Is the anterolateral ligament the smoking gun to explain rotational knee laxity or just vaporware?
2021; Elsevier BV; Volume: 6; Issue: 2 Linguagem: Inglês
10.1136/jisakos-2020-000529
ISSN2059-7762
Autores Tópico(s)Tendon Structure and Treatment
ResumoSince the publication of the ‘discovery’ of a new knee ligament in 2013, coined as anterolateral ligament (ALL),1Claes S Vereecke E Maes M et al.Anatomy of the anterolateral ligament of the knee.J Anat. 2013; 223: 321-32810.1111/joa.12087http://www.ncbi.nlm.nih.gov/pubmed/23906341Crossref PubMed Scopus (567) Google Scholar the scientific research into this ‘new’ anatomical structure has grown exponentially in the past years. The Journal of ISAKOS (JISAKOS) publishes in this issue three studies on the anatomy of the anterolateral capsule (ALC) of the knee2Iseki T Rothrauff BB Kihara S Paediatric knee anterolateral capsule does not contain a distinct ligament: analysis of histology, immunohistochemistry and gene expression.J Isakos. 2021; 6: 82-8710.1136/jisakos-2019-000339Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar and the biomechanics of the combined reconstruction of the anterior cruciate ligament (ACL) and the ALL.3Neri T Dabirrahmani D Beach A Different anterolateral procedures have variable impact on knee kinematics and stability when performed in combination with anterior cruciate ligament reconstruction.J Isakos. 2021; 6: 74-8110.1136/jisakos-2019-000360Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar, 4Neri T Cadman J Beach A Lateral tenodesis procedures increase lateral compartment pressures more than anterolateral ligament reconstruction, when performed in combination with ACL reconstruction: a pilot biomechanical study.J Isakos. 2021; 6: 66-7310.1136/jisakos-2019-000368Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar The history of the ALL takes us more than one century back to Segond's works,5Segond P Recherches cliniques et expérimentales sur les épanchements sanguins du genou par entorse. Bureaux du Progrès médical, Paris1879Google Scholar, 6Murgier J Devitt BM Sevre J et al.The origin of the knee anterolateral ligament discovery: a translation of Segond's original work with commentary.Arthroscopy. 2019; 35: 684-69010.1016/j.arthro.2018.10.003http://www.ncbi.nlm.nih.gov/pubmed/30612774Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar, 7Cavaignac E Ancelin D Chiron P et al.Historical perspective on the “discovery” of the anterolateral ligament of the knee.Knee Surg Sports Traumatol Arthrosc. 2017; 25: 991-99610.1007/s00167-016-4349-xhttp://www.ncbi.nlm.nih.gov/pubmed/27699439Crossref PubMed Scopus (15) Google Scholar as well as to some other reports (earlier than 2013) of this structure.8Campos JC Chung CB Lektrakul N et al.Pathogenesis of the Segond fracture: anatomic and MR imaging evidence of an iliotibial tract or anterior oblique band avulsion.Radiology. 2001; 219: 381-38610.1148/radiology.219.2.r01ma23381http://www.ncbi.nlm.nih.gov/pubmed/11323461Crossref PubMed Scopus (182) Google Scholar, 9Vieira ELC Vieira EA da Silva RT et al.An anatomic study of the iliotibial tract.Arthroscopy. 2007; 23: 269-27410.1016/j.arthro.2006.11.019http://www.ncbi.nlm.nih.gov/pubmed/17349469Abstract Full Text Full Text PDF PubMed Scopus (183) Google Scholar, 10Vincent J-P Magnussen RA Gezmez F et al.The anterolateral ligament of the human knee: an anatomic and histologic study.Knee Surg Sports Traumatol Arthrosc. 2012; 20: 147-15210.1007/s00167-011-1580-3http://www.ncbi.nlm.nih.gov/pubmed/21717216Crossref PubMed Scopus (289) Google Scholar Despite much controversy and conflicting findings on the macroscopic anatomical, histological and MRI of the ALL,11Caterine S Litchfield R Johnson M et al.A cadaveric study of the anterolateral ligament: re-introducing the lateral capsular ligament.Knee Surg Sports Traumatol Arthrosc. 2015; 23: 3186-319510.1007/s00167-014-3117-zhttp://www.ncbi.nlm.nih.gov/pubmed/24929656Crossref PubMed Scopus (214) Google Scholar, 12Dodds AL Halewood C Gupte CM et al.The anterolateral ligament: anatomy, length changes and association with the Segond fracture.Bone Joint J. 2014; 96-B (-b(3)): 325-33110.1302/0301-620X.96B3.33033http://www.ncbi.nlm.nih.gov/pubmed/24589786Crossref PubMed Google Scholar, 13Helito CP do Prado Torres JA Bonadio MB et al.Anterolateral ligament of the fetal knee: an anatomic and histological study.Am J Sports Med. 2017; 45: 91-9610.1177/0363546516664888http://www.ncbi.nlm.nih.gov/pubmed/27624543Crossref PubMed Scopus (31) Google Scholar, 14Kennedy MI Claes S Fuso FAF et al.The anterolateral ligament: an anatomic, radiographic, and biomechanical analysis.Am J Sports Med. 2015; 43: 1606-161510.1177/0363546515578253http://www.ncbi.nlm.nih.gov/pubmed/25888590Crossref PubMed Scopus (243) Google Scholar, 15Herbst E Albers M Burnham JM et al.The anterolateral complex of the knee: a pictorial essay.Knee Surg Sports Traumatol Arthrosc. 2017; 25: 1009-101410.1007/s00167-017-4449-2http://www.ncbi.nlm.nih.gov/pubmed/28233023Crossref PubMed Scopus (46) Google Scholar, 16Musahl V Rahnemai-Azar AA van Eck CF et al.Anterolateral ligament of the knee, fact or fiction?.Knee Surg Sports Traumatol Arthrosc. 2016; 24: 2-310.1007/s00167-015-3913-0http://www.ncbi.nlm.nih.gov/pubmed/26694486Crossref PubMed Scopus (49) Google Scholar, 17Herbst E Albers M Burnham JM et al.The anterolateral complex of the knee.Orthop J Sports Med. 2017; 5 (232596711773080)10.1177/2325967117730805http://www.ncbi.nlm.nih.gov/pubmed/29051903Crossref Scopus (35) Google Scholar, 18Musahl V Herbst E Burnham JM et al.The anterolateral complex and anterolateral ligament of the knee.J Am Acad Orthop Surg. 2018; 26: 261-26710.5435/JAAOS-D-16-00758http://www.ncbi.nlm.nih.gov/pubmed/29517517Crossref PubMed Scopus (22) Google Scholar, 19Dombrowski ME Costello JM Ohashi B et al.Macroscopic anatomical, histological and magnetic resonance imaging correlation of the lateral capsule of the knee.Knee Surg Sports Traumatol Arthrosc. 2016; 24: 2854-286010.1007/s00167-015-3517-8http://www.ncbi.nlm.nih.gov/pubmed/25649729Crossref PubMed Scopus (48) Google Scholar, 20Andrade R Rebelo-Marques A Bastos R et al.Identification of normal and injured anterolateral ligaments of the knee: a systematic review of magnetic resonance imaging studies.Arthroscopy. 2019; 35: 1594-161310.1016/j.arthro.2018.10.120http://www.ncbi.nlm.nih.gov/pubmed/31000390Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar, 21Ariel de Lima D Helito CP Lacerda de Lima L et al.Study of the nerve endings and mechanoreceptors of the anterolateral ligament of the knee.Arthroscopy. 2019; 35: 2918-292710.1016/j.arthro.2019.05.023http://www.ncbi.nlm.nih.gov/pubmed/31604514Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar, 22Ariel de Lima D Helito CP Lacerda de Lima L et al.Anatomy of the anterolateral ligament of the knee: a systematic review.Arthroscopy. 2019; 35: 670-68110.1016/j.arthro.2018.09.006http://www.ncbi.nlm.nih.gov/pubmed/30612770Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar a consensus paper by international knee experts has characterised the ALL as a structure within layer 3 of the ALC.23Getgood A Brown C Lording T et al.The anterolateral complex of the knee: results from the International alc consensus group meeting.Knee Surg Sports Traumatol Arthrosc. 2019; 27: 166-17610.1007/s00167-018-5072-6http://www.ncbi.nlm.nih.gov/pubmed/30046994Crossref PubMed Scopus (116) Google Scholar Nonetheless, if the ALL is really a distinct ligament structure or a thickening of the ALC remains open for debate. To better understand the phenotype of the ALC, Iseki et al 2Iseki T Rothrauff BB Kihara S Paediatric knee anterolateral capsule does not contain a distinct ligament: analysis of histology, immunohistochemistry and gene expression.J Isakos. 2021; 6: 82-8710.1136/jisakos-2019-000339Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar evaluated the histology, immunohistochemistry and genetic expression of the ALC from paediatric specimens to investigate if there are any ligament-like characteristics. They found no discernible histological and immunohistochemical characteristics consistent with a ligament phenotype and that the ligament genetic markers (scleraxis and tenomodulin) were largely absent and poorly expressed in the ALC. Their methodology still needs to be replicated in adult specimens, but their findings suggest that the ALC does not display ligament-like characteristics and do not support the belief that there is a distinct ligament at the ALC. In a recent systematic review of MRI studies,20Andrade R Rebelo-Marques A Bastos R et al.Identification of normal and injured anterolateral ligaments of the knee: a systematic review of magnetic resonance imaging studies.Arthroscopy. 2019; 35: 1594-161310.1016/j.arthro.2018.10.120http://www.ncbi.nlm.nih.gov/pubmed/31000390Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar high variability was found in the identification of the ALL, which appeared in 51%–100% of all assessed knees (with a very high intraobserver and interobserver reliability rates), and the entire portion of the ligament was often not seen. These findings suggest that the ALL may not really exist as a distinct ligament, which goes in line with several other publications.15Herbst E Albers M Burnham JM et al.The anterolateral complex of the knee: a pictorial essay.Knee Surg Sports Traumatol Arthrosc. 2017; 25: 1009-101410.1007/s00167-017-4449-2http://www.ncbi.nlm.nih.gov/pubmed/28233023Crossref PubMed Scopus (46) Google Scholar, 16Musahl V Rahnemai-Azar AA van Eck CF et al.Anterolateral ligament of the knee, fact or fiction?.Knee Surg Sports Traumatol Arthrosc. 2016; 24: 2-310.1007/s00167-015-3913-0http://www.ncbi.nlm.nih.gov/pubmed/26694486Crossref PubMed Scopus (49) Google Scholar, 17Herbst E Albers M Burnham JM et al.The anterolateral complex of the knee.Orthop J Sports Med. 2017; 5 (232596711773080)10.1177/2325967117730805http://www.ncbi.nlm.nih.gov/pubmed/29051903Crossref Scopus (35) Google Scholar, 18Musahl V Herbst E Burnham JM et al.The anterolateral complex and anterolateral ligament of the knee.J Am Acad Orthop Surg. 2018; 26: 261-26710.5435/JAAOS-D-16-00758http://www.ncbi.nlm.nih.gov/pubmed/29517517Crossref PubMed Scopus (22) Google Scholar, 19Dombrowski ME Costello JM Ohashi B et al.Macroscopic anatomical, histological and magnetic resonance imaging correlation of the lateral capsule of the knee.Knee Surg Sports Traumatol Arthrosc. 2016; 24: 2854-286010.1007/s00167-015-3517-8http://www.ncbi.nlm.nih.gov/pubmed/25649729Crossref PubMed Scopus (48) Google Scholar Being the case that the ALL was not a defined ligament, performing an anterolateral ligament reconstruction (ALLR) does not recreate the native anatomy of the knee, but should rather be considered as a lateral non-anatomical augmentation procedure.2Iseki T Rothrauff BB Kihara S Paediatric knee anterolateral capsule does not contain a distinct ligament: analysis of histology, immunohistochemistry and gene expression.J Isakos. 2021; 6: 82-8710.1136/jisakos-2019-000339Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar Lateral extra-articular tenodesis (LEAT) is being performed since the 1980s but has recently gained renewed interest. Lateral augmentation procedures—either LEAT or ALLR—are performed in the ACL-deficient knee in patients with high-risk profile of reinjury and aim to better control the knee internal rotation and decrease the risk of graft tear. The ALL strength varies between 49.9 N24Zens M Feucht MJ Ruhhammer J et al.Mechanical tensile properties of the anterolateral ligament.J Exp Orthop. 2015; 2: 710.1186/s40634-015-0023-3http://www.ncbi.nlm.nih.gov/pubmed/26914875Crossref PubMed Scopus (38) Google Scholar and 204.8 N,25Helito CP Bonadio MB Rozas JS et al.Biomechanical study of strength and stiffness of the knee anterolateral ligament.BMC Musculoskelet Disord. 2016; 17: 19310.1186/s12891-016-1052-5http://www.ncbi.nlm.nih.gov/pubmed/27129387Crossref PubMed Scopus (30) Google Scholar which is lower compared with the strength of the iliotibial band (487.9 N),26Rahnemai-Azar AA Miller RM Guenther D et al.Structural properties of the anterolateral capsule and Iliotibial band of the knee.Am J Sports Med. 2016; 44: 892-89710.1177/0363546515623500http://www.ncbi.nlm.nih.gov/pubmed/26811306Crossref PubMed Scopus (65) Google Scholar ALC (319.7 N)26Rahnemai-Azar AA Miller RM Guenther D et al.Structural properties of the anterolateral capsule and Iliotibial band of the knee.Am J Sports Med. 2016; 44: 892-89710.1177/0363546515623500http://www.ncbi.nlm.nih.gov/pubmed/26811306Crossref PubMed Scopus (65) Google Scholar or the distal iliotibial tract (769 N).27Noyes FR Butler DL Grood ES et al.Biomechanical analysis of human ligament grafts used in knee-ligament repairs and reconstructions.J Bone Joint Surg Am. 1984; 66: 344-35210.2106/00004623-198466030-00005http://www.ncbi.nlm.nih.gov/pubmed/6699049Crossref PubMed Scopus (1112) Google Scholar The strength of the iliotibial band (as compared with the ALL) suggests that this structure would be more fitted to withstand the high rotational torques. Indeed, adding a LEAT significantly decreases the forces at the ACL graft,28Marom N Ouanezar H Jahandar H et al.Lateral extra-articular Tenodesis reduces anterior cruciate ligament graft force and anterior tibial translation in response to applied pivoting and anterior Drawer loads.Am J Sports Med. 2020; 48: 3183-319310.1177/0363546520959322http://www.ncbi.nlm.nih.gov/pubmed/33017168Crossref PubMed Scopus (12) Google Scholar, 29Engebretsen L Lew WD Lewis JL et al.The effect of an iliotibial tenodesis on intraarticular graft forces and knee joint motion.Am J Sports Med. 1990; 18: 169-17610.1177/036354659001800210http://www.ncbi.nlm.nih.gov/pubmed/2343985Crossref PubMed Scopus (164) Google Scholar but an ALLR produces only a modest decrease.30Noyes FR Huser LE Jurgensmeier D et al.Is an anterolateral ligament reconstruction required in ACL-Reconstructed knees with associated injury to the anterolateral structures? A robotic analysis of rotational knee stability.Am J Sports Med. 2017; 45: 1018-102710.1177/0363546516682233http://www.ncbi.nlm.nih.gov/pubmed/28056513Crossref PubMed Scopus (66) Google Scholar The role of ALLR is still not well established and is currently not being broadly used in daily clinical practice, and thus, the biomechanical studies are still an important step to investigate the effect of adding an ALLR on the knee stability and contact pressures. Two of the studies published in this JISAKOS issue explore the biomechanics of anterolateral augmentation procedures in the setting of an ACL-deficient knee.3Neri T Dabirrahmani D Beach A Different anterolateral procedures have variable impact on knee kinematics and stability when performed in combination with anterior cruciate ligament reconstruction.J Isakos. 2021; 6: 74-8110.1136/jisakos-2019-000360Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar, 4Neri T Cadman J Beach A Lateral tenodesis procedures increase lateral compartment pressures more than anterolateral ligament reconstruction, when performed in combination with ACL reconstruction: a pilot biomechanical study.J Isakos. 2021; 6: 66-7310.1136/jisakos-2019-000368Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar Neri et al 3Neri T Dabirrahmani D Beach A Different anterolateral procedures have variable impact on knee kinematics and stability when performed in combination with anterior cruciate ligament reconstruction.J Isakos. 2021; 6: 74-8110.1136/jisakos-2019-000360Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar performed a cadaveric biomechanical study comparing ACL reconstruction isolated and combined with five different anterolateral augmentation procedures—ALLR and modified versions of Ellison, deep Lemaire, superficial Lemaire and MacIntosh LEAT procedures. They found that in the setting of an anterolateral-deficient knee, only the ALLR and Ellison procedures restored internal rotation laxity to the native intact state over the full range of knee flexion. The deep and superficial Lemaire and MacIntosh, although better controlling internal rotation, overconstrained the knee. The same group4Neri T Cadman J Beach A Lateral tenodesis procedures increase lateral compartment pressures more than anterolateral ligament reconstruction, when performed in combination with ACL reconstruction: a pilot biomechanical study.J Isakos. 2021; 6: 66-7310.1136/jisakos-2019-000368Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar performed a pilot biomechanical study on the tibiofemoral lateral compartment contact pressures after ACL reconstruction combined with the same five anterolateral procedures described in Neri and colleagues.3Neri T Dabirrahmani D Beach A Different anterolateral procedures have variable impact on knee kinematics and stability when performed in combination with anterior cruciate ligament reconstruction.J Isakos. 2021; 6: 74-8110.1136/jisakos-2019-000360Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar They found that the ACL reconstruction combined with ALLR or with the Ellison procedure did not change the contact pressures, while the Lemaire (either deep or superficial) and MacIntosh procedures increased the contact pressure during tibial internal rotation. However, this study only includes four specimens which highly increases the risk of type II error,and this should be taken into account when interpreting their findings. In opposition to their findings, conflicting evidence31Novaretti JV Arner JW Chan CK et al.Does lateral extra-articular Tenodesis of the knee affect anterior cruciate ligament graft in situ forces and Tibiofemoral contact pressures?.Arthroscopy. 2020; 36: 1365-137310.1016/j.arthro.2020.01.051http://www.ncbi.nlm.nih.gov/pubmed/32057987Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar has shown no significant increase in the tibiofemoral compartment after ACL reconstruction with LEAT and, despite that the findings from Neri et al 4Neri T Cadman J Beach A Lateral tenodesis procedures increase lateral compartment pressures more than anterolateral ligament reconstruction, when performed in combination with ACL reconstruction: a pilot biomechanical study.J Isakos. 2021; 6: 66-7310.1136/jisakos-2019-000368Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar that suggest an increased risk of knee overconstrain and subsequent risk of cartilage wear after ACL reconstruction with Lemaire and MacIntosh procedures, long-term clinical studies have shown no increase in the rate of knee osteoarthritis when a LEAT is added to the ACL reconstruction.32Devitt BM Bouguennec N Barfod KW et al.Combined anterior cruciate ligament reconstruction and lateral extra-articular tenodesis does not result in an increased rate of osteoarthritis: a systematic review and best evidence synthesis.Knee Surg Sports Traumatol Arthrosc. 2017; 25: 1149-116010.1007/s00167-017-4510-1http://www.ncbi.nlm.nih.gov/pubmed/28289822Crossref PubMed Scopus (56) Google Scholar Other biomechanical studies have reported opposite results when comparing traditional LEAT techniques and ALLR.33Inderhaug E Stephen JM Williams A et al.Biomechanical comparison of anterolateral procedures combined with anterior cruciate ligament reconstruction.Am J Sports Med. 2017; 45: 347-35410.1177/0363546516681555http://www.ncbi.nlm.nih.gov/pubmed/28027653Crossref PubMed Scopus (122) Google Scholar, 34Trentacosta N Pace JL Metzger M et al.Biomechanical evaluation of pediatric anterior cruciate ligament (ACL) reconstruction techniques with and without the anterolateral ligament (all).J Pediatr Orthop. 2020; 40: 8-1610.1097/BPO.0000000000001078http://www.ncbi.nlm.nih.gov/pubmed/31815856Crossref PubMed Scopus (11) Google Scholar Inderhaug et al 33Inderhaug E Stephen JM Williams A et al.Biomechanical comparison of anterolateral procedures combined with anterior cruciate ligament reconstruction.Am J Sports Med. 2017; 45: 347-35410.1177/0363546516681555http://www.ncbi.nlm.nih.gov/pubmed/28027653Crossref PubMed Scopus (122) Google Scholar showed that while deep Lemaire and MacIntosh procedures restored native rotational kinematics, the ALLR failed to restore normal internal rotation and underconstrained the knee. Trentacosta et al 34Trentacosta N Pace JL Metzger M et al.Biomechanical evaluation of pediatric anterior cruciate ligament (ACL) reconstruction techniques with and without the anterolateral ligament (all).J Pediatr Orthop. 2020; 40: 8-1610.1097/BPO.0000000000001078http://www.ncbi.nlm.nih.gov/pubmed/31815856Crossref PubMed Scopus (11) Google Scholar also showed that the LEAT technique using the iliotibial band better restored the intact kinematics as compared with ALLR. Other studies35Jette C Gutierrez D Sastre S et al.Biomechanical comparison of anterolateral ligament anatomical reconstruction with a semi-anatomical lateral extra-articular tenodesis. A cadaveric study.Knee. 2019; 26: 1003-100910.1016/j.knee.2019.07.005http://www.ncbi.nlm.nih.gov/pubmed/31427244Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar, 36Delaloye J-R Hartog C Blatter S et al.Anterolateral ligament reconstruction and modified Lemaire lateral extra-articular Tenodesis similarly improve knee stability after anterior cruciate ligament reconstruction: a biomechanical study.Arthroscopy. 2020; 36: 1942-195010.1016/j.arthro.2020.03.027http://www.ncbi.nlm.nih.gov/pubmed/32251683Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar, 37Smith PA Thomas DM Pomajzl RJ et al.A biomechanical study of the role of the anterolateral ligament and the deep Iliotibial band for control of a simulated pivot shift with comparison of minimally invasive extra-articular anterolateral tendon graft reconstruction versus modified Lemaire reconstruction after anterior cruciate ligament reconstruction.Arthroscopy. 2019; 35: 1473-148310.1016/j.arthro.2018.11.011http://www.ncbi.nlm.nih.gov/pubmed/30926192Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar have found comparable biomechanical outcomes between the two techniques and with no advantage of one over the other. Among other confounders, the results may vary between studies due to techniques employed and fixation angle and fixation site, as it has been shown that these can highly influence residual laxity after ALLR.38Katakura M Koga H Nakamura T et al.Biomechanical effects of additional anterolateral structure reconstruction with different femoral attachment sites on anterior cruciate ligament reconstruction.Am J Sports Med. 2019; 47: 3373-338010.1177/0363546519880192http://www.ncbi.nlm.nih.gov/pubmed/31657943Crossref PubMed Scopus (14) Google Scholar, 39Drews BH Kessler O Franz W et al.Function and strain of the anterolateral ligament Part II: reconstruction.Knee Surg Sports Traumatol Arthrosc. 2020; ([Epub ahead of print: 25 Jul 2020].)10.1007/s00167-020-06137-8http://www.ncbi.nlm.nih.gov/pubmed/32712685Crossref PubMed Scopus (1) Google Scholar Results from the pool of biomechanical studies discussed earlier suggest that anterolateral procedures using the LEAT seem to be superior in controlling rotational laxity due to ACL insufficiency,33Inderhaug E Stephen JM Williams A et al.Biomechanical comparison of anterolateral procedures combined with anterior cruciate ligament reconstruction.Am J Sports Med. 2017; 45: 347-35410.1177/0363546516681555http://www.ncbi.nlm.nih.gov/pubmed/28027653Crossref PubMed Scopus (122) Google Scholar, 34Trentacosta N Pace JL Metzger M et al.Biomechanical evaluation of pediatric anterior cruciate ligament (ACL) reconstruction techniques with and without the anterolateral ligament (all).J Pediatr Orthop. 2020; 40: 8-1610.1097/BPO.0000000000001078http://www.ncbi.nlm.nih.gov/pubmed/31815856Crossref PubMed Scopus (11) Google Scholar but no definitive conclusion still cannot be achieved due to some conflicting findings.35Jette C Gutierrez D Sastre S et al.Biomechanical comparison of anterolateral ligament anatomical reconstruction with a semi-anatomical lateral extra-articular tenodesis. A cadaveric study.Knee. 2019; 26: 1003-100910.1016/j.knee.2019.07.005http://www.ncbi.nlm.nih.gov/pubmed/31427244Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar, 36Delaloye J-R Hartog C Blatter S et al.Anterolateral ligament reconstruction and modified Lemaire lateral extra-articular Tenodesis similarly improve knee stability after anterior cruciate ligament reconstruction: a biomechanical study.Arthroscopy. 2020; 36: 1942-195010.1016/j.arthro.2020.03.027http://www.ncbi.nlm.nih.gov/pubmed/32251683Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar, 37Smith PA Thomas DM Pomajzl RJ et al.A biomechanical study of the role of the anterolateral ligament and the deep Iliotibial band for control of a simulated pivot shift with comparison of minimally invasive extra-articular anterolateral tendon graft reconstruction versus modified Lemaire reconstruction after anterior cruciate ligament reconstruction.Arthroscopy. 2019; 35: 1473-148310.1016/j.arthro.2018.11.011http://www.ncbi.nlm.nih.gov/pubmed/30926192Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar The addition of lateral augmentation procedures—either LEAT or ALLR—to ACL reconstruction remains one of the most controversial topics in ACL research, but their role in controlling high rotational laxity and protecting the graft in patients with high-risk profile has gained increasing support. Indeed, the Stability study40Getgood AMJ Bryant DM Litchfield R et al.Lateral extra-articular Tenodesis reduces failure of hamstring tendon autograft anterior cruciate ligament reconstruction: 2-year outcomes from the stability study randomized clinical trial.Am J Sports Med. 2020; 48: 285-29710.1177/0363546519896333http://www.ncbi.nlm.nih.gov/pubmed/31940222Crossref PubMed Scopus (89) Google Scholar has shown that adding a LEAT to an anatomical ACL reconstruction reduces the risk of clinical failure by 38% and graft rupture by 67% as compared with ACL reconstruction alone. In line with the renewed interest in LEAT, clinical studies41Helito CP Sobrado MF Giglio PN et al.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: 2648-265410.1016/j.arthro.2019.03.059http://www.ncbi.nlm.nih.gov/pubmed/31421960Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar, 42Hurley ET Fried JW Kingery MT et al.Antero-lateral ligament reconstruction improves knee stability alongside anterior cruciate ligament reconstruction.Knee Surg Sports Traumatol Arthrosc. 2020; ([Epub ahead of print: 22 Apr 2020] (Published Online First: 22 April 2020).)10.1007/s00167-020-06002-8http://www.ncbi.nlm.nih.gov/pubmed/32322949Google Scholar, 43Hamido F Habiba AA Marwan Y et al.Anterolateral ligament reconstruction improves the clinical and functional outcomes of anterior cruciate ligament reconstruction in athletes.Knee Surg Sports Traumatol Arthrosc. 2020; doi:10.1007/s00167-020-06119-wPubMed Google Scholar, 44Helito CP Camargo DB Sobrado MF et al.Combined reconstruction of the anterolateral ligament in chronic ACL injuries leads to better clinical outcomes than isolated ACL reconstruction.Knee Surg Sports Traumatol Arthrosc. 2018; 26: 3652-365910.1007/s00167-018-4934-2http://www.ncbi.nlm.nih.gov/pubmed/29610972Crossref PubMed Scopus (57) Google Scholar have reported the results of combined ACL and ALLR, suggesting superior outcomes when compared with ACL reconstruction alone. In patients displaying high-grade pivot-shift, the addition of LEAT45Rowan FE Huq SS Haddad FS Lateral extra-articular tenodesis with ACL reconstruction demonstrates better patient-reported outcomes compared to ACL reconstruction alone at 2 years minimum follow-up.Arch Orthop Trauma Surg. 2019; 139: 1425-143310.1007/s00402-019-03218-3http://www.ncbi.nlm.nih.gov/pubmed/31297583Crossref PubMed Scopus (9) Google Scholar, 46Alm L Drenck TC Frosch K-H et al.Lateral extra-articular tenodesis in patients with revision anterior cruciate ligament (ACL) reconstruction and high-grade anterior knee instability.Knee. 2020; 27: 1451-145710.1016/j.knee.2020.06.005http://www.ncbi.nlm.nih.gov/pubmed/33010761Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar or ALLR47Yoon KH Hwang IU Kim EJ et al.Anterolateral ligament reconstruction improves anteroposterior stability as well as rotational stability in revision anterior cruciate ligament reconstruction with high-grade pivot shift.J Knee Surg. 2020; ([Epub ahead of print: 05 May 2020] (Published Online First: 5 May 2020).)10.1055/s-0040-1708055http://www.ncbi.nlm.nih.gov/pubmed/32369841Google Scholar, 48Ibrahim SA Shohdy EM Marwan Y et al.Anatomic reconstruction of the anterior cruciate ligament of the knee with or without reconstruction of the anterolateral ligament: a randomized clinical trial.Am J Sports Med. 2017; 45: 1558-156610.1177/0363546517691517http://www.ncbi.nlm.nih.gov/pubmed/28293966Crossref PubMed Scopus (64) Google Scholar seem to result in significant improvement in controlling rotational laxity. However, in patients where concomitant high-grade ALL injury is present, Ahn et al 49Ahn JH Lee SK Mun JW et al.Degree of anterolateral ligament injury impacts outcomes after Double-Bundle anterior cruciate ligament reconstruction.Arthroscopy. 2021; 37: 222-23010.1016/j.arthro.2020.09.003http://www.ncbi.nlm.nih.gov/pubmed/32949631Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar have showed that there may be an increased risk of residual rotational laxity, even when an ALLR is performed; however, these results should be viewed with caution as there are some limitations associated with unbalanced groups in the sample size and the poor capability of MRI to discriminate the grade of ALL injuries.20Andrade R Rebelo-Marques A Bastos R et al.Identification of normal and injured anterolateral ligaments of the knee: a systematic review of magnetic resonance imaging studies.Arthroscopy. 2019; 35: 1594-161310.1016/j.arthro.2018.10.120http://www.ncbi.nlm.nih.gov/pubmed/31000390Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar, 50Hohmann E Editorial commentary: another take on the anterolateral ligament: high-grade are worse than low-grade injuries, but the categorization is problematic.Arthroscopy. 2021; 37: 231-23310.1016/j.arthro.2020.10.022http://www.ncbi.nlm.nih.gov/pubmed/33384084Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar In a similar fashion, when the LEAT or ALLR augmentation procedures are performed during ACL reconstruction revision cases, the addition of these augmentation procedures shows similar clinical and functional outcomes when comparing to isolated ACL revision, but displays a better control of rotational laxity.47Yoon KH Hwang IU Kim EJ et al.Anterolateral ligament reconstruction improves anteroposterior stability as well as rotational stability in revision anterior cruciate ligament reconstruction with high-grade pivot shift.J Knee Surg. 2020; ([Epub ahead of print: 05 May 2020] (Published Online First: 5 May 2020).)10.1055/s-0040-1708055http://www.ncbi.nlm.nih.gov/pubmed/32369841Google Scholar, 51Grassi A Zicaro JP Costa-Paz M et al.Good mid-term outcomes and low rates of residual rotatory laxity, complications and failures after revision anterior cruciate ligament reconstruction (ACL) and lateral extra-articular tenodesis (let).Knee Surg Sports Traumatol Arthrosc. 2020; 28: 418-43110.1007/s00167-019-05625-whttp://www.ncbi.nlm.nih.gov/pubmed/31324964Crossref PubMed Scopus (23) Google Scholar, 52Lee DW Kim JG Cho SI et al.Clinical outcomes of isolated revision anterior cruciate ligament reconstruction or in combination with anatomic anterolateral ligament reconstruction.Am J Sports Med. 2019; 47: 324-33310.1177/0363546518815888http://www.ncbi.nlm.nih.gov/pubmed/30640514Crossref PubMed Scopus (45) Google Scholar, 53Ventura A Legnani C Boisio F et al.The association of extra-articular tenodesis restores rotational stability more effectively compared to contralateral hamstring tendon autografts ACL reconstruction alone in patients undergoing ACL revision surgery.Orthop Traumatol Surg Res. 2020; ([Epub ahead of print: 31 Dec 2020] (Published Online First: 31 December 2020).)10.1016/j.otsr.2020.06.022http://www.ncbi.nlm.nih.gov/pubmed/33390331PubMed Google Scholar Although both procedures seem to play a meaningful clinical role as an augmentation in primary and revision ACL reconstructions, the role of the ALL in restoring the knee native kinematics is still controversial, with some studies demonstrating no significant contribution of the ALL in controlling tibial internal rotation.54Lagae KC Robberecht J Athwal KK et al.Acl reconstruction combined with lateral monoloop tenodesis can restore intact knee laxity.Knee Surg Sports Traumatol Arthrosc. 2020; 28: 1159-116810.1007/s00167-019-05839-yhttp://www.ncbi.nlm.nih.gov/pubmed/31980844Crossref PubMed Scopus (8) Google Scholar, 55Kittl C El-Daou H Athwal KK et al.The role of the anterolateral structures and the ACL in controlling laxity of the intact and ACL-Deficient knee.Am J Sports Med. 2016; 44: 345-35410.1177/0363546515614312http://www.ncbi.nlm.nih.gov/pubmed/26657572Crossref PubMed Scopus (193) Google Scholar, 56Araki D Matsushita T Hoshino Y et al.The anterolateral structure of the knee does not affect anterior and dynamic rotatory stability in anterior cruciate ligament injury: quantitative evaluation with the electromagnetic measurement system.Am J Sports Med. 2019; 47: 3381-338810.1177/0363546519879692http://www.ncbi.nlm.nih.gov/pubmed/31657944Crossref PubMed Scopus (8) Google Scholar More importantly, we still do not know which technique will yield better clinical outcomes and a greater reduction of the risk of graft tear. Future research should focus on high-powered and high-quality randomised controlled trials comparing ACL reconstruction combined with either LEAT or ALLR with systematic approaches (surgical indications, graft selection, surgical technique, graft positioning and fixation) to investigate if there is any superiority of any of these techniques in clinical improvement, laxity restoration and risk of graft tear. Future clinical trials comparing both techniques and with long-term follow-up should shed light on the effect of the potential risk of overconstraining the knee in the incidence of knee osteoarthritis. Only time will tell if the ALL will be the smoking gun to explain rotational knee laxity or if it will be just another vaporware. Paediatric knee anterolateral capsule does not contain a distinct ligament: analysis of histology, immunohistochemistry and gene expressionJournal of ISAKOSVol. 6Issue 2PreviewThe 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). Full-Text PDF Open AccessDifferent anterolateral procedures have variable impact on knee kinematics and stability when performed in combination with anterior cruciate ligament reconstructionJournal of ISAKOSVol. 6Issue 2PreviewThe optimal anterolateral procedure to control anterolateral rotational laxity of the knee is still unknown. The objective was to compare the ability of five anterolateral procedures performed in combination with anterior cruciate ligament reconstruction (ACLR) to restore native knee kinematics in the setting of a deficient anterior cruciate ligament (ACL) and anterolateral structures. Full-Text PDF Open AccessLateral tenodesis procedures increase lateral compartment pressures more than anterolateral ligament reconstruction, when performed in combination with ACL reconstruction: a pilot biomechanical studyJournal of ISAKOSVol. 6Issue 2PreviewGiven the common occurrence of residual laxity and re-injury post anterior cruciate ligament reconstruction (ACLR), additional anterolateral procedures are increasingly used in combination with an ACLR. Despite the perception that there is a risk of over-constraining the lateral tibiofemoral (LTF) compartment, potentially leading to osteoarthritis, assessment on their effect on intra-articular compartment pressures is still lacking. Our objective was therefore, through a pilot biomechanical study, to compare LTF contact pressures after the most commonly used anterolateral procedures. Full-Text PDF Open Access
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