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Alzouhayli K, Schilaty ND, Wei Y, Hooke AW, Sellon JL, Bates NA. Shear wave elastography demonstrates different material properties between the medial collateral ligament and anterolateral ligament. Clin Biomech (Bristol, Avon) 2024; 111:106155. [PMID: 38043170 PMCID: PMC10872362 DOI: 10.1016/j.clinbiomech.2023.106155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 11/17/2023] [Accepted: 11/21/2023] [Indexed: 12/05/2023]
Abstract
BACKGROUND Anterolateral ligament and medial collateral ligament injuries could happen concomitantly with anterior cruciate ligament ruptures. The anterolateral ligament is injured more often than the medial collateral ligament during concomitant anterior cruciate ligament ruptures although it offers less restraint to knee movement. Comparing the material properties of the medial collateral ligament and anterolateral ligament helps improve our understanding of their structure-function relationship and injury risk before the onset of injury. METHODS Eight cadaveric lower extremity specimens were prepared and mechanically tested to failure in a laboratory setting using a hydraulic platform. Measurements of surface strains of superficial surface of each medial collateral ligament and anterolateral ligament specimen were found using three-dimensional digital image correlation. Ligament stiffness was found using ultrasound shear-wave elastography. t-tests were used to assess for significant differences in strain, stress, Young's modulus, and stiffness in the two ligaments. FINDINGS The medial collateral ligament exhibited greater ultimate failure strain along its longitudinal axis (p = 0.03) and Young's modulus (p < 0.0018) than the anterolateral ligament. Conversely, the anterolateral ligament exhibited greater ultimate failure stress than the medial collateral ligament (p < 0.0001). Medial collateral ligament failure occurred mostly in the proximal aspect of the ligament, while most anterolateral ligament failure occurred in the distal or midsubstance aspect (P = 0.04). INTERPRETATION Despite both being ligamentous structures, the medial collateral ligament and anterolateral ligament exhibited separate material properties during ultimate failure testing. The weaker material properties of the anterolateral ligament likely contribute to higher rates of concomitant injury with anterior cruciate ligament ruptures.
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Affiliation(s)
- Kenan Alzouhayli
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, USA; The Ohio State University College of Medicine, Columbus, OH, USA
| | - Nathan D Schilaty
- University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Yi Wei
- Ohio University Heritage College of Osteopathic Medicine, Dublin, OH, USA
| | | | - Jacob L Sellon
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Nathaniel A Bates
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
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Kriener K, Whiting H, Storr N, Homes R, Lala R, Gabrielyan R, Kuang J, Rubin B, Frails E, Sandstrom H, Futter C, Midwinter M. Applied use of biomechanical measurements from human tissues for the development of medical skills trainers: a scoping review. JBI Evid Synth 2023; 21:2309-2405. [PMID: 37732940 DOI: 10.11124/jbies-22-00363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
OBJECTIVE The objective of this review was to identify quantitative biomechanical measurements of human tissues, the methods for obtaining these measurements, and the primary motivations for conducting biomechanical research. INTRODUCTION Medical skills trainers are a safe and useful tool for clinicians to use when learning or practicing medical procedures. The haptic fidelity of these devices is often poor, which may be because the synthetic materials chosen for these devices do not have the same mechanical properties as human tissues. This review investigates a heterogeneous body of literature to identify which biomechanical properties are available for human tissues, the methods for obtaining these values, and the primary motivations behind conducting biomechanical tests. INCLUSION CRITERIA Studies containing quantitative measurements of the biomechanical properties of human tissues were included. Studies that primarily focused on dynamic and fluid mechanical properties were excluded. Additionally, studies only containing animal, in silico , or synthetic materials were excluded from this review. METHODS This scoping review followed the JBI methodology for scoping reviews and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Sources of evidence were extracted from CINAHL (EBSCO), IEEE Xplore, MEDLINE (PubMed), Scopus, and engineering conference proceedings. The search was limited to the English language. Two independent reviewers screened titles and abstracts as well as full-text reviews. Any conflicts that arose during screening and full-text review were mediated by a third reviewer. Data extraction was conducted by 2 independent reviewers and discrepancies were mediated through discussion. The results are presented in tabular, figure, and narrative formats. RESULTS Data were extracted from a total of 186 full-text publications. All of the studies, except for 1, were experimental. Included studies came from 33 countries, with the majority coming from the United States. Ex vivo methods were the predominant approach for extracting human tissue samples, and the most commonly studied tissue type was musculoskeletal. In this study, nearly 200 unique biomechanical values were reported, and the most commonly reported value was Young's (elastic) modulus. The most common type of mechanical test performed was tensile testing, and the most common reason for testing human tissues was to characterize biomechanical properties. Although the number of published studies on biomechanical properties of human tissues has increased over the past 20 years, there are many gaps in the literature. Of the 186 included studies, only 7 used human tissues for the design or validation of medical skills training devices. Furthermore, in studies where biomechanical values for human tissues have been obtained, a lack of standardization in engineering assumptions, methodologies, and tissue preparation may implicate the usefulness of these values. CONCLUSIONS This review is the first of its kind to give a broad overview of the biomechanics of human tissues in the published literature. With respect to high-fidelity haptics, there is a large gap in the published literature. Even in instances where biomechanical values are available, comparing or using these values is difficult. This is likely due to the lack of standardization in engineering assumptions, testing methodology, and reporting of the results. It is recommended that journals and experts in engineering fields conduct further research to investigate the feasibility of implementing reporting standards. REVIEW REGISTRATION Open Science Framework https://osf.io/fgb34.
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Affiliation(s)
- Kyleigh Kriener
- School of Biomedical Sciences, The University of Queensland, Brisbane, QLD, Australia
| | - Harrison Whiting
- Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
- School of Clinical Medicine, Royal Brisbane Clinical Unit, The University of Queensland, Brisbane, QLD, Australia
| | - Nicholas Storr
- Gold Coast University Hospital, Southport, QLD Australia
| | - Ryan Homes
- School of Biomedical Sciences, The University of Queensland, Brisbane, QLD, Australia
| | - Raushan Lala
- School of Biomedical Sciences, The University of Queensland, Brisbane, QLD, Australia
| | - Robert Gabrielyan
- School of Biomedical Sciences, The University of Queensland, Brisbane, QLD, Australia
- Ochsner Clinical School, Jefferson, LA, United States
| | - Jasmine Kuang
- School of Biomedical Sciences, The University of Queensland, Brisbane, QLD, Australia
- Ochsner Clinical School, Jefferson, LA, United States
| | - Bryn Rubin
- School of Biomedical Sciences, The University of Queensland, Brisbane, QLD, Australia
- Ochsner Clinical School, Jefferson, LA, United States
| | - Edward Frails
- Department of Chemical Engineering, Georgia Institute of Technology, Atlanta, GA, United States
| | - Hannah Sandstrom
- Department of Exercise Science and Sport Management, Kennesaw State University, Kennesaw, GA, United States
| | - Christopher Futter
- Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
- Anaesthesia and Intensive Care Program, Herston Biofabrication institute, Brisbane, QLD, Australia
| | - Mark Midwinter
- School of Biomedical Sciences, The University of Queensland, Brisbane, QLD, Australia
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Hopper GP, Gousopoulos L, Ouanezar H, Walch A, Dijoud F, Vieira TD, Helito CP, Sonnery-Cottet B. Technique for Surgical Dissection and Histological Investigation of the Anterolateral Ligament in the Fetal Knee. Arthrosc Tech 2023; 12:e837-e841. [PMID: 37424652 PMCID: PMC10323693 DOI: 10.1016/j.eats.2023.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 02/11/2023] [Indexed: 07/11/2023] Open
Abstract
There is growing evidence into the structure and function of the anterolateral ligament (ALL) of the knee. However, debate still exists about the anatomical characteristics, biomechanical role, and even the existence of the ALL, despite numerous cadaveric, biomechanical, and clinical studies. This article describes, with video illustration, the surgical dissection of the ALL in human fetal lower limbs, including determination of detailed anatomical and histological features of the ALL during fetal development. The ALL was clearly identified in dissected fetal knees, and histologic analysis shows well-organized, dense collagenous tissue fibers with elongated fibroblasts, consistent with the properties of a ligament.
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Affiliation(s)
- Graeme P. Hopper
- NHS Lanarkshire University Hospitals, Glasgow, Scotland
- Centre Orthopédique Santy, FIFA Medical Centre of Excellence, Groupe Ramsay-Générale de Santé, Hopital Privé Jean Mermoz, Lyon, France
| | - Lampros Gousopoulos
- Centre Orthopédique Santy, FIFA Medical Centre of Excellence, Groupe Ramsay-Générale de Santé, Hopital Privé Jean Mermoz, Lyon, France
| | | | - Arnaud Walch
- Centre Orthopédique Santy, FIFA Medical Centre of Excellence, Groupe Ramsay-Générale de Santé, Hopital Privé Jean Mermoz, Lyon, France
| | - Frederique Dijoud
- Laboratoire d'Anatomopathologie, Centre de Biologie et Pathologie Est, Hospices Civils de Lyon, Bron, France
| | - Thais Dutra Vieira
- Centre Orthopédique Santy, FIFA Medical Centre of Excellence, Groupe Ramsay-Générale de Santé, Hopital Privé Jean Mermoz, Lyon, France
| | - Camilo P. Helito
- Knee Surgery Division, University of São Paulo, São Paulo, Brazil
| | - Bertrand Sonnery-Cottet
- Centre Orthopédique Santy, FIFA Medical Centre of Excellence, Groupe Ramsay-Générale de Santé, Hopital Privé Jean Mermoz, Lyon, France
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Taylan O, Slane J, van Beek N, Dandois F, Scheys L, Claes S. Characterizing the viscoelastic properties of the anterolateral ligament and grafts commonly used in its reconstruction. Clin Biomech (Bristol, Avon) 2023; 104:105949. [PMID: 37018954 DOI: 10.1016/j.clinbiomech.2023.105949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 03/07/2023] [Accepted: 03/27/2023] [Indexed: 04/07/2023]
Abstract
BACKGROUND Current anatomic anterolateral ligament reconstruction is typically performed using either a gracilis tendon or an iliotibial band graft based on their quasi-static behavior. However, there is limited knowledge about their viscoelastic behaviors. This study aimed to characterize the viscoelastic properties of the anterolateral ligament, distal iliotibial band, distal gracilis tendon and proximal gracilis tendon for graft material choice in anterolateral ligament reconstruction. METHODS All the tissues were harvested from thirteen fresh-frozen cadaveric knees and subjected to preconditioning (3-6 MPa), sinusoidal cycle (1.2-12 MPa), dwell at constant load (12 MPa), and load to failure (3%/s). The quasi-static and viscoelastic properties of the soft tissues were computed and compared using a linear mixed model (p < 0.05). FINDINGS The hysteresis of anterolateral ligament (mean:0.4 Nm) was comparable with gracilis halves (p > 0.85) but iliotibial band (6 Nm) was significantly higher (p < 0.001,ES = 6.5). In contrast, the dynamic creep of anterolateral ligament (0.5 mm) was similar to iliotibial band (0.7 mm, p > 0.82) whereas both gracilis halves were significantly lower (p < 0.007,ES > 1.4). The elastic modulus of anterolateral ligament (181.4 MPa, p < 0.001,ES > 2.1) was the lowest compared to the grafts materials (distal gracilis tendon:835 MPa, distal gracilis tendon:726 MPa, iliotibial band:910 MPa). Additionally, the failure load of the anterolateral ligament (124.5 N, p < 0.001,ES > 2.9) was also the lowest. INTERPRETATION The mechanical properties of the gracilis halves and iliotibial band were significantly different from anterolateral ligament, except for hysteresis and dynamic creep, respectively. Our findings showed that the gracilis halves may be a more appropriate graft choice for anterolateral ligament reconstruction due to its low energy dissipation and permanent deformation under dynamic loads.
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Affiliation(s)
- Orçun Taylan
- Institute for Orthopaedic Research and Training (IORT), KU Leuven, Leuven, Belgium; FIBEr, KU Leuven Core Facility for Biomechanical Experimentation, KU Leuven, Leuven, Belgium.
| | - Josh Slane
- Institute for Orthopaedic Research and Training (IORT), KU Leuven, Leuven, Belgium
| | - Nathalie van Beek
- Department of Orthopaedic Surgery, AZ St Elisabeth, Herentals, Belgium
| | - Félix Dandois
- Institute for Orthopaedic Research and Training (IORT), KU Leuven, Leuven, Belgium
| | - Lennart Scheys
- Institute for Orthopaedic Research and Training (IORT), KU Leuven, Leuven, Belgium; FIBEr, KU Leuven Core Facility for Biomechanical Experimentation, KU Leuven, Leuven, Belgium; Division of Orthopedics, University Hospitals Leuven, Leuven, Belgium
| | - Steven Claes
- Department of Orthopaedic Surgery, AZ St Elisabeth, Herentals, Belgium
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5
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Devitt BM, Neri T, Fritsch BA. Combined anterolateral complex and anterior cruciate ligament injury: Anatomy, biomechanics, and management-State-of-the-art. J ISAKOS 2023; 8:37-46. [PMID: 36368633 DOI: 10.1016/j.jisako.2022.10.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 10/06/2022] [Accepted: 10/25/2022] [Indexed: 11/11/2022]
Abstract
Anterior cruciate ligament (ACL) rupture typically occurs because of sudden axial loading of the knee in conjunction with a coupled valgus and rotational moment about the tibia. However, the ACL is not the only structure damaged during this mechanism of injury, and studies have shown that the anterolateral complex (ALC) of the knee is also commonly involved. Biomechanical studies have established that the ALC plays an important role as a secondary stabiliser to control anterolateral rotatory laxity (ALRL). Indeed, it has been suggested that failure to address injury to the ALC at the time of ACL reconstruction (ACLR) may increase the risk of graft failure owing to persistent ALRL. The concept of combining a lateral extra-articular procedure to augment ACLR for the treatment of ACL injury emerged with a view to decrease the failure rate of either procedure in isolation. This state-of-the-art review discusses the history of the anatomy of the ALC, the biomechanics of a variety of lateral extra-articular augmentation procedures, and provides clinical guidelines for their use in primary ACLR.
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Affiliation(s)
- Brian M Devitt
- Dublin City University, School of Health and Human Performance & Sports Surgery Clinic, Dublin, D09 C523, Ireland.
| | - Thomas Neri
- Department of Orthopaedic Surgery, University Hospital of Saint-Etienne, University of Lyon - Jean Monnet, 42000, France
| | - Brett A Fritsch
- Sydney Orthopaedic Research Institute, Level 1, The Gallery, 445 Victoria Avenue, Chatswood, NSW 2067, Australia
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Patel RM, Castile RM, Jenkins MJ, Lake SP, Brophy RH. Microstructural and Mechanical Properties of the Anterolateral Ligament of the Knee. Am J Sports Med 2021; 49:172-182. [PMID: 33381993 DOI: 10.1177/0363546520974381] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The variable anatomy and controversy of the anterolateral ligament (ALL) reflect the complex relationship among the anterolateral knee structures. PURPOSE/HYPOTHESIS The purpose was to quantify the microstructural and mechanical properties of the ALL as compared with the anterolateral capsule (ALC) and lateral collateral ligament (LCL). The primary hypotheses were that (1) there is no difference in these properties between the ALL and ALC and (2) the LCL has significantly different properties from the ALL and ALC. STUDY DESIGN Descriptive laboratory study. METHODS The LCL, ALL, and ALC were harvested from 25 cadaveric knees. Mechanical testing and microstructural analyses were performed using quantitative polarized light imaging. The average degree of linear polarization (AVG DoLP; mean strength of collagen alignment) and standard deviation of the angle of polarization (STD AoP; degree of variation in collagen angle orientation) were calculated. RESULTS Linear region moduli were not different between the ALC and ALL (3.75 vs 3.66 MPa, respectively; P > .99). AVG DoLP values were not different between the ALC and ALL in the linear region (0.10 vs 0.10; P > .99). Similarly, STD AoP values were not different between the ALC and ALL (24.2 vs 21.7; P > .99). The LCL had larger modulus, larger AVG DoLP, and smaller STD AoP values than the ALL and ALC. Of 25 knee specimens, 3 were observed to have a distinct ALL, which exhibited larger modulus, larger AVG DoLP, and smaller STD AoP values as compared with nondistinct ALL samples. CONCLUSION There were no differences in the mechanical and microstructural properties between the ALL and ALC. The ALC and ALL exhibited comparably weak and disperse collagen alignment. However, when a distinct ALL was present, the properties were suggestive of a ligamentous structure. CLINICAL RELEVANCE The properties of the ALL are similar to those of a ligament only when a distinct ALL is present, but otherwise, for the majority of specimens, ALL properties are closer to those of the capsule. Variability in the ligamentous structure of the ALL suggests that it may be more important in some patients than others and reconstruction may be considered in selective patients. Further study is needed to better understand its selective role and optimal indications for reconstruction.
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Affiliation(s)
- Ronak M Patel
- Washington University in St Louis, St Louis, Missouri, USA
| | - Ryan M Castile
- Washington University in St Louis, St Louis, Missouri, USA
| | | | - Spencer P Lake
- Washington University in St Louis, St Louis, Missouri, USA
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7
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Iseki T, Rothrauff BB, Kihara S, Novaretti JV, Shea KG, Tuan RS, Fu FH, Alexander PG, Musahl V. Paediatric knee anterolateral capsule does not contain a distinct ligament: analysis of histology, immunohistochemistry and gene expression. J ISAKOS 2020; 6:82-87. [PMID: 33832981 DOI: 10.1136/jisakos-2019-000339] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2020] [Indexed: 12/22/2022]
Abstract
OBJECTIVES The presence of a discrete ligament within the knee anterolateral capsule (ALC) is controversial. Tendons and ligaments have typical collagens, ultrastructure, transcription factors and proteins. However, these characteristics have not been investigated in paediatric ALC. The purpose of this study was to characterise the paediatric ALC in terms of tissue ultrastructure and cellular expression of ligament markers scleraxis (SCX)-a basic helix-loop-helix transcription factor-and the downstream transmembrane glycoprotein tenomodulin (TNMD), as compared with the paediatric lateral collateral ligament (LCL) and paediatric quadriceps tendon (QT). We hypothesised that, in comparison to the LCL and QT, the ALC would possess poor collagen orientation and reduced SCX and TNMD expression. METHODS 15 paediatric ALCs (age 6.3±3.3 years), 5 paediatric LCLs (age 3.4±1.3 years) and 5 paediatric QTs (age 2.0±1.2 years) from fresh cadaveric knees were used in this study. Fresh-frozen samples from each region were cryosectioned and then stained with H&E to evaluate collagen alignment and cell morphology. Expression of SCX and TNMD was determined by gene expression analysis and immunohistochemistry. RESULTS The histological sections of the paediatric LCL and QT showed well-organised, dense collagenous tissue fibres with elongated fibroblasts, while the ALC showed more random collagen orientation without clear cellular directionality. The aspect ratio of cells in the ALC was significantly lower than that of the LCL and QT (p<0.0001 and p<0.0001, respectively). The normalised distribution curve of the inclination angles of the nuclei in the ALC was more broadly distributed than that of the LCL or QT, indicating random cell alignment in the ALC. SCX immunostaining was apparent in the paediatric LCL within regions of aligned fibres, while the comparatively disorganised structure of the ALC was negative for SCX. The paediatric LCL also stained positive for TNMD, while the ALC was only sparsely positive for this tendon/ligament cell-surface molecule. Relative gene expression of SCX and TNMD were higher in the LCL and QT than in the ALC. CONCLUSION In this study, a distinct ligament could not be discerned in the ALC based on histology, immunohistochemistry and gene expression analysis. LEVEL OF EVIDENCE Controlled laboratory study.
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Affiliation(s)
- Tomoya Iseki
- Department of Orthopaedic Surgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan.,Center for Cellular and Molecular Engineering, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Benjamin B Rothrauff
- Center for Cellular and Molecular Engineering, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Shinsuke Kihara
- Center for Cellular and Molecular Engineering, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - João V Novaretti
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Ortopedia e Traumatologia, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Kevin G Shea
- Department of Orthopaedic Surgery, Stanford University, Stanford, California, USA
| | - Rocky S Tuan
- Center for Cellular and Molecular Engineering, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Freddie H Fu
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Peter G Alexander
- Center for Cellular and Molecular Engineering, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Volker Musahl
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Redler A, Miglietta S, Monaco E, Matassa R, Relucenti M, Daggett M, Ferretti A, Familiari G. Ultrastructural Assessment of the Anterolateral Ligament. Orthop J Sports Med 2019; 7:2325967119887920. [PMID: 31897411 PMCID: PMC6920591 DOI: 10.1177/2325967119887920] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background: The anterolateral ligament (ALL) has been identified as a structure on the
lateral side of the knee, but debate exists regarding whether it is a
capsular thickening or a ligament. Hypothesis: A detailed ultrastructural characterization of the ALL and its ultrastructure
collagen arrangement will reveal it more closely resembles ligamentous
tissue than joint capsule. Study Design: Descriptive laboratory study. Methods: Eight paired knee samples from 4 fresh-frozen male cadavers were used for
this study. Samples were harvested from the ALL, the joint capsule, and the
medial collateral ligament (MCL). All samples were evaluated with light
microscopy (LM), transmission electron microscopy (TEM), and variable
pressure scanning electron microscopy (VP-SEM). With LM, the 3 tissues were
analyzed and their morphology described. With TEM, the ultrastructure and
collagen characteristics were quantified and compared among specimens. Then,
the 3-dimensional characteristics were compared with VP-SEM. Results: Ultrastructure analysis demonstrated similar morphology between the ALL and
MCL, with significant differences in these 2 structures as compared with the
joint capsule. On LM, the ALL and MCL were characterized by the presence of
a dense collagen fiber oriented in the longitudinal and transversal
directions of the fiber bundles, while the joint capsule was found to have a
more disorganized architecture. On TEM, the collagen fibers of the ALL and
MCL demonstrated similar ultrastructural morphology, with both having
collagen fibers in parallel, longitudinal alignment. A quantitative analysis
was also performed, with the mean (± SD) diameter of fibrils in the ALL and
MCL being 80 ± 2.66 nm and 150 ± 3.35 nm, respectively (all
P < .001). The VP-SEM highlighted that ALL and MCL
morphology demonstrated arrangements of fiber bundles that are densely
packed and organized, in contrast to the disorganized fibers of the joint
capsule. Conclusion: The ALL and MCL have comparable ultrastructures that are distinctly different
from the joint capsule, as visualized on LM, TEM, and VP-SEM. Clinical Relevance: The ALL should be considered a distinctive structure of the knee, although
strictly connected to the surrounding capsule.
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Affiliation(s)
- Andrea Redler
- Orthopaedic Unit and Kirk Kilgour Sports Injury Centre, S. Andrea Hospital, University of Rome Sapienza, Rome, Italy.,Department of Anatomy, Histology, Forensic Medicine and Orthopaedics, University of Rome Sapienza, Rome, Italy
| | - Selenia Miglietta
- Department of Anatomy, Histology, Forensic Medicine and Orthopaedics, University of Rome Sapienza, Rome, Italy
| | - Edoardo Monaco
- Orthopaedic Unit and Kirk Kilgour Sports Injury Centre, S. Andrea Hospital, University of Rome Sapienza, Rome, Italy
| | - Roberto Matassa
- Department of Anatomy, Histology, Forensic Medicine and Orthopaedics, University of Rome Sapienza, Rome, Italy
| | - Michela Relucenti
- Department of Anatomy, Histology, Forensic Medicine and Orthopaedics, University of Rome Sapienza, Rome, Italy
| | - Matthew Daggett
- Kansas City University of Medicine and Biosciences, Kansas City, Missouri, USA
| | - Andrea Ferretti
- Orthopaedic Unit and Kirk Kilgour Sports Injury Centre, S. Andrea Hospital, University of Rome Sapienza, Rome, Italy
| | - Giuseppe Familiari
- Department of Anatomy, Histology, Forensic Medicine and Orthopaedics, University of Rome Sapienza, Rome, Italy
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Smeets K, Van Haver A, Van den Bempt S, Verheyden M, Bruckers L, Verdonk P, Truijen J, Bellemans J. Risk analysis of tunnel collision in combined anterior cruciate ligament and anterolateral ligament reconstructions. Knee 2019; 26:962-968. [PMID: 31431338 DOI: 10.1016/j.knee.2019.06.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 05/23/2019] [Accepted: 06/13/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND To assess the risk of tunnel collision in combined anterior cruciate ligament (ACL) and anterolateral ligament (ALL) reconstructions. METHODS Three-dimensional (3D) CT reconstructions of 32 knees after transtibial (TT) (N = 16) or anteromedial portal (AMP) (N = 16) ACL reconstruction were used to simulate potential tunnel collision of the femoral ACL tunnel if combined with a virtual ALL reconstruction. The minimal distance between tunnels, the ALL tunnel length, and the lateral femoral condyle (LFC) width were measured. Moreover, the relationship between the ALL tunnel and the intercondylar notch, trochlear groove and posterior femoral cortex was determined. RESULTS The highest rate of tunnel collision (81%) was observed when the ALL tunnel was aimed at 20° in the coronal plane and 0° in the axial plane. However, by aiming the ALL tunnel at 0° coronal and 40° axial angulation, collision was avoided in all patients and no violation of the trochlea was observed. Tunnel collision rate was significantly higher (P = 0.002) when the ACL tunnel was drilled by the AMP technique. CONCLUSIONS Risk of tunnel collision was significantly increased when the tunnel was drilled at 0° in the axial plane. Tunnel collision was avoided by aiming the ALL tunnel 40° anteriorly and perpendicular to the anatomical axis of the femur. A more horizontal orientation of the ACL with the AMP technique is a risk factor for tunnel conflicts. CLINICAL RELEVANCE ALL tunnel orientation needs to be adjusted to avoid tunnel conflicts in combined ACL-ALL reconstructions.
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Affiliation(s)
- K Smeets
- Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium; Department of Orthopedic Surgery, AZ Vesalius, Tongeren, Belgium; GRIT Belgian Sports Clinic, Leuven, Belgium.
| | - A Van Haver
- Monica Orthopedic Research (MoRe) Foundation, Monica Hospital, Antwerp, Belgium
| | - S Van den Bempt
- Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium.
| | - M Verheyden
- Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium.
| | - L Bruckers
- I-BioStat, University of Hasselt, Diepenbeek, Belgium.
| | - P Verdonk
- Monica Orthopedic Research (MoRe) Foundation, Monica Hospital, Antwerp, Belgium
| | - J Truijen
- Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium; Department of Orthopedic Surgery, ZOL Genk, Genk, Belgium.
| | - J Bellemans
- Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium; GRIT Belgian Sports Clinic, Leuven, Belgium; Department of Orthopedic Surgery, ZOL Genk, Genk, Belgium
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Getgood A, Brown C, Lording T, Amis A, Claes S, Geeslin A, Musahl V. The anterolateral complex of the knee: results from the International ALC Consensus Group Meeting. Knee Surg Sports Traumatol Arthrosc 2019; 27:166-176. [PMID: 30046994 DOI: 10.1007/s00167-018-5072-6] [Citation(s) in RCA: 211] [Impact Index Per Article: 42.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Accepted: 07/18/2018] [Indexed: 12/18/2022]
Abstract
The structure and function of the anterolateral complex (ALC) of the knee has created much controversy since the 're-discovery' of the anterolateral ligament (ALL) and its proposed role in aiding control of anterolateral rotatory laxity in the anterior cruciate ligament (ACL) injured knee. A group of surgeons and researchers prominent in the field gathered to produce consensus as to the anatomy and biomechanical properties of the ALC. The evidence for and against utilisation of ALC reconstruction was also discussed, generating a number of consensus statements by following a modified Delphi process. Key points include that the ALC consists of the superficial and deep aspects of the iliotibial tract with its Kaplan fibre attachments on the distal femur, along with the ALL, a capsular structure within the anterolateral capsule. A number of structures attach to the area of the Segond fracture including the capsule-osseous layer of the iliotibial band, the ALL and the anterior arm of the short head of biceps, and hence it is not clear which is responsible for this lesion. The ALC functions to provide anterolateral rotatory stability as a secondary stabiliser to the ACL. Whilst biomechanical studies have shown that these structures play an important role in controlling stability at the time of ACL reconstruction, the optimal surgical procedure has not yet been defined clinically. Concern remains that these procedures may cause constraint of motion, yet no clinical studies have demonstrated an increased risk of osteoarthritis development. Furthermore, clinical evidence is currently lacking to support clear indications for lateral extra-articular procedures as an augmentation to ACL reconstruction. The resulting statements and scientific rationale aim to inform readers on the most current thinking and identify areas of needed basic science and clinical research to help improve patient outcomes following ACL injury and subsequent reconstruction.Level of evidence V.
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Affiliation(s)
- Alan Getgood
- Fowler Kennedy Sport Medicine Clinic, University of Western Ontario, 3M Centre, London, ON, N6A 3K7, Canada.
| | | | | | | | | | | | - Volker Musahl
- University of Pittsburgh Medical Centre, Pittsburgh, PA, USA
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Daggett M, Stephenson C, Dobson J, Whitaker A, Redler A, Monaco E, Wright B, Saithna A, Sonnery-Cottet B. Anatomic and Histological Study of the Anterolateral Aspect of the Knee: A SANTI Group Investigation. Orthop J Sports Med 2018; 6:2325967118799970. [PMID: 30345320 PMCID: PMC6187433 DOI: 10.1177/2325967118799970] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [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 structure and function of the anterolateral aspect of the knee have been significantly debated, with renewed interest in this topic since the description of the anterolateral ligament (ALL). Purpose: To define and describe the distinct structures of the lateral knee and to correlate the macroscopic and histologic anatomic features. Study Design: Descriptive laboratory study. Methods: Twelve fresh-frozen human cadavers were used for anatomic analysis. In the left knee, a layer-by-layer dissection and macroscopic analysis were performed. In the right knee, an en bloc specimen was obtained encompassing an area from the Gerdy tubercle to the posterior fibular head and extending proximally from the anterior aspect to the posterior aspect of the lateral femoral epicondyle. The en bloc resection was then frozen, sliced at the level of the joint line, and reviewed by a musculoskeletal pathologist. Results: Macroscopically, the lateral knee has 4 main layers overlying the capsule of the knee: the aponeurotic layer, the superficial layer including the iliotibial band (ITB), the deep fascial layer, and the ALL. Histologically, 8 of 12 specimens demonstrated 4 consistent, distinct structures: the ITB, the ALL, the lateral collateral ligament, and the meniscus. Conclusion: The lateral knee has a complex orientation of layers and fibers. The ALL is a distinct structure from the ITB and is synonymous to the previously described capsulo-osseous layer of the ITB. Clinical Relevance: Increasingly, lateral extra-articular procedures are performed at the time of anterior cruciate ligament reconstruction. Understanding the anatomic features of the anterolateral aspect of the knee is necessary to understand the biomechanics and function of the structures present and allows surgeons to attempt to replicate those anatomic characteristics when performing extra-articular reconstruction.
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Affiliation(s)
- Matt Daggett
- Kansas City University of Medicine and Biosciences, Kansas City, Missouri, USA
- Matt Daggett, DO, Kansas City University of Medicine and Biosciences, 1750 Independence Ave, Kansas City, MO 64106, USA () (Twitter: @DrMattDaggett)
| | - Clark Stephenson
- Kansas City University of Medicine and Biosciences, Kansas City, Missouri, USA
| | - John Dobson
- Kansas City University of Medicine and Biosciences, Kansas City, Missouri, USA
| | - Amy Whitaker
- Kansas City University of Medicine and Biosciences, Kansas City, Missouri, USA
| | - Andrea Redler
- II School of Medicine, Sant’Andrea Hospital, Kirk Kilgour Sports Injury Center, University of Rome “La Sapienza,” Rome, Italy
| | - Edoardo Monaco
- II School of Medicine, Sant’Andrea Hospital, Kirk Kilgour Sports Injury Center, University of Rome “La Sapienza,” Rome, Italy
| | - Barth Wright
- Kansas City University of Medicine and Biosciences, Kansas City, Missouri, USA
| | - Adnan Saithna
- Renacres Ln, Ormskirk, Lancashire, Halsall, Ormskirk, UK
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12
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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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