Fig 3 - uploaded by Nathanael Heckmann
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The origin and insertion of the anterolateral ligament (ALL) are represented by blue and green dots, respectively. The origin of the ALL is positioned 9 mm distal to Blumensaat's line and 5 mm posterior to the posterior femoral condylar line, and the ALL insertion is positioned 4 mm anterior to the 50% anterior-posterior width (i.e., vertical green line) 14 mm below the articular surface. The lateral femoral epicondyle (LFE) and Gerdy's tubercle (GT) are marked by the dashed lines.
Source publication
Purpose:
To identify the radiographic position of the origin and insertion of the anterolateral ligament (ALL) of the knee on a lateral radiograph.
Methods:
Twelve unpaired, fresh-frozen cadaveric knees were dissected to expose the ALL. The origin and insertion of the ALL on each cadaver were then tagged using 2-mm radiopaque beads. True lateral...
Contexts in source publication
Context 1
... 12 lateral radiographs were then standardized using the AP lengths of the femur and tibia as refer- ences. The pixel locations of the origin and insertion were placed on the AP axis of the femur and tibia as a percentage of the total AP length and then plotted on one standard lateral radiograph (Fig 3). ...
Context 2
... our findings, we suggest that the origin of the ALL be positioned at a point 5 mm posterior to a line drawn from the posterior cortex of the femoral diaph- ysis and 9 mm distal to a line drawn along Blumensaat's line (Fig 3). We recommend that the insertion be placed 4 mm anterior to the 50% mark of the AP width of the tibia and 14 mm distal to the articular surface. ...
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PURPOSE: To identify the radiographic position of the origin and insertion of the anterolateral ligament (ALL) of the knee on a lateral radiograph.
METHODS: Twelve unpaired, fresh-frozen cadaveric knees were dissected to expose the ALL. The origin and insertion of the ALL on each cadaver were then tagged using 2-mm radiopaque beads. True lateral fl...
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Citations
... Accurate identification of the radiographic landmarks allows not only for minimally invasive reconstruction surgery, but also for a reconstruction which closely mimics the patient's natural anatomy [41,77]. With regard to the ALL, there are four published studies that focus on its radiographic landmarks [28,33,42,72]. These studies reveal differences in the femoral landmark and similarities in the tibial landmark. ...
... described the ALL origin as being along the posterior femoral cortical line, positioned between Blumensaat's line and a line taken from the posterior condylar articular edge parallel to Blumensaat's line. Heckmann et al. located the ALL origin at a distance of around 37% from the posterior edge of the femoral condyle, measured along Blumensaat's line [28]. ...
... On a lateral view, the tibial landmark was found slightly posterior to the centre of the tibial plateau width by Helito et al. [33] and Kennedy et al. [32,42] and slightly anterior to the centre of the tibial plateau width by Heckmann et al. [28]. However, Rezansoff et al. [72], described the tibial attachment as more posterior to the location identified by the other authors (Fig. 2). ...
Purpose of this paper is to provide an overview of the latest research on the anterolateral ligament (ALL) and present the consensus of the ALL Expert Group on the anatomy, radiographic landmarks, biomechanics, clinical and radiographic diagnosis, lesion classification, surgical technique and clinical outcomes. A consensus on controversial subjects surrounding the ALL and anterolateral knee instability has been established based on the opinion of experts, the latest publications on the subject and an exchange of experiences during the ALL Experts Meeting (November 2015, Lyon, France). The ALL is found deep to the iliotibial band. The femoral origin is just posterior and proximal to the lateral epicondyle; the tibial attachment is 21.6 mm posterior to Gerdy’s tubercle and 4–10 mm below the tibial joint line. On a lateral radiographic view the femoral origin is located in the postero-inferior quadrant and the tibial attachment is close to the centre of the proximal tibial plateau. Favourable isometry of an ALL reconstruction is seen when the femoral position is proximal and posterior to the lateral epicondyle, with the ALL being tight upon extension and lax upon flexion. The ALL can be visualised on ultrasound, or on T2-weighted coronal MRI scans with proton density fat-suppressed evaluation. The ALL injury is associated with a Segond fracture, and often occurs in conjunction with acute anterior cruciate ligament (ACL) injury. Recognition and repair of the ALL lesions should be considered to improve the control of rotational stability provided by ACL reconstruction. For high-risk patients, a combined ACL and ALL reconstruction improves rotational control and reduces the rate of re-rupture, without increased postoperative complication rates compared to ACL-only reconstruction. In conclusion this paper provides a contemporary consensus on all studied features of the ALL. The findings warrant future research in order to further test these early observations, with the ultimate goal of improving the long-term outcomes of ACL-injured patients.
Level of evidence Level V—Expert opinion.
Background
Lateral collateral ligament (LCL) injuries are implicated in varus instability of the knee. Often, these accompany other ligamentous injuries including anterior cruciate ligament (ACL), posterior cruciate ligament (PCL) tears, and injury to the anterolateral capsular complex (ALCC). Use of internal brace augmentation with anatomic repair is an alternative to reconstruction to improve patient outcomes and facilitate early range of motion and weight bearing.
Indications
We present a case of an anatomic repair of a LCL and an ALCC injury with internal brace augmentation.
Technique Description
A curvilinear incision centered over the lateral epicondyle is used. The avulsed LCL and biceps tendon was exposed and a placed #5 FiberWire was placed into the distal LCL, biceps tendon, and the popliteofibular ligament. A split was made in the iliotibial (IT) band and a second #5 FiberWire was placed proximally in the LCL/biceps tendon for additional fixation. A tunnel was made in the fibular head and tibia using a 2.4-mm beath pin and the two #5 FiberWires were passed to the anteromedial tibia. The FiberWires were fixed to the tibia using a 14-mm attachable button system (ABS) manhole cover for suspensory fixation. Repair and internal bracing of the anterolateral capsular complex was accomplished with 2 interlocked TightRopes and a #2 FiberTape. This fixation method achieved repair by compressing the anterolateral capsular complex onto its tibial origin. The suture devices also served to augment the repair and were fixed proximally to the femur using another 14-mm ABS manhole cover. The FiberTape was fixed to the anterolateral tibia distally with a 4.5 mm SwiveLock. The TightRopes were passed through a tunnel to the anterolateral tibia and secured using an ABS Dog Bone. The construct was tensioned in near full extension and gapping was matched fluoroscopically to the contralateral knee.
Results
Patient was cleared for full return to sports 9 months postoperatively. At the final follow up visit, the patient had excellent strength, stability, and 135° range of motion on the operative knee. Patient had returned to exercise at home but was unable to return to sports due to COVID-19 restrictions.
Conclusion
Anatomic repair of the LCL and the ALCC with internal brace augmentation can serve as an effective alternative to reconstruction and demonstrates excellent patient outcomes regarding restoring stability, ROM, and return to preoperative sports.
The following case report is of a 36 year old female with a BMI of 43 with a Schenck Knee Dislocation (KD) 4 ligament us knee injury who underwent anterior cruciate ligament (ACL), posterior cruciate ligament (PCL) and posterolateral corner (PLC) reconstruction with allograft that subsequently required revision lateral collateral ligament (LCL) and lateral capsule reconstruction with internal brace augmentation to treat persistent varus instability. Keywords: Multiligament; Knee; Injury; Internal; Brace; Dislocation
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.
Résumé
Introduction
La rupture du ligament croisé antérieur est une pathologie fréquente. L’IRM reste à ce jour l’examen de référence pour le diagnostic de rupture et la recherche des lésions associées (méniscales, ligamentaires, tendineuses, osseuses et cartilagineuses) afin d’aider au mieux le chirurgien orthopédique.
Données récentes
Le LCA est une structure bi-fasciculaire avec un faisceau antéro-médial (FAM) et un faisceau postéro-latéral (FPL). La radiographie doit orienter vers des signes indirects de rupture comme l’avulsion du massif spinal (plus fréquent chez l’enfant), la fracture de Segond (reflet d’une atteinte du ligament antéro-latéral) ou la fracture de la tête fibulaire (reflet d’une atteinte du point d’angle postéro-latéral). L’IRM reste à ce jour l’examen de référence, à réaliser idéalement 3 à 4 semaines après le traumatisme. En plus des séquences habituelles, des séquences plus spécifiques sont possibles, en cas de doute sur une rupture partielle notamment. Les signes directs (interruption ligamentaire) mais aussi indirects (tels les contusions osseuses) permettent de confirmer le diagnostic, en particulier s’il existe des doutes quant à une rupture partielle. La description des lésions associées représente l’enjeu majeur de l’IRM avec notamment la recherche de lésions méniscales, ostéochondrales, ligamentaires ou l’atteinte des points d’angle.
Conclusion
L’IRM permet de rechercher les signes directs et indirects de rupture. Son but principal n’est pas tant la confirmation de rupture du LCA, déjà souvent diagnostiquée par le chirurgien orthopédique, mais bien le bilan des lésions associées qui modifiera la prise en charge chirurgicale. Il faudra préciser le type de rupture en utilisant en cas d’hésitation entre rupture partielle ou complète des séquences spécifiques (3D millimétriques ou « BIF-TECH » par exemple).
Identifying the structures of the lateral knee is critical during knee posterolateral corner reconstruction. Several methods exist that can help estimate the femoral insertions of these structures on lateral radiographs. However, it is important to recognize the limitations of these methods and that anatomic visualization is often more practical and more accurate. Until percutaneous or more minimally invasive techniques become standardized, intraoperative fluoroscopy is seldom needed or used for posterolateral corner reconstruction, whereas radiographic analysis of lateral knee structures could be of benefit in cases of failed reconstruction to assess tunnel placement.
Purpose
To compare previously described radiographic parameters for the localization of lateral knee (LK) structures, including the popliteus tendon (Pop), anterolateral ligament (ALL), and lateral collateral ligament (LCL) to determine which method best estimates the femoral attachment of each LK structure.
Methods
Twenty-nine human cadaveric knee specimens were carefully dissected to identify the LCL, ALL and Pop. The femoral attachment for each structure was labeled with a radiopaque bead. LK radiographic images were obtained using fluoroscopy. Two radiographic approaches were used to identify each LK structure (Pop-A, Pop-B, LCL-A, LCL-B, ALL-A, and ALL-B) using previously published methods based on radiographic landmarks including the posterior femoral cortex and Blumensaat’s line. The identification of radiographic landmarks was repeated at two different time points by two different surgeons to determine a Pearson’s correlation between values as well as inter- and intra-observer reliability and reproducibility. A paired t-test was conducted to compare the distance from the actual attachment site (as determined by the bead location) and the two radiographically identified estimations of attachment locations.
Results
For the LCL, the mean difference between the actual location and the estimated location via application of LCL-B method (5.0mm ± 2.4) was significantly less than that estimated using LCL-A (8.2mm ± 3.3), p<.0001. Likewise, methods Pop-B (5.7mm ± 2.0) and ALL-B (9.3mm ± 4.5) were shown to have a smaller difference between the actual and estimated femoral attachment site of the popliteus tendon insertion and the ALL insertion, respectively, p<0.0001. Methods for estimating the ALL femoral origin were the worst of the LK structures analyzed, with 90% of estimated values > 5 mm from its anatomic origin. Inter- and intra-observer interclass correlation coefficients were 0.785 or higher.
Conclusion
Previously described radiographic methods for localization of the femoral attachment sites of lateral knee structures resulted in estimated locations that were significantly different than the locations of the radiographic beads placed at the anatomic femoral attachment site of these structures. Therefore, radiographic methods used to localize the femoral attachments of the lateral knee structures may not be reliable.
Clinical relevance
This study demonstrates the variability of anatomy of lateral knee structures and the lack of reproducible radiographic criteria to identify these structures. As a result, there will be decreased reliance on radiographic landmarks to identify the placement femoral grafts and fixation when reconstructing these structures.
Background
To determine the influence of anterolateral ligament reconstruction (ALLR) on knee constraint through the analysis of knee abduction (valgus) moment when the knee is subjected to external translational (anterior) or rotational (internal) loads.
Methods
A knee computer model simulated from a three-dimensional computed tomography scan of healthy male was implemented for this study. Three groups were designed: (1) intact knee, (2) combined Anterior Cruciate Ligament (ACL) and Antero-Lateral Complex (ALC) deficient knee, and (3) combined ACL and Antero- lateral Ligament (ALL) reconstructed knee. The reconstructed knee group was subdivided into four groups according to attachment of reconstructed anterolateral ligament to the femoral epicondyle. Each group of simulated knees was placed at 0°, 10°, 20°, 30°, 40° and 50° of knee flexion. For each position an external anterior (drawer) 90-N force or a five-newton meter internal rotation moment was applied to the tibia. The interaction effect between the group of knees and knee flexion angle (0–50°) on knee kinematics and knee abduction moment under external loads was tested.
Results
When reconstructed knees were subjected to a 90-N anterior force or a five-newton meter internal rotation moment there was significant reduction in anterior translation and internal rotation compared with deficient knees. Only the ALLR procedure using posterior and proximal femoral attachment sites for graft fixation combined with ACL reconstruction allowed similar mechanical behavior to that observed in the intact knee.
Conclusions
Combined ACL and ALLR using a minimally invasive method in an anatomically reproducible manner prevents excessive anterior translation and internal rotation. Using postero-proximal femoral attachment tunnel for reconstruction of ALL does not produce overconstraint of the lateral tibiofemoral compartment.
» The femoral attachment of the anterolateral ligament (ALL) of the knee is still under debate, but the tibial attachment is consistently between Gerdy’s tubercle and the fibular head. The structure is less identifiable and more variable in younger patients.
» The ALL likely plays a role in rotational stability, but its impact on anterior stability is less clear.
» Numerous ALL reconstruction techniques have been described. Biomechanical analysis of these techniques has not shown clear benefits, but this literature is limited by the heterogeneity of techniques, graft choices, and study methodology.
» Clinical studies of combined anterior cruciate ligament (ACL) and ALL reconstruction are few but promising in lowering the risk of an ACL reinjury.
» To our knowledge, there are no studies showing the clinical outcomes of combined ACL and ALL reconstruction in pediatric patients, who are at higher risk for ACL graft failure than adults.
Background: Clinical testing has demonstrated the role of the anterolateral ligament (ALL) in controlling anterolateral laxity and knee instability at high angles of flexion. Few studies have discussed the association between an anterior cruciate ligament (ACL) injury and ALL injury, specifically after residual internal rotation and a post-ACL reconstruction positive pivot-shift that could be attributed to ALL injury. The goal of this study was to assess the correlation between ALL injury and ALL injury with concomitant ACL injury using MRI.
Material and Methods: This was a retrospective study of 246 patients with unilateral ACL knee injuries from a database that was reexamined to identify whether ALL injuries occurred in association with ACL injuries. We excluded the postoperative reconstructed cases. The charts were reviewed on the basis of the presence or absence of diagnosed ACL injury with no regard for age or sex.
Results: Of the 246 patients with ACL injury, there were 165 (67.1%) patients with complete tears, 55 (22.4%) with partial tears, and 26 (10.6%) with sprains. There were 176 (71.5%) patients with ALL and associated ACL injuries, whereas 70 (28.5%) did not have associated ACL injuries. There was a significant statistical relationship between ACL and ALL injuries (P<0.0001).
Conclusions: There is high incidence of ALL tears associated with ACL injuries. Clinicians should be aware of this injury and consider the possibility of simultaneous ALL and ACL repair to prevent further knee instability.
