Inter-rater reliability of an ultrasound protocol to evaluate the anterolateral ligament of the knee

The feasibility of ultrasound-guided latex labeling of the anterolateral ligament in anatomical dissection - A cadaveric study

BACKGROUND

The present study aims to investigate the feasibility of labeling ligaments using ultrasound-guided injections. On formalin-fixed cadavers, the anterolateral ligament was selected and targeted for demonstration. The development of portable ultrasound machines and the ability to connect them to tablets via Bluetooth or WLAN makes it an accessible tool to implement into the anatomical dissection courses in order to associate medical imaging (MRI and ultrasound), anatomical structures and their subsequent dissection.

METHODS

8 formalin fixed human cadavers were used for the ultrasound-guided injections of 1 mL of blue latex into the anterolateral ligament. 8 cadavers were not injected with latex for comparative purposes. The injections were performed by an experienced ultra-sonographer. After approximately 10 months, five dissections were carried out by students during the dissection course and three specimens were dissected by anatomists.

RESULTS

The anterolateral ligament was successfully marked and demonstrated in 7 out of 8 cases. In 4 out of 5 cases, the dissection was primarily conducted by students, while in 3 out of 3 cases, it was performed by anatomists. The accuracy was 80 % and 100 %, respectively.

CONCLUSION

The present study demonstrated that labeling obscure ligaments, such as the anterolateral ligament, using ultrasound guidance is feasible on formalin-fixed cadavers. It also showed that students can successfully perform the dissections as the structure is highlighted and that the time between injection and dissection (approximately 10 months) has little impact on the outcome. The use of ultrasound in dissection courses should be further encouraged.

Review of ultrasound-guided labeling: exploring its potential in teaching cadaveric ligaments during anatomical dissection courses

Objectives

This scoping review aimed to give an overview of the existing literature about ultrasound-guided labeling techniques of human cadaver ligaments and tried to work out the possibilities of integrating ultrasound into dissection courses.

Methods

A literature review was carried out on the 3rd of January 2023, with relevant studies discovered in the following databases: MEDLINE, EMBASE, CENTRAL, BIOSIS Previews and Web of Science Core Collection. Grey literature was also considered. The reference lists of all relevant papers were scanned. Only ultrasound studies on human cadaver ligaments were included. The included studies' general characteristics and ultrasound-guided approaches to label the ligaments were taken from them and examined.

Results

The search found 8899 matches, but only 96 of them met the criteria. The transverse carpal ligament (15.62%) and the annular pulleys (19.79%) were the ligaments that had received the greatest research attention. Twenty-three studies are included in the methodological analysis. Both the marking substrate and the injected volume were diverse. Although 65% of the included studies achieved 100% accuracy using the ultrasound directed labeling approaches.

Conclusions

Ultrasound-guided labeling techniques achieve a high accuracy. Therefore, this methodology could be a potential teaching tool for students during the dissection course. But caution is advised in drawing general conclusions because of the small sample sizes and different methodologies in the studies. Future larger-scale research is necessary.

Progress in research on and classification of surgical methods of arthroscopic reconstruction of the ACL and ALL using a shared tendon graft through the femoral tunnel

Anterior cruciate ligament (ACL) tear is a common clinical injury, and ACL reconstruction has reached a very mature stage. However, with the accumulation of cases, scholars have found that isolated ACL reconstruction may not completely solve the problem of knee rotational stability. With the increase in our understanding of knee joint structure, ACL combined with anterolateral ligament (ALL) reconstruction has become accepted by most scholars, and this operation has also achieved good clinical results. At present, there is no unified surgical method for ACL combined with ALL reconstruction. There are differences in bone tunnel location, reconstruction methods, and graft selection. Compared with the independent reconstruction of the ACL and ALL during the operation, shared tendon graft reconstruction of the ACL and ALL has the advantages of preserving tendon and avoiding tunnel convergence. So far, there is no relevant literature summarizing the reconstruction of the ACL and ALL with a shared tendon graft. This paper reviews the anatomic study of the ALL, the study of isometric points, surgical indications, and surgical methods and their classification for shared tendon graft reconstruction of the ACL and ALL.

The Anterolateral Ligament of the Knee in Pediatric Patients: What Do We Know? A Scoping Review

The knowledge on the anatomy, function and biomechanics and the role of surgical procedures on the anterolateral ligament (ALL) of the knee is still controversial. Only a few papers have examined the ALL in children. The aim of this review is to analyze all the available literature about ALL in the pediatric population. Following the PRISMA criteria, the literature was systematically reviewed, examining all the articles about ALL in pediatric patients. Eight articles were involved in this study. Five cadaveric studies, two diagnostic studies, and one cross-sectional study were found. The identification of the ALL is not always possible in diagnostic studies using magnetic resonance (MRI) or in dissecting specimens. A high variability in the presence of the ligament and in its origin and insertion were found among the studies. It is more difficult to identify the ligament in younger patients than in older children, suggesting that its presence may develop at some point during the growth. Further studies are needed for a detailed knowledge of the ALL.

Dynamic Ultrasound Assessment of the Anterior Tibial Translation for Anterior Cruciate Ligament Tears Diagnostic

The aim of our study was to investigate the accuracy of dynamic ultrasound assessment of the anterior tibial translation, in diagnosing anterior cruciate ligament tears, and to assess its test−retest reliability. Twenty-three patients (32 ± 8.42 years; 69.56% males) with a history of knee trauma and knee instability participated in the study. Knee ultrasound was performed by an experienced orthopedic surgeon. The anterior tibial translation was measured in both knees and differences between the injured and uninjured knee were calculated. Side-to-side differences > 1 mm were considered a positive diagnosis of an ACL tear. The anterior tibial translation values were 3.34 ± 1.48 mm in injured knees and 0.86 ± 0.78 mm in uninjured knees. Side-to-side differences > 1 mm were found in 22 cases (95.65%). The diagnosis accuracy was 91.30% (95%CI: 71.96−98.92%) and sensitivity 95.45% (95%CI: 77.15−99.88%). The intraclass correlation coefficient showed an excellent test−retest reliability (ICC3,1 = 0.97 for the side-to-side difference in anterior tibial translation). The study highlights the accuracy and reliability of the dynamic ultrasound assessment of the anterior tibial translation in the diagnosis of unilateral anterior cruciate ligament tears. Ultrasound assessment is an accessible imaging tool that can provide valuable information and should be used together with physical examination in suspected cases of ACL injuries.

Tibial internal rotation in combined anterior cruciate ligament and high-grade anterolateral ligament injury and its influence on ACL length

Background

Assessment of combined anterolateral ligament (ALL) and anterior cruciate ligament (ACL) injury remains challenging but of high importance as the ALL is a contributing stabilizer of tibial internal rotation. The effect of preoperative static tibial internal rotation on ACL -length remains unknown. The aim of the study was analyze the effect of tibial internal rotation on ACL length in single-bundle ACL reconstructions and to quantify tibial internal rotation in combined ACL and ALL injuries.

Methods

The effect of tibial internal rotation on ACL length was computed in a three-dimensional (3D) model of 10 healthy knees with 5° increments of tibial internal rotation from 0 to 30° resulting in 70 simulations. For each step ACL length was measured. ALL injury severity was graded by a blinded musculoskeletal radiologist in a retrospective analysis of 61 patients who underwent single-bundle ACL reconstruction. Preoperative tibial internal rotation was measured in magnetic resonance imaging (MRI) and its diagnostic performance was analyzed.

Results

ACL length linearly increased 0.7 ± 0.1 mm (2.1 ± 0.5% of initial length) per 5° of tibial internal rotation from 0 to 30° in each patient.

Seventeen patients (27.9%) had an intact ALL (grade 0), 10 (16.4%) a grade 1, 21 (34.4%) a grade 2 and 13 (21.3%) a grade 3 injury of the ALL. Patients with a combined ACL and ALL injury grade 3 had a median static tibial internal rotation of 8.8° (interquartile range (IQR): 8.3) compared to 5.6° (IQR: 6.6) in patients with an ALL injury (grade 0–2) (p = 0.03). A cut-off > 13.3° of tibial internal rotation predicted a high-grade ALL injury with a specificity of 92%, a sensitivity of 30%; area under the curve (AUC) 0.70 (95% CI: 0.54–0.85) (p = 0.03) and an accuracy of 79%.

Conclusion

ACL length linearly increases with tibial internal rotation from 0 to 30°. A combined ACL and high-grade ALL injury was associated with greater preoperative tibial internal rotation. This potentially contributes to unintentional graft laxity in ACL reconstructed patients, in particular with concomitant high-grade ALL tears.

Study design

Cohort study; Level of evidence, 3.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05218-8.

Femoral Positioning of the Anterolateral Ligament Graft With and Without Ultrasound Location of the Lateral Epicondyle

BACKGROUND

In anterior cruciate ligament (ACL) reconstruction with anterolateral ligament (ALL) reconstruction, precise positioning of the ALL graft on the femur and tibia is key to achieve rotational control. The lateral femoral epicondyle is often used as a reference point for positioning of the ALL graft and can be located by palpation or with ultrasound guidance.

PURPOSE

To compare the ALL graft positioning on the femoral side between an ultrasound-guided technique and a palpation technique for the location of the lateral epicondyle.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

A total of 120 patients receiving a primary combined ACL and ALL reconstruction between June and December 2019 were included. The location of the lateral epicondyle was determined by palpation in the palpation group (n = 60) and with preoperative ultrasound guidance in the ultrasound group (n = 60). Groups were comparable in age, sex, body mass index (BMI), and operated side. The planned positioning of the femoral ALL graft was proximal and posterior to the lateral epicondyle. The effective positioning of the femoral ALL graft was evaluated on postoperative lateral radiographs. The primary outcome was location of the graft in a 10-mm quadrant posterior and proximal to the lateral epicondyle. Results were analyzed in 2 subgroups according to BMI.

RESULTS

All 60 anterolateral grafts (100%) in the ultrasound group were positioned in a 10-mm quadrant posterior and proximal to the lateral epicondyle, as opposed to 52 (87%) in the palpation group (P = .006). Errors in graft positioning with palpation occurred in overweight patients (BMI >25) as well as nonoverweight patients (P = .3).

CONCLUSION

Femoral positioning of the ALL graft posterior and proximal to the lateral epicondyle is more reproducible with ultrasound guidance when compared with palpation alone, regardless of BMI.

The EFSUMB Guidelines and Recommendations for Musculoskeletal Ultrasound - Part I: Extraarticular Pathologies

The first part of the guidelines and recommendations for musculoskeletal ultrasound, produced under the auspices of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB), provides information about the use of musculoskeletal ultrasound for assessing extraarticular structures (muscles, tendons, entheses, ligaments, bones, bursae, fasciae, nerves, skin, subcutaneous tissues, and nails) and their pathologies. Clinical applications, practical points, limitations, and artifacts are described and discussed for every structure. After an extensive literature review, the recommendations have been developed according to the Oxford Centre for Evidence-based Medicine and GRADE criteria and the consensus level was established through a Delphi process. The document is intended to guide clinical users in their daily practice.

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

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.