Recently the Anterolateral ligament has been suggested as an important anatomical structure for rotational stability of the knee? What is your opinion on the relevance of this structure?
Dear Philipp
Last month, knee surgeons from the University Hospitals Leuven in Belgium announced that they had found a new knee ligament (ALL - Anterolateral Ligament), one that had not previously been specifically identified despite untold numbers of past knee dissections and scans. This surprising announcement, in The Journal of Anatomy, should improve our understanding of how the knee works and why some knee surgeries disappoint and also underscores the continually astonishing complexity of human anatomy.
The orthopedic surgeons Dr. Steven Claes and Dr. Johann Bellemans and their colleagues gathered 41 knee joints from human cadavers and began minutely dissecting them.Positioned at the front of the knee, it would be vulnerable to tearing when an A.C.L. was injured; the same forces would move through both ligaments. In my opinion more studies are needed to determine the real importance of this ligament
Dear Nelson, thanks for your comprehensive answer. Although this structure has been described earlier by various surgeons, the study you mentioned was certainly the study my question referred to and this study certainly provided the most detailed anatomical description of the ALL. Furthermore, the potential relevance of the ALL has certainly been pointed out by this publication. Nevertheless, my question yielded more to figure out wether the scientists in this forum believe in the idea of the importance of this ligament. Any opinions & comments are welcome ...
The ALL was described by Kaplan in 1958. He thought it was "an accesssory anterior lateral ligament of the knee."
The ligament contributes to the rotational stability and should be evaluated in all repairs of the ACL. Along with the popliteus tendon, the ALL provides rotational stability. In my book entitled "Reflections and Conclusions about the Problem Knee" there is a discussion of the anatomy of the ligament and the relationship to the ACL injuries.
Dudley A Ferrari M.D.
The recent Belgian study was nothing more than dissections of embalmed cadavers. It is a huge leap from there to declare that the ALL is an important part of knee stability, much less to recommend reconstruction of this "ligament" (which is actually a capsular thickening) as a part of ACL reconstruction.
Dear All,
the first description of this ligament was in 1869 by a french surgeon named Segond;
it existes really and a very reliable symptom , when we have an ACL injury is as we know since more than 20 years but not published, a pain when we press at this place (especially when patient is seen after many hours and pivot shift not possible because of too much tense)
Philipp, I think this is a very interesting topic.
Although the classic concept of anterolateral rotatory knee instability developed by Hughston [JBJS Am 1976], already implied a combination of injuries to both the ACL and the “anterolateral stabilizing structures”, this interesting notion has seemingly become obsolete under the boom of arthroscopic surgery .
The existence of a “pearly, fibrous band” at the anterolateral aspect of the human knee was already described by dr. Segond In 1879 [Progres Med 1879]. This structure can also cause a small avulsion fracture at the level of the anterolateral tibia, also known as Segond’s fracture. To date, the enigma surrounding this anatomical structure is reflected in confusing names like “(mid-third) lateral capsular ligament”, “capsulo-osseous layer of the ITB”, or “anterolateral ligament”, and no clear function has yet been attributed to it. The high incidence of anterolateral ligament lesions on MR images of ACL-injured subjects and its causative relationship with a high-grade pivot-shift, stimulated researchers to better investigate the anatomy and function of the antero-lateral ligaments of the knee and understand the interaction between anterolateral ligament and ACL [SE73 Bellemans AAOS Metting 2013, Chicago]. In this scenario, a return to extrarticular anterolateral tenodeses combined with classic ACL reconstruction can be hypothesized.
In my experience, performing an anterolateral plasty is sometimes the only way to reduce the pivot shift. In selected cases, (i.e. ACL revision and High grade pivot shift) I perform the Marcacci technique [Marcacci KSSTA 1998, Zaffagnini KSSTA 2006, Marcacci AJSM 2009] with good results so far (around 15 cases). It is easy, reliable, inexpensive (3 richard's staples for fixation), and can be performed both with autologous HS and allografts. Drawbacks: the non anatomic over the top femoral position of the graft (in ACL revision with prior correct femoral tunnel placement, the over the top position can also be an advantage), the discomfort at the level of the proximal staples.
For those interested, my co-authors and I will present a video at the multimedia Theater this year at the AAOS annual meeting in New Orleans, discussing this technique with a brief intro on the ALL.
Avulsed ALL appears to represent the Sigond fracture which had been used as a pathognomonic feature of an existing ACL injury. However whether we should be repairing this ligament in an ACL deficient knee in order to get better knee anatomy needs to be substantiated with more studies.
the ACL controls the screw home mechanism of the knee. antero-subluxation occurs between 0-30 degrees if the screw home does not occur{i.e. if there is an absent ACL]. The capsular ligaments give proprioceptive feedback to the hamstrings and it is difficult to bio-mechanically understand how such a variable ligament could oppose such a force. When we wrote the article with Dr Hughston, i always had difficulty explaining its significance in the majority of cases. there is no doubt the Secund fracture coincides with ACL failure, but obviously not in every case.
Mervyn Cross
Cite
Harald Boszotta
Hospital of the Brothers of Mercy
Dealing with this Problem we saw a high rate of degenerative changes in the lateral compartment ,depending on the Point of Fixation on the lateral Condyle.
Article Physiopathology of the knee joint after distal iliotibial ba...
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