clinical Anatomy, Interfaculty Chair of Anatomy and Histology, Medical University of Lodz, Poland
| | - Konrad Kurtys
- Department of Normal and Clinical Anatomy, Interfaculty Chair of Anatomy and Histology, Medical University of Lodz, Poland
| | - Michał Podgórski
- Department of Diagnostic Imaging Lodz, Polish Mother's Memorial Hospital Research Institute, Poland
| | - Michał Polguj
- Department of Angiology, Interfaculty Chair of Anatomy and Histology, Medical University of Lodz, Poland
| | - Marcin Sibiński
- Clinic of Orthopaedics and Paediatric Orthopaedics, Medical University of Lodz, Poland
| | - Mirosław Topol
- Department of Normal and Clinical Anatomy, Interfaculty Chair of Anatomy and Histology, Medical University of Lodz, Poland
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25
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Sonnery-Cottet B, Claes S, Blakeney WG, Cavaignac E, Saithna A, Daggett M, Helito CP, Muramatsu K, de Padua VBC, Vieira TD, Canuto S, Ouanezar H, Thaunat M. Anterolateral Ligament: Let's Stick to the Facts! Arthroscopy 2018; 34:2259-2262. [PMID: 30077244 DOI: 10.1016/j.arthro.2018.05.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 05/21/2018] [Indexed: 02/02/2023]
Affiliation(s)
- Bertrand Sonnery-Cottet
- Centre Orthopédique Santy, FIFA Medical Center of Excellence, Groupe Ramsay-Generale de Santé, Lyon, France
| | | | | | - Etienne Cavaignac
- Department of Orthopedic Surgery and Trauma, Hôpital Pierre Paul Riquet, Toulouse, France
| | - Adnan Saithna
- Ormskirk Hospital, Wigan Road, Ormskirk, Lancashire, UK
| | - Matt Daggett
- Kansas City University, Kansas City, Missouri, U.S.A
| | - Camilo Partezani Helito
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | | | - Vitor B C de Padua
- Associaçao Beneficente Hospital Universita rio de Marilia-SP Brazil, Cidade Universita ria, Brazil
| | | | | | - Herve Ouanezar
- Centre Orthopédique Santy, FIFA Medical Center of Excellence, Groupe Ramsay-Generale de Santé, Lyon, France
| | - Mathieu Thaunat
- Centre Orthopédique Santy, FIFA Medical Center of Excellence, Groupe Ramsay-Generale de Santé, Lyon, France
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Lee DW, Lee JH, Kim JN, Moon SG, Kim NR, Kim DH, Kim JG. Evaluation of Anterolateral Ligament Injuries and Concomitant Lesions on Magnetic Resonance Imaging After Acute Anterior Cruciate Ligament Rupture. Arthroscopy 2018; 34:2398-2406. [PMID: 29730210 DOI: 10.1016/j.arthro.2018.02.048] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Revised: 02/17/2018] [Accepted: 02/17/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the prevalence and characteristics of anterolateral ligament (ALL) injuries with a ruptured acute anterior cruciate ligament (ACL) and to analyze the presence of concomitant bone contusions and meniscal lesions. METHODS From March 2015 to March 2017, we retrospectively analyzed 378 patients who underwent primary ACL reconstructions. Using magnetic resonance imaging, we evaluated the presence of ALL injury and concomitant lesions within 3 weeks of the injury. Meniscal tears were also identified on representative arthroscopic images. RESULTS Following the inclusion criteria, we included a total of 275 patients in this study. The mean duration from ACL rupture to magnetic resonance imaging examination was 5.0 ± 6.0 days. We visualized ALL in 98.2% of patients, of whom 64% had ALL injuries (10.9%, 4.7%, and 48.4% were complete ruptures, Segond fracture, and partial ruptures, respectively). We found that ALL injuries were most commonly found in the femoral location. The intra- and interobserver agreement on the severity of ALL injury (κ = 0.83 and 0.81, respectively) and the location of ALL injury (κ = 0.85 and 0.84, respectively) were excellent. The association between ALL injury and lateral meniscal lesions was significant (P = .03). In particular, the proportion of the lateral meniscal posterior horn radial tears was significantly larger in nonintact ALL than in intact ALL (P = .042). The correlation between the severity of ALL injury and the degree of bone contusion at lateral compartments was significant but weak (P < .001). CONCLUSIONS We found that more than half of acute ACL ruptures have ALL injuries. The presence of ALL injury was significantly associated with the presence of lateral meniscal lesions, especially lateral meniscal posterior horn radial tears, or lateral bone contusions. Interestingly, the severity of ALL injury significantly correlated with the degree of lateral bone contusions. LEVEL OF EVIDENCE Level III, diagnostic cross-sectional study.
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Affiliation(s)
- Dhong Won Lee
- Department of Orthopaedic Surgery, KonKuk University Medical Center, Seoul, Republic of Korea
| | - Ji Hwan Lee
- Department of Orthopaedic Surgery, KonKuk University Medical Center, Seoul, Republic of Korea
| | - Ji Nam Kim
- Department of Orthopaedic Surgery, KonKuk University Medical Center, Seoul, Republic of Korea
| | - Sung Gyu Moon
- Department of Radiology, KonKuk University Medical Center, Seoul, Republic of Korea
| | - Na Ra Kim
- Department of Radiology, KonKuk University Medical Center, Seoul, Republic of Korea
| | - Du Han Kim
- Department of Orthopaedic Surgery, KonKuk University Medical Center, Seoul, Republic of Korea
| | - Jin Goo Kim
- Department of Orthopaedic Surgery, KonKuk University Medical Center, Seoul, Republic of Korea.
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Anterolateral Ligament Injury in Knee Dislocations. Arthroscopy 2018; 34:1891-1897. [PMID: 29510889 DOI: 10.1016/j.arthro.2018.01.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Revised: 01/08/2018] [Accepted: 01/12/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study is to describe the prevalence and associated factors of anterolateral ligament (ALL) injury in knee dislocation (KD). METHODS A retrospective review of charts and radiological images was done for patients who underwent multiligamentous knee reconstruction surgery for KD in the authors' institution from May 2008 to December 2016. The inclusion criteria were both genders, skeletally mature, and first dislocation. Previous anterior cruciate ligament injury or surgery were the exclusion criteria. Magnetic resonance imaging was used to describe the ALL injury. The association of ALL injury with other variables related to the injury and the patient's background features was examined. RESULTS Forty-eight patients (49 knees) were included. The mean age of the patients was 32.3 ± 10.6 years. High-energy trauma was the mechanism of dislocation in 28 (57.1%) knees. Thirty-one knees (63.3%) were classified as KD type IV. Forty-five (91.8%) knees had a complete ALL injury, and 3 (6.1%) knees had incomplete ALL injury. Forty (81.6%) knees had a complete ALL injury at the proximal fibers of the ALL, while 23 (46.9%) knees had complete distal ALL injury. None of the 46 (93.9%) knees with lateral collateral ligament injury had normal proximal ALL fibers (P = .012). Injury to the distal fibers of the ALL, as well as overall ALL injury, was not associated with any other variables (P > .05). Moreover, all patients with associated tibial plateau fractures (9; 18.4%) had abnormality of the proximal fibers of the ALL (P = .033). CONCLUSIONS ALL injury is highly prevalent among dislocated knees. Most of the injuries are of high grade and involve the proximal, suprameniscal, fibers of the ligament. LEVEL OF EVIDENCE Level IV, retrospective case series with no comparison group.
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Kraeutler MJ, Welton KL, Chahla J, LaPrade RF, McCarty EC. Current Concepts of the Anterolateral Ligament of the Knee: Anatomy, Biomechanics, and Reconstruction. Am J Sports Med 2018; 46:1235-1242. [PMID: 28426251 DOI: 10.1177/0363546517701920] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
In 1879, Paul Segond described an avulsion fracture (now known as a Segond fracture) at the anterolateral proximal tibia with the presence of a fibrous band at the location of this fracture. Although references to this ligament were occasionally made in the anatomy literature after Segond's discovery, it was not until 2012 that Vincent et al named this ligament what we know it as today, the anterolateral ligament (ALL) of the knee. The ALL originates near the lateral epicondyle of the distal femur and inserts on the proximal tibia near Gerdy's tubercle. The ALL exists as a ligamentous structure that comes under tension during internal rotation at 30°. In the majority of specimens, the ALL can be visualized as a ligamentous structure, whereas in some cases it may only be palpated as bundles of more tense capsular tissue when internal rotation is applied. Biomechanical studies have shown that the ALL functions as a secondary stabilizer to the anterior cruciate ligament (ACL) in resisting anterior tibial translation and internal tibial rotation. These biomechanical studies indicate that concurrent reconstruction of the ACL and ALL results in significantly reduced internal rotation and axial plane tibial translation compared with isolated ACL reconstruction (ACLR) in the presence of ALL deficiency. Clinically, a variety of techniques are available for ALL reconstruction (ALLR). Current graft options include the iliotibial (IT) band, gracilis tendon autograft or allograft, and semitendinosus tendon autograft or allograft. Fixation angle also varies between studies from full knee extension to 60° to 90° of flexion. To date, only 1 modern study has described the clinical outcomes of concomitant ALLR and ACLR: a case series of 92 patients with a minimum 2-year follow-up. Further studies are necessary to define the ideal graft type, location of fixation, and fixation angle for ALLR. Future studies also must be designed in a prospective comparative manner to compare the clinical outcomes of patients undergoing ACLR with ALL reconstruction versus without ALL reconstruction. By discovering the true effect of the ALL, investigators can elucidate the importance of ALLR in the setting of an ACL tear.
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Affiliation(s)
- Matthew J Kraeutler
- University of Colorado School of Medicine, Department of Orthopedics, Aurora, Colorado, USA
| | - K Linnea Welton
- University of Colorado School of Medicine, Department of Orthopedics, Aurora, Colorado, USA
| | - Jorge Chahla
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | - Robert F LaPrade
- Steadman Philippon Research Institute, Vail, Colorado, USA.,The Steadman Clinic, Vail, Colorado, USA
| | - Eric C McCarty
- University of Colorado School of Medicine, Department of Orthopedics, Aurora, Colorado, USA
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Moroz PA, Quick EE, Horner NS, Duong A, Simunovic N, Ayeni OR. What Is the State of the Evidence in Anterolateral Ligament Research? Clin Sports Med 2018; 37:137-159. [DOI: 10.1016/j.csm.2017.07.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Abstract
The anterolateral ligament (ALL) of the knee has gained attention recently for its potential role in rotational stability of the knee, especially in association with anterior cruciate ligament (ACL) injuries. Anatomic studies have characterized the ALL as it runs in an anteroinferior and oblique direction from the lateral distal femur to the anterolateral proximal tibia, although the prevalence and variance of this ligament are not well understood. Magnetic resonance imaging and ultrasound have identified the ligament and linked it with the classically described Segond fracture. While the ALL likely plays a role in rotational stability of the knee, further studies investigating the significance of ALL injuries and the role of ALL reconstruction in combination with ACL reconstruction are warranted.
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Affiliation(s)
- Ronak M Patel
- Department of Orthopaedic Surgery, Washington University in St Louis, Chesterfield, Missouri, USA
| | - Robert H Brophy
- Department of Orthopaedic Surgery, Washington University in St Louis, Chesterfield, Missouri, USA
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Helito CP, Helito PVP. Magnetic Resonance Imaging Analysis of the Anterolateral Complex of the Knee. ACTA ACUST UNITED AC 2017. [DOI: 10.1053/j.oto.2017.02.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Sonnery-Cottet B, Daggett M, Fayard JM, Ferretti A, Helito CP, Lind M, Monaco E, de Pádua VBC, Thaunat M, Wilson A, Zaffagnini S, Zijl J, Claes S. Anterolateral Ligament Expert Group consensus paper on the management of internal rotation and instability of the anterior cruciate ligament - deficient knee. J Orthop Traumatol 2017; 18:91-106. [PMID: 28220268 PMCID: PMC5429259 DOI: 10.1007/s10195-017-0449-8] [Citation(s) in RCA: 149] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Purpose of this paper is to provide an overview of the latest research on the anterolateral ligament (ALL) and present the consensus of the ALL Expert Group on the anatomy, radiographic landmarks, biomechanics, clinical and radiographic diagnosis, lesion classification, surgical technique and clinical outcomes. A consensus on controversial subjects surrounding the ALL and anterolateral knee instability has been established based on the opinion of experts, the latest publications on the subject and an exchange of experiences during the ALL Experts Meeting (November 2015, Lyon, France). The ALL is found deep to the iliotibial band. The femoral origin is just posterior and proximal to the lateral epicondyle; the tibial attachment is 21.6 mm posterior to Gerdy's tubercle and 4-10 mm below the tibial joint line. On a lateral radiographic view the femoral origin is located in the postero-inferior quadrant and the tibial attachment is close to the centre of the proximal tibial plateau. Favourable isometry of an ALL reconstruction is seen when the femoral position is proximal and posterior to the lateral epicondyle, with the ALL being tight upon extension and lax upon flexion. The ALL can be visualised on ultrasound, or on T2-weighted coronal MRI scans with proton density fat-suppressed evaluation. The ALL injury is associated with a Segond fracture, and often occurs in conjunction with acute anterior cruciate ligament (ACL) injury. Recognition and repair of the ALL lesions should be considered to improve the control of rotational stability provided by ACL reconstruction. For high-risk patients, a combined ACL and ALL reconstruction improves rotational control and reduces the rate of re-rupture, without increased postoperative complication rates compared to ACL-only reconstruction. In conclusion this paper provides a contemporary consensus on all studied features of the ALL. The findings warrant future research in order to further test these early observations, with the ultimate goal of improving the long-term outcomes of ACL-injured patients. Level of evidence Level V-Expert opinion.
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Affiliation(s)
- Bertrand Sonnery-Cottet
- Centre Orthopédique Paul Santy, FIFA Medical Center of Excellence, Groupe Ramsay-Generale de Santé, 24 avenue Paul Santy, 69008 Lyon, France
| | | | - Jean-Marie Fayard
- Centre Orthopédique Paul Santy, FIFA Medical Center of Excellence, Groupe Ramsay-Generale de Santé, 24 avenue Paul Santy, 69008 Lyon, France
| | - Andrea Ferretti
- Orthopaedic Unit and Kirk Kilgour Sports Injury Center, Sant’Andrea University Hospital, “Sapienza” University of Rome, Rome, Italy
| | | | - Martin Lind
- Division of Sportstraumatology, Department of Orthopedics, Aarhus University Hospital, Tage Hansens Gade 2, 8000 Aarhus C, Denmark
| | - Edoardo Monaco
- Orthopaedic Unit and Kirk Kilgour Sports Injury Center, Sant’Andrea University Hospital, “Sapienza” University of Rome, Rome, Italy
| | - Vitor Barion Castro de Pádua
- Associação Beneficente Hospital Universitário de Marilia-SP Brazil, Cidade Universitária, Rua Dr Prospero Cecilio Coimbra 80, Marilia, SP 17525-160 Brazil
| | - Mathieu Thaunat
- Centre Orthopédique Paul Santy, FIFA Medical Center of Excellence, Groupe Ramsay-Generale de Santé, 24 avenue Paul Santy, 69008 Lyon, France
| | - Adrian Wilson
- Department of Sport and Exercise, Sport and Exercise Research Centre, University of Winchester, Winchester, SO22 4NR UK
| | - Stefano Zaffagnini
- Dipartimento Rizzoli Sicilia, Ortopedia e Traumatologia, Università di Bologna, SS 113 al km 246, 90011 Bagheria, PA Italy
| | - Jacco Zijl
- St. Antonius Hospital, Soestwetering 1, 3543 AZ Utrecht, The Netherlands
| | - Steven Claes
- Department of Orthopaedic Surgery and Traumatology, AZ Herentals, Herentals, Belgium
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The anterolateral ligament: A cadaveric study in fetuses. Clin Anat 2017; 30:625-634. [DOI: 10.1002/ca.22887] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 04/08/2017] [Indexed: 01/26/2023]
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Helito CP, Helito PVP, Leão RV, Demange MK, Bordalo-Rodrigues M. Anterolateral ligament abnormalities are associated with peripheral ligament and osseous injuries in acute ruptures of the anterior cruciate ligament. Knee Surg Sports Traumatol Arthrosc 2017; 25:1140-1148. [PMID: 28293698 DOI: 10.1007/s00167-017-4498-6] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 02/27/2017] [Indexed: 12/21/2022]
Abstract
PURPOSE Few studies have used MRI to identify the ALL. As it was shown that it is not possible to precisely characterize this ligament in all examination, it is important to identify concomitant lesions that can help in diagnosing ALL abnormalities. It is important to characterise this injury due to its association with anterolateral knee instability. Thus, the present study was performed to determine the frequency of ALL injuries in patients with acute ACL rupture and to analyse its associated knee lesions. METHODS Patients with acute ACL injuries were evaluated by MRI. Among this population, the ALL was classified as non-visualised, injured or normal. The possible abnormalities of the meniscus, collateral ligaments, popliteus tendon, posterior cruciate ligament, Iliotibial band (ITB), anterolateral capsule and osseus injuries were evaluated. The association of an ALL injury with these other knee structures as well as sex and age was calculated. RESULTS Among the 228 knees evaluated, the ALL could not be entirely identified in 61 (26.7%). Of the remaining 167, 66 (39.5%) presented an ALL abnormality and only four (6.1%) were Segond fractures. ALL abnormalities were associated with lesions of the lateral collateral ligament, medial collateral ligament, popliteus tendon, ITB, anterolateral capsule and osseous contusions of the femoral condyle and tibial plateau. No correlation was found with medial meniscus, lateral meniscus and posterior cruciate ligament injuries. There was no association between ALL injuries and gender, and older patients were more likely to present an ALL injury. CONCLUSION ALL injuries are present in approximately 40% of ACL injuries, and a minority of these are Segond fractures. These injuries are associated with peripheral ligament injuries, anterolateral structures lesions and bone contusions, but there is no association with meniscal injuries. Surgeons must be aware of these associations to consider an ALL lesion even if it is not completely clear in imaging evaluation, especially if a high degree of anterolateral instability is present on physical examination. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Camilo Partezani Helito
- Hospital Sírio-Libanês, São Paulo, Brazil. .,Knee Surgery Division, Faculty of Medicine, Institute of Orthopedics and Traumatology, University of São Paulo, São Paulo, Brazil.
| | - Paulo Victor Partezani Helito
- Hospital Sírio-Libanês, São Paulo, Brazil.,Musculoskeletal Radiology Department, Faculty of Medicine, Institute of Orthopedics and Traumatology, University of São Paulo, São Paulo, Brazil
| | | | - Marco Kawamura Demange
- Knee Surgery Division, Faculty of Medicine, Institute of Orthopedics and Traumatology, University of São Paulo, São Paulo, Brazil
| | - Marcelo Bordalo-Rodrigues
- Hospital Sírio-Libanês, São Paulo, Brazil.,Musculoskeletal Radiology Department, Faculty of Medicine, Institute of Orthopedics and Traumatology, University of São Paulo, São Paulo, Brazil
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Corbo G, Norris M, Getgood A, Burkhart TA. The infra-meniscal fibers of the anterolateral ligament are stronger and stiffer than the supra-meniscal fibers despite similar histological characteristics. Knee Surg Sports Traumatol Arthrosc 2017; 25:1078-1085. [PMID: 28124108 DOI: 10.1007/s00167-017-4424-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 01/03/2017] [Indexed: 01/26/2023]
Abstract
PURPOSE The purpose of the current investigation was to characterize biomechanical differences between the supra- and infra-meniscal sections of the anterolateral ligament (ALL). We hypothesized that the supra-meniscal fibers of the ALL would be stronger and stiffer than the infra-meniscal fiber. METHODS Nine cadaveric knee specimens [mean (SD) age = 79 (14.6) years] were dissected to identify the borders of the ALL while maintaining the anatomy of the lateral meniscus. The specimens were randomly assigned to either a supra-meniscal (the ALL below the meniscus was sectioned leaving only the supra-meniscal ALL intact) or an infra-meniscal (the ALL above the meniscus was sectioned leaving only the infra-meniscal attachment intact) group. The specimens were potted into dental cement such that the ALL was pulling laterally on the meniscus when the specimens were secured within an Instron materials testing machine. The specimens were subjected to a tensile failure test at 1 mm/s. The load at failure and stiffness were calculated from the force-displacement curves, while peak stress was calculated by normalizing the peak force to the cross-sectional area of the ALL. Furthermore, one intact knee specimen was used to perform a histological analysis on the two ALL sections using Masson's Trichome staining. RESULTS The infra-meniscal ALL had a significantly (p = 0.03) higher load to failure (195.0 vs. 132.1 N) and was significantly (p = 0.03) stiffer than the supra-meniscal fibers (24.8 vs. 12.3 N/mm). The relatively similar cross-section areas also resulted in the infra-meniscal sections having a greater peak stress (p = 0.04) (11.1 vs. 5.4 MPa). Histological analysis showed relatively consistent fiber orientation with similar organization noted throughout the fibers. CONCLUSIONS The ALL-meniscal construct that includes the infra-meniscal fibers was significantly stronger and stiffer than the construct that includes the supra-meniscal fibers. The infra-meniscal ALL is another important component of the anterolateral complex of the knee, and should be considered when presented with an ACL and/or meniscal injury.
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Affiliation(s)
- Gillian Corbo
- Anatomy and Cell Biology, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Madeleine Norris
- Anatomy and Cell Biology, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Alan Getgood
- Fowler Kennedy Sport Medicine Clinic, 3M Centre, Western University, London, ON, Canada
| | - Timothy A Burkhart
- Department of Surgery, Lawson Health Research Institute, London, ON, Canada.
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Daggett M, Helito C, Cullen M, Ockuly A, Busch K, Granite J, Wright B, Sonnery-Cottet B. The Anterolateral Ligament: An Anatomic Study on Sex-Based Differences. Orthop J Sports Med 2017; 5:2325967116689387. [PMID: 28321423 PMCID: PMC5347435 DOI: 10.1177/2325967116689387] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND The anterolateral ligament (ALL) has been shown to have an important role in rotatory stability of the knee. While there is abundant research on sex-based differences related to anterior cruciate ligament (ACL) rupture, there is a paucity of literature related to such differences in the ALL. PURPOSE To define any sex-based differences in the ALL with regard to length, width, and thickness. STUDY DESIGN Descriptive laboratory study. METHODS The ALL was initially evaluated in 165 unpaired knees (92 males and 65 females after exclusion criteria applied). The length, width, and thickness of the ALL were measured using a digital caliper. Width and thickness were measured at the joint line just superior to the lateral meniscus. The Mann-Whitney test and Student t tests were used to compare measurements between males and females. The Pearson product-moment correlation was subsequently used to determine the correlation between height and weight and the statistically different morphometric variables. RESULTS The mean (±SD) thickness of the ALL in males was 2.09 ± 0.56 mm, almost twice as thick as females (1.05 ± 0.49 mm; P = 8.8 × 10-20). There was also a statistically significant difference in ALL length (P = 3.8 × 10-7), but no significant difference was found for width. A moderate association was found between donor height and ALL thickness and length. CONCLUSION The anatomic measurements of the ALL demonstrate a difference between sexes, and the ALL is significantly thicker in males than females. CLINICAL RELEVANCE As the role of the ALL in rotatory stability of the knee becomes better understood, the difference in the thickness of the ALL we have found between the sexes may be another factor why female athletes have an increased incidence of ACL rupture compared with males. This may also help explain why females have issues with knee laxity and rotatory instability.
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Affiliation(s)
- Matt Daggett
- Kansas City University, Kanas City, Missouri, USA
| | | | | | | | - Kyle Busch
- Kansas City University, Kanas City, Missouri, USA
| | | | - Barth Wright
- Kansas City University, Kanas City, Missouri, USA
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Roessler PP, Schüttler KF, Stein T, Gravius S, Heyse TJ, Prescher A, Wirtz DC, Efe T. Anatomic dissection of the anterolateral ligament (ALL) in paired fresh-frozen cadaveric knee joints. Arch Orthop Trauma Surg 2017; 137:249-255. [PMID: 28005166 DOI: 10.1007/s00402-016-2617-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Indexed: 01/26/2023]
Abstract
INTRODUCTION Different dissection studies as well as comparative studies about the anterolateral ligament of the knee (ALL) already exist and the structure's topology and properties have been shown. However, most of the studies investigating the ligament were performed in embalmed knees, which is thought to change the structural integrity of ligaments and thus the topologic and dynamic measurements. Since the biomechanical function of the ALL is not fully understood until today and a correlation with the pivot shift phenomenon is yet speculative, further studies will have to clarify its definitive importance. Its function as a limiter of internal rotation and lateral meniscal extrusion leads to the assumption of a secondary knee stabilizer. METHODS Twenty paired fresh-frozen cadaveric knees of ten donors have been dissected in a layerwise fashion. After identification of the ALL, topologic measurements were undertaken using a digital caliper. RESULTS The ALL could be identified as a tender, pearly structure in front of the anterolateral joint capsule in only 60% of the dissected knee joints. Only 20% of donors had a bilateral ALL while 80% had an ALL only in one side. Mean length, thickness and width as well as topographic measurements were comparable to other available studies investigating fresh-frozen cadavers. CONCLUSION Anatomy and topography of the ALL seem to be highly variable, but consistent within certain borders. Prevalence has to be argued though as it strongly differs between studies. The impact of an ALL absence, even if only unilateral, needs to be investigated in clinical and imaging studies to finally clarify its importance.
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Affiliation(s)
- Philip P Roessler
- Department of Orthopaedics and Trauma Surgery, University Hospital Bonn, Sigmund-Freud-Straße 25, 53127, Bonn, Germany.
| | - Karl F Schüttler
- Center for Orthopaedics and Trauma Surgery, University Hospital Marburg, Marburg, Germany
| | - Thomas Stein
- Department of Sporttraumatology-Knee- and Shoulder-Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Frankfurt Am Main, Germany.,Department of Sports Science, University of Bielefeld, Bielefeld, Germany
| | - Sascha Gravius
- Department of Orthopaedics and Trauma Surgery, University Hospital Bonn, Sigmund-Freud-Straße 25, 53127, Bonn, Germany
| | - Thomas J Heyse
- Center for Orthopaedics and Trauma Surgery, University Hospital Marburg, Marburg, Germany
| | - Andreas Prescher
- Institute of Molecular and Cellular Anatomy, RWTH Aachen University, Aachen, Germany
| | - Dieter C Wirtz
- Department of Orthopaedics and Trauma Surgery, University Hospital Bonn, Sigmund-Freud-Straße 25, 53127, Bonn, Germany
| | - Turgay Efe
- Center for Orthopaedics and Trauma Surgery, University Hospital Marburg, Marburg, Germany.,Orthopaedicum Lich, Lich, Germany
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Helito CP, Helito PVP, Costa HP, Demange MK, Bordalo-Rodrigues M. Assessment of the Anterolateral Ligament of the Knee by Magnetic Resonance Imaging in Acute Injuries of the Anterior Cruciate Ligament. Arthroscopy 2017; 33:140-146. [PMID: 27324971 DOI: 10.1016/j.arthro.2016.05.009] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 04/29/2016] [Accepted: 05/03/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the epidemiology of injuries and abnormalities of the anterolateral ligament (ALL) by magnetic resonance imaging (MRI) in cases of acute anterior cruciate ligament (ACL) injury. METHODS MRIs of patients with acute ACL injury were evaluated. Acute injuries of the ACL were considered in cases in which the patient reported knee trauma occurring less than 3 weeks prior and when bone bruise in the femoral condyles and tibial plateau was identified. ALL abnormality was considered when it showed proximal or distal bone detachment, discontinuity of fibers, or irregular contour associated with periligamentous edema. The ALL was divided into femoral, tibial, and meniscal portions, and the lesions and/or abnormalities of each portion were characterized. The correlation of ALL injury with injuries of the lateral meniscus was evaluated. RESULTS A total of 101 MRIs were initially evaluated. The ALL was not characterized in 13 (12.8%) examinations, resulting in 88 (87.1%) cases of injury evaluation. Of these, 55 (54.4%) patients had a normal ALL, and 33 (32.6%) showed signs of injury. Among the cases with injury, 24 (72%) patients showed proximal lesions, 7 (21%) showed distal lesions, and 2 (6.0%) patients presented both proximal and distal lesions. The meniscal portion of the ALL appeared abnormal in 16 (48%) patients. No relationship was found between ALL injury and lateral meniscus injury. CONCLUSIONS Based on MRI analysis of acute ACL injuries with bone bruising of the lateral femoral condyle and lateral tibial plateau, approximately a third demonstrated ALL injuries of which the majority was proximal. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Camilo Partezani Helito
- Hospital Sírio-Libanês, São Paulo, Brazil; Knee Surgery Division, Faculty of Medicine, Institute of Orthopedics and Traumatology, University of São Paulo, São Paulo, Brazil.
| | - Paulo Victor Partezani Helito
- Hospital Sírio-Libanês, São Paulo, Brazil; Musculoskeletal Radiology Department, Faculty of Medicine, Institute of Orthopedics and Traumatology, University of São Paulo, São Paulo, Brazil
| | - Hugo Pereira Costa
- Hospital Sírio-Libanês, São Paulo, Brazil; Musculoskeletal Radiology Department, Faculty of Medicine, Institute of Orthopedics and Traumatology, University of São Paulo, São Paulo, Brazil
| | - Marco Kawamura Demange
- Knee Surgery Division, Faculty of Medicine, Institute of Orthopedics and Traumatology, University of São Paulo, São Paulo, Brazil
| | - Marcelo Bordalo-Rodrigues
- Hospital Sírio-Libanês, São Paulo, Brazil; Musculoskeletal Radiology Department, Faculty of Medicine, Institute of Orthopedics and Traumatology, University of São Paulo, São Paulo, Brazil
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Helito CP, do Prado Torres JA, Bonadio MB, Aragão JA, de Oliveira LN, Natalino RJM, Pécora JR, Camanho GL, Demange MK. Anterolateral Ligament of the Fetal Knee: An Anatomic and Histological Study. Am J Sports Med 2017; 45:91-96. [PMID: 27624543 DOI: 10.1177/0363546516664888] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The anterolateral ligament (ALL) of the knee has recently been described in detail. Most studies of the ALL have been conducted in adults; therefore, little is known about the anatomy and histology of the ALL in younger patients, and nothing is known about the fetal presence of the ALL. PURPOSE To evaluate the ALL in human fetuses to determine its presence or absence and to describe its microscopic anatomy and histological features compared with the findings of studies conducted in adults. STUDY DESIGN Descriptive laboratory study. METHODS Twenty human fetal cadaveric specimens were used. The mean age of the fetuses was 28.64 ± 3.20 weeks. The ALL was dissected in the anterolateral region of the knee, and its anatomic parameters, including its origin, insertion, and path in relation to known adjacent anatomic landmarks, in addition to its length, width, and thickness over the path toward the tibia, were measured. After dissection, the ALL was removed en bloc with a portion of the lateral meniscus for histological analysis of 4-μm sections, hematoxylin and eosin staining, and immunohistochemical staining for type I collagen. RESULTS The ALL was located in all dissected knees. Its origin was located at a mean distance of 1.87 mm from the origin of the lateral collateral ligament, with variations from the center of the lateral epicondyle to posterior and proximal to it, and it exhibited an anterior-inferior path toward the tibia, an insertion in the lateral meniscus approximately 2.08 mm anterior to the popliteal tendon, and another insertion in the tibia between the Gerdy tubercle and the fibular head at 2.46 mm below the articular cartilage. The histological sections of the ALL showed well-organized, dense collagenous tissue fibers with elongated fibroblasts (mean, 1631 fibroblasts/mm2) and a predominance of type I collagen. CONCLUSION The ALL is present during fetal development, with anatomic and histological features similar to those of the adult ALL. CLINICAL RELEVANCE The findings of this study help to better understand the ALL's anatomy and histology from the fetal period to adulthood. The study presents the existence of the ALL since fetal development, emphasizes the characterization of the ALL, and brings important information to future pediatric ALL lesion studies.
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Helito CP, do Amaral C, Nakamichi YDC, Gobbi RG, Bonadio MB, Natalino RJM, Pécora JR, Cardoso TP, Camanho GL, Demange MK. Why Do Authors Differ With Regard to the Femoral and Meniscal Anatomic Parameters of the Knee Anterolateral Ligament?: Dissection by Layers and a Description of Its Superficial and Deep Layers. Orthop J Sports Med 2016; 4:2325967116675604. [PMID: 28203587 PMCID: PMC5298406 DOI: 10.1177/2325967116675604] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background: No consensus exists regarding the anatomic characteristics of the knee anterolateral ligament (ALL). A critical analysis of the dissections described in previous studies allows the division of the ALL into 2 groups with similar characteristics. The presence of considerable variability suggests that the authors may not be referring to the same structure. Purpose/Hypothesis: To perform a lateral anatomic dissection, by layers, seeking to characterize the 2 variants described for the ALL on the same knee. We hypothesized that we would identify the 2 variants described for the ALL and that these variants would have distinct characteristics. Study Design: Descriptive laboratory study. Methods: Thirteen unpaired cadaveric knees were used in this study. The dissection protocol followed the parameters described in previous studies. Immediately below the iliotibial tract, we isolated a structure designated as the superficial ALL, whereas between this structure and the articular capsule, we isolated a structure designated as the deep ALL. The 2 structures were measured for length at full extension and at 90° of flexion and for distance from the tibial insertion relative to the Gerdy tubercle. Potential contact with the lateral meniscus was also evaluated. After measurements were obtained, the 2 dissected structures underwent histologic analysis. Results: The superficial ALL presented a posterior and proximal origin to the center of the lateral epicondyle, its length increased on knee extension, and it exhibited no contact with the lateral meniscus. The deep ALL was located in the center of the lateral epicondyle, its length increased on knee flexion, and it presented a meniscal insertion. Both structures had a similar tibial insertion site; however, the insertion site of the deep ALL was located more posteriorly. The analysis of the histological sections for both structures indicated the presence of dense and well-organized collagen fibers. Conclusion: This anatomic study clearly identified 2 structures, described as the superficial and deep ALL, which were consistent with previous but conflicting descriptions of the ALL. Clinical Relevance: This study clarifies numerous controversies encountered in anatomic studies of the ALL. Knowledge regarding the existence of 2 distinct structures in the anterolateral knee will allow more accurate evaluation of their functions and characteristics.
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Affiliation(s)
- Camilo Partezani Helito
- Knee Surgery Division, Department of Orthopaedics and Traumatology, Institute of Orthopedics and Traumatology-Hospital and Clinics, Faculty of Medicine, University of São Paulo (IOT-HCFMUSP), São Paulo, Brazil
| | - Carlos do Amaral
- Department of Orthopaedic Surgery, Catholic University of São Paulo, Sorocaba, São Paulo, Brazil
| | - Yuri da Cunha Nakamichi
- Department of Orthopaedic Surgery, Catholic University of São Paulo, Sorocaba, São Paulo, Brazil
| | - Riccardo Gomes Gobbi
- Knee Surgery Division, Department of Orthopaedics and Traumatology, Institute of Orthopedics and Traumatology-Hospital and Clinics, Faculty of Medicine, University of São Paulo (IOT-HCFMUSP), São Paulo, Brazil
| | - Marcelo Batista Bonadio
- Knee Surgery Division, Department of Orthopaedics and Traumatology, Institute of Orthopedics and Traumatology-Hospital and Clinics, Faculty of Medicine, University of São Paulo (IOT-HCFMUSP), São Paulo, Brazil
| | - Renato José Mendonça Natalino
- Knee Surgery Division, Department of Orthopaedics and Traumatology, Institute of Orthopedics and Traumatology-Hospital and Clinics, Faculty of Medicine, University of São Paulo (IOT-HCFMUSP), São Paulo, Brazil
| | - José Ricardo Pécora
- Knee Surgery Division, Department of Orthopaedics and Traumatology, Institute of Orthopedics and Traumatology-Hospital and Clinics, Faculty of Medicine, University of São Paulo (IOT-HCFMUSP), São Paulo, Brazil
| | - Tulio Pereira Cardoso
- Department of Orthopaedic Surgery, Catholic University of São Paulo, Sorocaba, São Paulo, Brazil
| | - Gilberto Luis Camanho
- Knee Surgery Division, Department of Orthopaedics and Traumatology, Institute of Orthopedics and Traumatology-Hospital and Clinics, Faculty of Medicine, University of São Paulo (IOT-HCFMUSP), São Paulo, Brazil
| | - Marco Kawamura Demange
- Knee Surgery Division, Department of Orthopaedics and Traumatology, Institute of Orthopedics and Traumatology-Hospital and Clinics, Faculty of Medicine, University of São Paulo (IOT-HCFMUSP), São Paulo, Brazil
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Sonnery-Cottet B, Daggett M, Helito CP, Fayard JM, Thaunat M. Combined Anterior Cruciate Ligament and Anterolateral Ligament Reconstruction. Arthrosc Tech 2016; 5:e1253-e1259. [PMID: 28149722 PMCID: PMC5263705 DOI: 10.1016/j.eats.2016.08.003] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 08/02/2016] [Indexed: 02/03/2023] Open
Abstract
Despite technologic advances in the surgical technique for anterior cruciate ligament (ACL) reconstruction, some patients continue to have rotational instability postoperatively. Recently, authors have reported the anatomic and functional characteristics of the anterolateral ligament (ALL), a structure that originates near the lateral epicondyle on the femur and inserts on the tibia between the Gerdy tubercle and the fibular head. Recent biomechanical studies have shown the ALL is an important stabilizer against anterolateral tibial rotation, and its reconstruction has shown excellent initial clinical results. Several techniques have been developed to try to anatomically address this structure in the setting of an ACL reconstruction. This article details a simple anatomic technique to reconstruct the ACL and the ALL of the knee using hamstring tendon autograft and maintaining the semitendinosus insertion.
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Affiliation(s)
- Bertrand Sonnery-Cottet
- Centre Orthopédique Santy, FIFA Medical Center of Excellence, Group Ramsay-Générale de Santé, Lyon, France,Address correspondence to Bertrand Sonnery-Cottet, M.D., Centre Orthopédique Santy, 24 Avenue Paul Santy, F-69008 Lyon, France.Centre Orthopédique Santy24 Avenue Paul SantyF-69008 LyonFrance
| | - Matt Daggett
- Kansas City University, Kansas City, Missouri, U.S.A
| | | | - Jean-Marie Fayard
- Centre Orthopédique Santy, FIFA Medical Center of Excellence, Group Ramsay-Générale de Santé, Lyon, France
| | - Mathieu Thaunat
- Centre Orthopédique Santy, FIFA Medical Center of Excellence, Group Ramsay-Générale de Santé, Lyon, France
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Musahl V, Karlsson J, Zaffagnini S, Fu FH. Authors' Reply. Arthroscopy 2016; 32:1741-4. [PMID: 27594325 DOI: 10.1016/j.arthro.2016.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 07/06/2016] [Indexed: 02/02/2023]
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Wascher DC, Lording TD, Neyret P. Extra-articular procedures for the ACL-deficient knee: a state of the art review. J ISAKOS 2016. [DOI: 10.1136/jisakos-2016-000053] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Helito CP, Bonadio MB, Rozas JS, Wey JMP, Pereira CAM, Cardoso TP, Pécora JR, Camanho GL, Demange MK. Biomechanical study of strength and stiffness of the knee anterolateral ligament. BMC Musculoskelet Disord 2016; 17:193. [PMID: 27129387 PMCID: PMC4851806 DOI: 10.1186/s12891-016-1052-5] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Accepted: 04/26/2016] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Recent studies clearly characterize the anatomical parameters of the knee anterolateral ligament (ALL). The potential clinical importance of this ligament is exemplified by some patients with possible combined Anterior Cruciate Ligament (ACL) and ALL rupture who do not progress satisfactorily following isolated ACL reconstruction. Previous biomechanical studies have assessed the resistance parameters of the ALL in order to address potential reconstruction strategies; however, these have reported conflicting results. Thus, this study aimed to evaluate the linear resistance of the ALL by means of a biomechanical study in cadaveric knees. METHODS Fourteen cadaveric knees were used. The ALL was dissected, and all structures that connect the femur and the tibia, except for the ALL, were sectioned. The ALL was subjected to a tensile test with the knee around 30 to 40 degrees, in a way that the ALL was aligned with the machine. The strength at the maximum resistance limit, deformation and stiffness of the ALL were evaluated. RESULTS The mean maximum strength of the ALL was 204.8 +/- 114.9 N. The stiffness was 41.9 +/- 25.7 N/mm and the deformation 10.3 +/- 3.5 mm. CONCLUSION The ALL has a mean ultimate tensile strength of 204.8 N. This suggests that simple bands of all autologous or homologous grafts commonly used in clinical practice for ligament reconstruction around the knee possess the required biomechanical resistance characteristics for ALL reconstruction.
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Affiliation(s)
- Camilo Partezani Helito
- Knee Surgery Division, Department of Orthopaedics and Traumatology, Institute of Orthopedics and Traumatology-Hospital and Clinics, Faculty of Medicine, University of São Paulo (IOT-HCFMUSP), São Paulo, Brazil.
- , Rua Dr. Ovídio Pires de Campos, 333, Cerqueira Cesar, São Paulo SP, CEP: 05403-010, Brazil.
| | - Marcelo Batista Bonadio
- Knee Surgery Division, Department of Orthopaedics and Traumatology, Institute of Orthopedics and Traumatology-Hospital and Clinics, Faculty of Medicine, University of São Paulo (IOT-HCFMUSP), São Paulo, Brazil
| | - João Stefan Rozas
- Department of Orthopaedic Surgery, Catholic University of São Paulo, Sorocaba, São Paulo, Brazil
| | - João Marcelo Pedroso Wey
- Department of Orthopaedic Surgery, Catholic University of São Paulo, Sorocaba, São Paulo, Brazil
| | - Cesar Augusto Martins Pereira
- Biomechanical Laboratory Division, Department of Orthopaedics and Traumatology, Institute of Orthopedics and Traumatology-Hospital and Clinics, Faculty of Medicine, University of São Paulo (IOT-HCFMUSP), São Paulo, Brazil
| | - Tulio Pereira Cardoso
- Department of Orthopaedic Surgery, Catholic University of São Paulo, Sorocaba, São Paulo, Brazil
| | - José Ricardo Pécora
- Knee Surgery Division, Department of Orthopaedics and Traumatology, Institute of Orthopedics and Traumatology-Hospital and Clinics, Faculty of Medicine, University of São Paulo (IOT-HCFMUSP), São Paulo, Brazil
| | - Gilberto Luis Camanho
- Knee Surgery Division, Department of Orthopaedics and Traumatology, Institute of Orthopedics and Traumatology-Hospital and Clinics, Faculty of Medicine, University of São Paulo (IOT-HCFMUSP), São Paulo, Brazil
| | - Marco Kawamura Demange
- Knee Surgery Division, Department of Orthopaedics and Traumatology, Institute of Orthopedics and Traumatology-Hospital and Clinics, Faculty of Medicine, University of São Paulo (IOT-HCFMUSP), São Paulo, Brazil
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Helito CP, Helito PVP, Bonadio MB, Pécora JR, Bordalo-Rodrigues M, Camanho GL, Demange MK. Correlation of Magnetic Resonance Imaging With Knee Anterolateral Ligament Anatomy: A Cadaveric Study. Orthop J Sports Med 2015; 3:2325967115621024. [PMID: 26779553 PMCID: PMC4710116 DOI: 10.1177/2325967115621024] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Anatomic and magnetic resonance imaging (MRI) studies have recently characterized the knee anterolateral ligament (ALL). So far, no study has focused on confirming whether the evaluated MRI parameters truly correspond with ALL anatomy. PURPOSE To assess the validity of MRI in detecting the ALL using an anatomic evaluation as reference. STUDY DESIGN Descriptive laboratory study. METHODS A total of 13 cadaveric knees were subjected to MRI and then to anatomic dissection. Dissection was performed according to previous anatomic study methodology. MRIs were performed with a 0.6- to 1.5-mm slice thickness and prior saline injection. The following variables were analyzed: distance from the origin of the ALL to the origin of the lateral collateral ligament (LCL), distance from the origin of the ALL to its bifurcation point, maximum length of the ALL, distance from the tibial insertion of the ALL to the articular surface of the tibia, ALL thickness, and ALL width. The 2 sets of measurements were analyzed using the Spearman correlation coefficient (ρ) and Bland-Altman plots. RESULTS The ALL was clearly observed in all dissected knees and MRI scans. It originated anterior and distal to the LCL, close to the lateral epycondile center, and showed an anteroinferior path toward the tibia, inserting between the Gerdy tubercle and the fibular head, around 5 mm under the lateral plateau. The ρ values tended to increase together for all studied variables between the 2 methods, and all were statistically significant, except for thickness (P = .077). Bland-Altman plots showed a tendency toward a reduction of ALL thickness and width by MRI compared with anatomic dissection. CONCLUSION MRI scanning as described can accurately assess the ALL and demonstrates characteristics similar to those seen under anatomic dissection. CLINICAL RELEVANCE MRI can accurately characterize the ALL in the anterolateral region of the knee, despite the presence of structures that might overlap and thus cause confusion when making assessments based on imaging methods.
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Affiliation(s)
- Camilo Partezani Helito
- Department of Orthopaedics and Traumatology, Knee Surgery Division, Institute of Orthopedics and Traumatology–Hospital and Clinics, Faculty of Medicine, University of São Paulo (IOT\-HCFMUSP), São Paulo, Brazil
| | - Paulo Victor Partezani Helito
- Department of Orthopaedics and Traumatology, Musculoskeletal Radiology Division, Institute of Orthopedics and Traumatology–Hospital and Clinics, Faculty of Medicine, University of São Paulo (IOT\-HCFMUSP), São Paulo, Brazil
| | - Marcelo Batista Bonadio
- Department of Orthopaedics and Traumatology, Knee Surgery Division, Institute of Orthopedics and Traumatology–Hospital and Clinics, Faculty of Medicine, University of São Paulo (IOT\-HCFMUSP), São Paulo, Brazil
| | - José Ricardo Pécora
- Department of Orthopaedics and Traumatology, Knee Surgery Division, Institute of Orthopedics and Traumatology–Hospital and Clinics, Faculty of Medicine, University of São Paulo (IOT\-HCFMUSP), São Paulo, Brazil
| | - Marcelo Bordalo-Rodrigues
- Department of Orthopaedics and Traumatology, Musculoskeletal Radiology Division, Institute of Orthopedics and Traumatology–Hospital and Clinics, Faculty of Medicine, University of São Paulo (IOT\-HCFMUSP), São Paulo, Brazil
| | - Gilberto Luis Camanho
- Department of Orthopaedics and Traumatology, Knee Surgery Division, Institute of Orthopedics and Traumatology–Hospital and Clinics, Faculty of Medicine, University of São Paulo (IOT\-HCFMUSP), São Paulo, Brazil
| | - Marco Kawamura Demange
- Department of Orthopaedics and Traumatology, Knee Surgery Division, Institute of Orthopedics and Traumatology–Hospital and Clinics, Faculty of Medicine, University of São Paulo (IOT\-HCFMUSP), São Paulo, Brazil
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Macchi V, Porzionato A, Morra A, Stecco C, Tortorella C, Menegolo M, Grignon B, De Caro R. The anterolateral ligament of the knee: a radiologic and histotopographic study. Surg Radiol Anat 2015; 38:341-8. [DOI: 10.1007/s00276-015-1566-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 10/05/2015] [Indexed: 12/11/2022]
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