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Ultrasound-Guided Percutaneous Reconstruction of the Anterolateral Ligament: Surgical Technique and Case Report
Restoring native kinematics of the knee has been a primary goal of anterior cruciate ligament (ACL) procedures. Double-bundle ACL reconstruction, compared to single-bundle, has been hypothesized to more effectively re-establish rotational stability by re-creating the anatomic ACL, but has not yet proven to result in better clinical outcomes.1
In 1879, Dr. Paul Segond described a “fibrous, pearly band” at the lateral aspect of the knee that avulsed off the anterolateral proximal tibia during many ACL injuries.2 The role of the lateral tissues in knee stability and their relationship with ACL pathology has attracted noteworthy attention in recent time. There have been multiple studies presenting an anatomical description of a structure at the anterolateral portion of the knee with definitive femoral, meniscal, and tibial attachments, which helps control internal rotational forces.3-7 Claes and colleagues4 later found that band of tissue to be the anterolateral ligament (ALL) and determined its injury to be pathognomonic with ACL ruptures.
The ALL is a vital static stabilizer of the tibio-femoral joint, especially during internal tibial rotation.8-10 In their report on ALL and ACL reconstruction, Helito and colleagues11 acknowledge the necessity of accurate assessment of the lateral structures through imaging to determine the presence of extra-articular injury. Musculoskeletal diagnostic ultrasound has been established as an appropriate means to identify the ALL.12
Ultrasound can accurately determine the exact anatomic location of the origin and insertion of the ALL. Reconstruction of the ALL could yield better patient outcomes for those who experience concurrent ACL/ALL injury. Here we present an innovative technique for an ultrasound-guided percutaneous method for reconstruction of the ALL and report on a patient who had underwent ALL reconstruction.
Surgical Indications
All patients undergo an ultrasound evaluation preoperatively to determine if the ALL is intact or injured. Our experience has shown that when ultrasound evaluation reveals an intact ALL, the pivot shift has never been a grade III. 
Surgical Technique
For a demonstration of this technique, see the video that accompanies this article.
The pivot shift test is conducted under anesthesia to determine whether an ALL reconstruction is required. The patient is placed in a supine position with the knee flexed at 30o, at neutral rotation, and without any varus or valgus stress. 
A No. 15 blade is used to make a small incision centered on each spinal needle. The spinal needle is replaced with a 2.4-mm drill pin (Figure 2). 
The graft and FiberTape are then passed under the IT band to the distal incision. Using the length of the BioComposite SwiveLock anchor as a guide, a mark is made on the graft after tensioning the construct in line with the leg, distal to the tibial drill pin (Table 2, Figure 4). 
Rehabilitation
Rehabilitation following an ALL procedure is similar to traditional ACL rehabilitation with an added emphasis on minimizing rotational torque of the tibia in the early stages. 
Case Report
In January 2013, a 17-year-old male soccer player suffered an ACL rupture of his right knee. Later that spring, he had an ACL reconstruction with an allograft. Twelve months postoperatively, the patient returned, saying that he felt much better; however, anytime he tried to plant his foot and rotate over that fixed foot, his knee felt unstable. The physical examination revealed both negative Lachman and anterior drawer tests but a I+ pivot shift test. A magnetic resonance imaging (MRI) examination revealed an intact ACL graft. A diagnostic ultrasound evaluation revealed a distal ALL injury. After discussing the risks, benefits, and goals with the patient, we opted for a diagnostic arthroscopy and a percutaneous, ultrasound-guided reconstruction of the ALL.
Postoperatively, the patient did very well. One week after surgery, he returned, saying he felt completely stable and demonstrated by repeating the rotation of his knee. The patient continued to have no issues until he returned 13 months post-ALL surgery, complaining of a recent injury that had caused the return of his feelings of instability. An MRI evaluation showed an intact ACL graft and the possibility of a ruptured ALL. Fifteen months after the initial ALL reconstruction, we proceeded with surgery. At arthroscopy, the patient was found to have a pivot shift of I+ and an intact ACL graft. The ALL was reconstructed again using an allograft, internal brace, and bone marrow concentrate. At 13 months post-ALL reconstruction revision, the patient had no complaints.
Discussion
Reconstruction of the ALL is aimed to restore anatomic rotational kinematics. Sonnery-Cottet and colleagues14 have reported promising initial results in their 2-year follow-up study of combined ACL and ALL reconstruction outcomes. This surgical technique includes use of an internal brace, which negates the necessity for external support devices and allows for earlier mobilization of the joint. A reconstruction of the ALL, performed concurrently with the ACL, does not add recovery time, but could prevent postsurgical complications and improve rehabilitation by eliminating rotational instability that presents in some ACL-reconstructed patients.
Sonnery-Cottet and colleagues15 state that their arthroscopic identification of the ALL can help to cultivate a “less invasive and more anatomic” reconstruction. The use of musculoskeletal ultrasound allows our technique to utilize a completely noninvasive imaging tool that allows proper establishment of ALL anatomy prior to the procedure. The entirety of the ALL is easily identifiable,4,12 which has proven to be shortcoming of MRI evaluation.15-17 Accurate preoperative assessment of the lateral structures is necessary in ACL-deficient individuals.11,15 Sonography also provides a means of accurate guidance and socket creation, without generating large incisions.
If the ALL is responsible for internal rotatory stability as asserted, the structure should exhibit biomechanical properties during movement. In their study on the function of the ligament, Parsons and colleagues9 established the inverse relationship between the ALL and ACL during internal rotation. As their cadaveric knees were subjected to an internal rotatory force through increasing angles of flexion, the contribution of the ALL towards stability significantly increased while the ACL declined. Helito and colleagues8 and Zens and colleagues10 have demonstrated length changes of the ligament through varying degrees of flexion and internal rotation. Their reports indicate greater tension during knee movements, coinciding with the description of increasing ALL stability contribution by Parsons and colleagues.9 Kennedy and colleagues7 conducted a pull-to-failure test on the ALL. The average failure load was 175 N with a stiffness of 20 N/mm, illustrating the structure is a candidate for most traditional soft tissue grafts. The biomechanical evidence of the structural properties of the ALL confirms its importance in knee function and the necessity for its reconstruction.
With the understanding that ACL contributes to rotatory stability to some extent, the notion begs the question of how a centrally located ligament is able to prevent excessive rotation in a structure with a large relative radius. Biomechanically, with such a small moment arm, the ACL would experience tremendous stress when a rotatory force is applied. The same torque applied to a more superficial structure, with a greater moment, would sustain a large reduction in the applied force. The concept of a wheel and an axle should be considered. The equation is F1 × R1 = F2 × R2. We measured on a cadaveric knee the distance from the center of rotation to the ACL and the ALL, finding the radii were 5 mm and 30 mm, respectively. Taking these measurements, we would then expect the force experienced on the axle (ACL) to be 6 times greater than what would be experienced on the periphery of the wheel (ALL). The ALL (wheel) has a significant biomechanical advantage over the ACL (axle) in controlling and enduring internal rotatory forces of the knee. This would imply that if the ALL were damaged and not re-established, the ACL would experience a 6 times greater force trying to control internal rotation, which would result in a significantly increased chance of failure and rupture.
While there is a degree of dissent on the presence of the ALL, a number of studies have classified the tissue as an independent ligamentous structure.3-7 While there is disagreement on the precise location of the femoral attachment, there is a consensus on the location of the tibial and meniscal attachments. Claes and colleagues4 originally outlined the femoral attachment as anterior and distal to the origin of the fibular collateral ligament (FCL), which is the description this technique follows. Since Claes and colleagues’4 report, many have investigated the ligament’s femoral origin with delineations ranging from posterior and proximal3,5,7 to anterior and distal.6,16-18
The accurate, noninvasive nature of the musculoskeletal ultrasound prior to any incisions being made makes this technique innovative and superior to other open surgical techniques or those that require fluoroscopy. 
Conclusion
The ALL has been determined to play an integral role in the rotational stability of the knee. In the setting of instability and insufficiency, reconstruction will lead to better patient outcomes for concurrent ACL/ALL injuries and postsurgical rotatory instability following ACL procedures. This innovative technique utilizes ultrasound to ascertain the precise anatomical attachments of the ALL prior to the operation. The novel nature of this ultrasound-guided reconstruction has the potential to be applicable in many other surgical procedures.
1. Suomalainen P, Järvelä T, Paakkala A, Kannus P, Järvinen M. Double-bundle versus single-bundle anterior cruciate ligament reconstruction: A prospective randomized study with 5-year results. Am J Sports Med. 2012;40(7):1511-1518.
2. Segond P. Recherches cliniques et expérimentales sur les épanchements sanguins du genou par entorse. Progrés Médical. 1879;6(6):1-85. French.
3. Caterine S, Litchfield R, Johnson M, Chronik B, Getgood A. A cadaveric study of the anterolateral ligament: re-introducing the lateral capsular ligament. Knee Surg Sports Traumatol Athrosc. 2015;23(11):3186-3195.
4. Claes S, Vereecke E, Maes M, Victor J, Verdonk P, Bellemans J. Anatomy of the anterolateral ligament of the knee. J Anat. 2013;223(4):321-328.
5. Dodds AL, Halewood C, Gupte CM, Williams A, Amis AA. The anterolateral ligament: Anatomy, length changes and association with the segond fracture. Bone Joint J. 2014;96-B(3):325-331.
6. Helito CP, Demange MK, Bonadio MB, et al. Anatomy and histology of the knee anterolateral ligament. Orthop J Sports Med. 2013;1(7):2325967113513546.
7. Kennedy MI, Claes S, Fuso FA, et al. The anterolateral ligament: An anatomic, radiographic, and biomechanical analysis. Am J Sports Med. 2015;43(7):1606-1615.
8. Helito CP, Helito PV, Bonadio MB, et al. Evaluation of the length and isometric pattern of the anterolateral ligament with serial computer tomography. Orthop J Sports Med. 2014;2(12):2325967114562205.
9. Parsons EM, Gee AO, Spiekerman C, Cavanagh PR. The biomechanical function of the anterolateral ligament of the knee. Am J Sports Med. 2015;43(3):669-674.
10. Zens M, Niemeyer P, Ruhhamer J, et al. Length changes of the anterolateral ligament during passive knee motion: A human cadaveric study. Am J Sports Med. 2015;43(10):2545-2552.
11. Helito CP, Bonadio MB, Gobbi RG, et al. Combined intra- and extra-articular reconstruction of the anterior cruciate ligament: the reconstruction of the knee anterolateral ligament. Arthrosc Tech. 2015;4(3):e239-e244.
12. Cianca J, John J, Pandit S, Chiou-Tan FY. Musculoskeletal ultrasound imaging of the recently described anterolateral ligament of the knee. Am J Phys Med Rehabil. 2014;93(2):186
13. Adams JE, Zobitz ME, Reach JS, et al. Rotator cuff repair using an acellular dermal matrix graft: An in vivo study in a canine model. Arthroscopy. 2006;22(7):700-709.
14. Sonnery-Cottet B, Thaunat M, Freychet B, Pupim BHB, Murphy CG, Claes S. Outcome of a combined anterior cruciate ligament and anterolateral ligament reconstruction technique with a minimum 2-year follow-up. Am J Sports Med. 2015;43(7):1598-1605.
15. Sonnery-Cottet B, Archbold P, Rezende FC, Neto AM, Fayard JM, Thaunat M. Arthroscopic identification of the anterolateral ligament of the knee. Arthrosc Tech. 2014;3(3):e389-e392.
16. Helito CP, Helito PV, Costa HP, et al. MRI evaluation of the anterolateral ligament of the knee: assessment in routine 1.5-T scans. Skeletal Radiol. 2014;43(10):1421-1427.
17. Helito CP, Demange MK, Helito PV, et al. Evaluation of the anterolateral ligament of the knee by means of magnetic resonance examination. Rev Bras Orthop. 2015;50(2):214-219.
18. Helito CP, Demange MK, Bonadio MB, et al. Radiographic landmarks for locating the femoral origin and tibial insertion of the knee anterolateral ligament. Am J Sports Med. 2014;42(10):2356-2362.
Restoring native kinematics of the knee has been a primary goal of anterior cruciate ligament (ACL) procedures. Double-bundle ACL reconstruction, compared to single-bundle, has been hypothesized to more effectively re-establish rotational stability by re-creating the anatomic ACL, but has not yet proven to result in better clinical outcomes.1
In 1879, Dr. Paul Segond described a “fibrous, pearly band” at the lateral aspect of the knee that avulsed off the anterolateral proximal tibia during many ACL injuries.2 The role of the lateral tissues in knee stability and their relationship with ACL pathology has attracted noteworthy attention in recent time. There have been multiple studies presenting an anatomical description of a structure at the anterolateral portion of the knee with definitive femoral, meniscal, and tibial attachments, which helps control internal rotational forces.3-7 Claes and colleagues4 later found that band of tissue to be the anterolateral ligament (ALL) and determined its injury to be pathognomonic with ACL ruptures.
The ALL is a vital static stabilizer of the tibio-femoral joint, especially during internal tibial rotation.8-10 In their report on ALL and ACL reconstruction, Helito and colleagues11 acknowledge the necessity of accurate assessment of the lateral structures through imaging to determine the presence of extra-articular injury. Musculoskeletal diagnostic ultrasound has been established as an appropriate means to identify the ALL.12
Ultrasound can accurately determine the exact anatomic location of the origin and insertion of the ALL. Reconstruction of the ALL could yield better patient outcomes for those who experience concurrent ACL/ALL injury. Here we present an innovative technique for an ultrasound-guided percutaneous method for reconstruction of the ALL and report on a patient who had underwent ALL reconstruction.
Surgical Indications
All patients undergo an ultrasound evaluation preoperatively to determine if the ALL is intact or injured. Our experience has shown that when ultrasound evaluation reveals an intact ALL, the pivot shift has never been a grade III.
Surgical Technique
For a demonstration of this technique, see the video that accompanies this article.
The pivot shift test is conducted under anesthesia to determine whether an ALL reconstruction is required. The patient is placed in a supine position with the knee flexed at 30o, at neutral rotation, and without any varus or valgus stress.
A No. 15 blade is used to make a small incision centered on each spinal needle. The spinal needle is replaced with a 2.4-mm drill pin (Figure 2).
The graft and FiberTape are then passed under the IT band to the distal incision. Using the length of the BioComposite SwiveLock anchor as a guide, a mark is made on the graft after tensioning the construct in line with the leg, distal to the tibial drill pin (Table 2, Figure 4).
Rehabilitation
Rehabilitation following an ALL procedure is similar to traditional ACL rehabilitation with an added emphasis on minimizing rotational torque of the tibia in the early stages.
Case Report
In January 2013, a 17-year-old male soccer player suffered an ACL rupture of his right knee. Later that spring, he had an ACL reconstruction with an allograft. Twelve months postoperatively, the patient returned, saying that he felt much better; however, anytime he tried to plant his foot and rotate over that fixed foot, his knee felt unstable. The physical examination revealed both negative Lachman and anterior drawer tests but a I+ pivot shift test. A magnetic resonance imaging (MRI) examination revealed an intact ACL graft. A diagnostic ultrasound evaluation revealed a distal ALL injury. After discussing the risks, benefits, and goals with the patient, we opted for a diagnostic arthroscopy and a percutaneous, ultrasound-guided reconstruction of the ALL.
Postoperatively, the patient did very well. One week after surgery, he returned, saying he felt completely stable and demonstrated by repeating the rotation of his knee. The patient continued to have no issues until he returned 13 months post-ALL surgery, complaining of a recent injury that had caused the return of his feelings of instability. An MRI evaluation showed an intact ACL graft and the possibility of a ruptured ALL. Fifteen months after the initial ALL reconstruction, we proceeded with surgery. At arthroscopy, the patient was found to have a pivot shift of I+ and an intact ACL graft. The ALL was reconstructed again using an allograft, internal brace, and bone marrow concentrate. At 13 months post-ALL reconstruction revision, the patient had no complaints.
Discussion
Reconstruction of the ALL is aimed to restore anatomic rotational kinematics. Sonnery-Cottet and colleagues14 have reported promising initial results in their 2-year follow-up study of combined ACL and ALL reconstruction outcomes. This surgical technique includes use of an internal brace, which negates the necessity for external support devices and allows for earlier mobilization of the joint. A reconstruction of the ALL, performed concurrently with the ACL, does not add recovery time, but could prevent postsurgical complications and improve rehabilitation by eliminating rotational instability that presents in some ACL-reconstructed patients.
Sonnery-Cottet and colleagues15 state that their arthroscopic identification of the ALL can help to cultivate a “less invasive and more anatomic” reconstruction. The use of musculoskeletal ultrasound allows our technique to utilize a completely noninvasive imaging tool that allows proper establishment of ALL anatomy prior to the procedure. The entirety of the ALL is easily identifiable,4,12 which has proven to be shortcoming of MRI evaluation.15-17 Accurate preoperative assessment of the lateral structures is necessary in ACL-deficient individuals.11,15 Sonography also provides a means of accurate guidance and socket creation, without generating large incisions.
If the ALL is responsible for internal rotatory stability as asserted, the structure should exhibit biomechanical properties during movement. In their study on the function of the ligament, Parsons and colleagues9 established the inverse relationship between the ALL and ACL during internal rotation. As their cadaveric knees were subjected to an internal rotatory force through increasing angles of flexion, the contribution of the ALL towards stability significantly increased while the ACL declined. Helito and colleagues8 and Zens and colleagues10 have demonstrated length changes of the ligament through varying degrees of flexion and internal rotation. Their reports indicate greater tension during knee movements, coinciding with the description of increasing ALL stability contribution by Parsons and colleagues.9 Kennedy and colleagues7 conducted a pull-to-failure test on the ALL. The average failure load was 175 N with a stiffness of 20 N/mm, illustrating the structure is a candidate for most traditional soft tissue grafts. The biomechanical evidence of the structural properties of the ALL confirms its importance in knee function and the necessity for its reconstruction.
With the understanding that ACL contributes to rotatory stability to some extent, the notion begs the question of how a centrally located ligament is able to prevent excessive rotation in a structure with a large relative radius. Biomechanically, with such a small moment arm, the ACL would experience tremendous stress when a rotatory force is applied. The same torque applied to a more superficial structure, with a greater moment, would sustain a large reduction in the applied force. The concept of a wheel and an axle should be considered. The equation is F1 × R1 = F2 × R2. We measured on a cadaveric knee the distance from the center of rotation to the ACL and the ALL, finding the radii were 5 mm and 30 mm, respectively. Taking these measurements, we would then expect the force experienced on the axle (ACL) to be 6 times greater than what would be experienced on the periphery of the wheel (ALL). The ALL (wheel) has a significant biomechanical advantage over the ACL (axle) in controlling and enduring internal rotatory forces of the knee. This would imply that if the ALL were damaged and not re-established, the ACL would experience a 6 times greater force trying to control internal rotation, which would result in a significantly increased chance of failure and rupture.
While there is a degree of dissent on the presence of the ALL, a number of studies have classified the tissue as an independent ligamentous structure.3-7 While there is disagreement on the precise location of the femoral attachment, there is a consensus on the location of the tibial and meniscal attachments. Claes and colleagues4 originally outlined the femoral attachment as anterior and distal to the origin of the fibular collateral ligament (FCL), which is the description this technique follows. Since Claes and colleagues’4 report, many have investigated the ligament’s femoral origin with delineations ranging from posterior and proximal3,5,7 to anterior and distal.6,16-18
The accurate, noninvasive nature of the musculoskeletal ultrasound prior to any incisions being made makes this technique innovative and superior to other open surgical techniques or those that require fluoroscopy.
Conclusion
The ALL has been determined to play an integral role in the rotational stability of the knee. In the setting of instability and insufficiency, reconstruction will lead to better patient outcomes for concurrent ACL/ALL injuries and postsurgical rotatory instability following ACL procedures. This innovative technique utilizes ultrasound to ascertain the precise anatomical attachments of the ALL prior to the operation. The novel nature of this ultrasound-guided reconstruction has the potential to be applicable in many other surgical procedures.
Restoring native kinematics of the knee has been a primary goal of anterior cruciate ligament (ACL) procedures. Double-bundle ACL reconstruction, compared to single-bundle, has been hypothesized to more effectively re-establish rotational stability by re-creating the anatomic ACL, but has not yet proven to result in better clinical outcomes.1
In 1879, Dr. Paul Segond described a “fibrous, pearly band” at the lateral aspect of the knee that avulsed off the anterolateral proximal tibia during many ACL injuries.2 The role of the lateral tissues in knee stability and their relationship with ACL pathology has attracted noteworthy attention in recent time. There have been multiple studies presenting an anatomical description of a structure at the anterolateral portion of the knee with definitive femoral, meniscal, and tibial attachments, which helps control internal rotational forces.3-7 Claes and colleagues4 later found that band of tissue to be the anterolateral ligament (ALL) and determined its injury to be pathognomonic with ACL ruptures.
The ALL is a vital static stabilizer of the tibio-femoral joint, especially during internal tibial rotation.8-10 In their report on ALL and ACL reconstruction, Helito and colleagues11 acknowledge the necessity of accurate assessment of the lateral structures through imaging to determine the presence of extra-articular injury. Musculoskeletal diagnostic ultrasound has been established as an appropriate means to identify the ALL.12
Ultrasound can accurately determine the exact anatomic location of the origin and insertion of the ALL. Reconstruction of the ALL could yield better patient outcomes for those who experience concurrent ACL/ALL injury. Here we present an innovative technique for an ultrasound-guided percutaneous method for reconstruction of the ALL and report on a patient who had underwent ALL reconstruction.
Surgical Indications
All patients undergo an ultrasound evaluation preoperatively to determine if the ALL is intact or injured. Our experience has shown that when ultrasound evaluation reveals an intact ALL, the pivot shift has never been a grade III.
Surgical Technique
For a demonstration of this technique, see the video that accompanies this article.
The pivot shift test is conducted under anesthesia to determine whether an ALL reconstruction is required. The patient is placed in a supine position with the knee flexed at 30o, at neutral rotation, and without any varus or valgus stress.
A No. 15 blade is used to make a small incision centered on each spinal needle. The spinal needle is replaced with a 2.4-mm drill pin (Figure 2).
The graft and FiberTape are then passed under the IT band to the distal incision. Using the length of the BioComposite SwiveLock anchor as a guide, a mark is made on the graft after tensioning the construct in line with the leg, distal to the tibial drill pin (Table 2, Figure 4).
Rehabilitation
Rehabilitation following an ALL procedure is similar to traditional ACL rehabilitation with an added emphasis on minimizing rotational torque of the tibia in the early stages.
Case Report
In January 2013, a 17-year-old male soccer player suffered an ACL rupture of his right knee. Later that spring, he had an ACL reconstruction with an allograft. Twelve months postoperatively, the patient returned, saying that he felt much better; however, anytime he tried to plant his foot and rotate over that fixed foot, his knee felt unstable. The physical examination revealed both negative Lachman and anterior drawer tests but a I+ pivot shift test. A magnetic resonance imaging (MRI) examination revealed an intact ACL graft. A diagnostic ultrasound evaluation revealed a distal ALL injury. After discussing the risks, benefits, and goals with the patient, we opted for a diagnostic arthroscopy and a percutaneous, ultrasound-guided reconstruction of the ALL.
Postoperatively, the patient did very well. One week after surgery, he returned, saying he felt completely stable and demonstrated by repeating the rotation of his knee. The patient continued to have no issues until he returned 13 months post-ALL surgery, complaining of a recent injury that had caused the return of his feelings of instability. An MRI evaluation showed an intact ACL graft and the possibility of a ruptured ALL. Fifteen months after the initial ALL reconstruction, we proceeded with surgery. At arthroscopy, the patient was found to have a pivot shift of I+ and an intact ACL graft. The ALL was reconstructed again using an allograft, internal brace, and bone marrow concentrate. At 13 months post-ALL reconstruction revision, the patient had no complaints.
Discussion
Reconstruction of the ALL is aimed to restore anatomic rotational kinematics. Sonnery-Cottet and colleagues14 have reported promising initial results in their 2-year follow-up study of combined ACL and ALL reconstruction outcomes. This surgical technique includes use of an internal brace, which negates the necessity for external support devices and allows for earlier mobilization of the joint. A reconstruction of the ALL, performed concurrently with the ACL, does not add recovery time, but could prevent postsurgical complications and improve rehabilitation by eliminating rotational instability that presents in some ACL-reconstructed patients.
Sonnery-Cottet and colleagues15 state that their arthroscopic identification of the ALL can help to cultivate a “less invasive and more anatomic” reconstruction. The use of musculoskeletal ultrasound allows our technique to utilize a completely noninvasive imaging tool that allows proper establishment of ALL anatomy prior to the procedure. The entirety of the ALL is easily identifiable,4,12 which has proven to be shortcoming of MRI evaluation.15-17 Accurate preoperative assessment of the lateral structures is necessary in ACL-deficient individuals.11,15 Sonography also provides a means of accurate guidance and socket creation, without generating large incisions.
If the ALL is responsible for internal rotatory stability as asserted, the structure should exhibit biomechanical properties during movement. In their study on the function of the ligament, Parsons and colleagues9 established the inverse relationship between the ALL and ACL during internal rotation. As their cadaveric knees were subjected to an internal rotatory force through increasing angles of flexion, the contribution of the ALL towards stability significantly increased while the ACL declined. Helito and colleagues8 and Zens and colleagues10 have demonstrated length changes of the ligament through varying degrees of flexion and internal rotation. Their reports indicate greater tension during knee movements, coinciding with the description of increasing ALL stability contribution by Parsons and colleagues.9 Kennedy and colleagues7 conducted a pull-to-failure test on the ALL. The average failure load was 175 N with a stiffness of 20 N/mm, illustrating the structure is a candidate for most traditional soft tissue grafts. The biomechanical evidence of the structural properties of the ALL confirms its importance in knee function and the necessity for its reconstruction.
With the understanding that ACL contributes to rotatory stability to some extent, the notion begs the question of how a centrally located ligament is able to prevent excessive rotation in a structure with a large relative radius. Biomechanically, with such a small moment arm, the ACL would experience tremendous stress when a rotatory force is applied. The same torque applied to a more superficial structure, with a greater moment, would sustain a large reduction in the applied force. The concept of a wheel and an axle should be considered. The equation is F1 × R1 = F2 × R2. We measured on a cadaveric knee the distance from the center of rotation to the ACL and the ALL, finding the radii were 5 mm and 30 mm, respectively. Taking these measurements, we would then expect the force experienced on the axle (ACL) to be 6 times greater than what would be experienced on the periphery of the wheel (ALL). The ALL (wheel) has a significant biomechanical advantage over the ACL (axle) in controlling and enduring internal rotatory forces of the knee. This would imply that if the ALL were damaged and not re-established, the ACL would experience a 6 times greater force trying to control internal rotation, which would result in a significantly increased chance of failure and rupture.
While there is a degree of dissent on the presence of the ALL, a number of studies have classified the tissue as an independent ligamentous structure.3-7 While there is disagreement on the precise location of the femoral attachment, there is a consensus on the location of the tibial and meniscal attachments. Claes and colleagues4 originally outlined the femoral attachment as anterior and distal to the origin of the fibular collateral ligament (FCL), which is the description this technique follows. Since Claes and colleagues’4 report, many have investigated the ligament’s femoral origin with delineations ranging from posterior and proximal3,5,7 to anterior and distal.6,16-18
The accurate, noninvasive nature of the musculoskeletal ultrasound prior to any incisions being made makes this technique innovative and superior to other open surgical techniques or those that require fluoroscopy.
Conclusion
The ALL has been determined to play an integral role in the rotational stability of the knee. In the setting of instability and insufficiency, reconstruction will lead to better patient outcomes for concurrent ACL/ALL injuries and postsurgical rotatory instability following ACL procedures. This innovative technique utilizes ultrasound to ascertain the precise anatomical attachments of the ALL prior to the operation. The novel nature of this ultrasound-guided reconstruction has the potential to be applicable in many other surgical procedures.
1. Suomalainen P, Järvelä T, Paakkala A, Kannus P, Järvinen M. Double-bundle versus single-bundle anterior cruciate ligament reconstruction: A prospective randomized study with 5-year results. Am J Sports Med. 2012;40(7):1511-1518.
2. Segond P. Recherches cliniques et expérimentales sur les épanchements sanguins du genou par entorse. Progrés Médical. 1879;6(6):1-85. French.
3. Caterine S, Litchfield R, Johnson M, Chronik B, Getgood A. A cadaveric study of the anterolateral ligament: re-introducing the lateral capsular ligament. Knee Surg Sports Traumatol Athrosc. 2015;23(11):3186-3195.
4. Claes S, Vereecke E, Maes M, Victor J, Verdonk P, Bellemans J. Anatomy of the anterolateral ligament of the knee. J Anat. 2013;223(4):321-328.
5. Dodds AL, Halewood C, Gupte CM, Williams A, Amis AA. The anterolateral ligament: Anatomy, length changes and association with the segond fracture. Bone Joint J. 2014;96-B(3):325-331.
6. Helito CP, Demange MK, Bonadio MB, et al. Anatomy and histology of the knee anterolateral ligament. Orthop J Sports Med. 2013;1(7):2325967113513546.
7. Kennedy MI, Claes S, Fuso FA, et al. The anterolateral ligament: An anatomic, radiographic, and biomechanical analysis. Am J Sports Med. 2015;43(7):1606-1615.
8. Helito CP, Helito PV, Bonadio MB, et al. Evaluation of the length and isometric pattern of the anterolateral ligament with serial computer tomography. Orthop J Sports Med. 2014;2(12):2325967114562205.
9. Parsons EM, Gee AO, Spiekerman C, Cavanagh PR. The biomechanical function of the anterolateral ligament of the knee. Am J Sports Med. 2015;43(3):669-674.
10. Zens M, Niemeyer P, Ruhhamer J, et al. Length changes of the anterolateral ligament during passive knee motion: A human cadaveric study. Am J Sports Med. 2015;43(10):2545-2552.
11. Helito CP, Bonadio MB, Gobbi RG, et al. Combined intra- and extra-articular reconstruction of the anterior cruciate ligament: the reconstruction of the knee anterolateral ligament. Arthrosc Tech. 2015;4(3):e239-e244.
12. Cianca J, John J, Pandit S, Chiou-Tan FY. Musculoskeletal ultrasound imaging of the recently described anterolateral ligament of the knee. Am J Phys Med Rehabil. 2014;93(2):186
13. Adams JE, Zobitz ME, Reach JS, et al. Rotator cuff repair using an acellular dermal matrix graft: An in vivo study in a canine model. Arthroscopy. 2006;22(7):700-709.
14. Sonnery-Cottet B, Thaunat M, Freychet B, Pupim BHB, Murphy CG, Claes S. Outcome of a combined anterior cruciate ligament and anterolateral ligament reconstruction technique with a minimum 2-year follow-up. Am J Sports Med. 2015;43(7):1598-1605.
15. Sonnery-Cottet B, Archbold P, Rezende FC, Neto AM, Fayard JM, Thaunat M. Arthroscopic identification of the anterolateral ligament of the knee. Arthrosc Tech. 2014;3(3):e389-e392.
16. Helito CP, Helito PV, Costa HP, et al. MRI evaluation of the anterolateral ligament of the knee: assessment in routine 1.5-T scans. Skeletal Radiol. 2014;43(10):1421-1427.
17. Helito CP, Demange MK, Helito PV, et al. Evaluation of the anterolateral ligament of the knee by means of magnetic resonance examination. Rev Bras Orthop. 2015;50(2):214-219.
18. Helito CP, Demange MK, Bonadio MB, et al. Radiographic landmarks for locating the femoral origin and tibial insertion of the knee anterolateral ligament. Am J Sports Med. 2014;42(10):2356-2362.
1. Suomalainen P, Järvelä T, Paakkala A, Kannus P, Järvinen M. Double-bundle versus single-bundle anterior cruciate ligament reconstruction: A prospective randomized study with 5-year results. Am J Sports Med. 2012;40(7):1511-1518.
2. Segond P. Recherches cliniques et expérimentales sur les épanchements sanguins du genou par entorse. Progrés Médical. 1879;6(6):1-85. French.
3. Caterine S, Litchfield R, Johnson M, Chronik B, Getgood A. A cadaveric study of the anterolateral ligament: re-introducing the lateral capsular ligament. Knee Surg Sports Traumatol Athrosc. 2015;23(11):3186-3195.
4. Claes S, Vereecke E, Maes M, Victor J, Verdonk P, Bellemans J. Anatomy of the anterolateral ligament of the knee. J Anat. 2013;223(4):321-328.
5. Dodds AL, Halewood C, Gupte CM, Williams A, Amis AA. The anterolateral ligament: Anatomy, length changes and association with the segond fracture. Bone Joint J. 2014;96-B(3):325-331.
6. Helito CP, Demange MK, Bonadio MB, et al. Anatomy and histology of the knee anterolateral ligament. Orthop J Sports Med. 2013;1(7):2325967113513546.
7. Kennedy MI, Claes S, Fuso FA, et al. The anterolateral ligament: An anatomic, radiographic, and biomechanical analysis. Am J Sports Med. 2015;43(7):1606-1615.
8. Helito CP, Helito PV, Bonadio MB, et al. Evaluation of the length and isometric pattern of the anterolateral ligament with serial computer tomography. Orthop J Sports Med. 2014;2(12):2325967114562205.
9. Parsons EM, Gee AO, Spiekerman C, Cavanagh PR. The biomechanical function of the anterolateral ligament of the knee. Am J Sports Med. 2015;43(3):669-674.
10. Zens M, Niemeyer P, Ruhhamer J, et al. Length changes of the anterolateral ligament during passive knee motion: A human cadaveric study. Am J Sports Med. 2015;43(10):2545-2552.
11. Helito CP, Bonadio MB, Gobbi RG, et al. Combined intra- and extra-articular reconstruction of the anterior cruciate ligament: the reconstruction of the knee anterolateral ligament. Arthrosc Tech. 2015;4(3):e239-e244.
12. Cianca J, John J, Pandit S, Chiou-Tan FY. Musculoskeletal ultrasound imaging of the recently described anterolateral ligament of the knee. Am J Phys Med Rehabil. 2014;93(2):186
13. Adams JE, Zobitz ME, Reach JS, et al. Rotator cuff repair using an acellular dermal matrix graft: An in vivo study in a canine model. Arthroscopy. 2006;22(7):700-709.
14. Sonnery-Cottet B, Thaunat M, Freychet B, Pupim BHB, Murphy CG, Claes S. Outcome of a combined anterior cruciate ligament and anterolateral ligament reconstruction technique with a minimum 2-year follow-up. Am J Sports Med. 2015;43(7):1598-1605.
15. Sonnery-Cottet B, Archbold P, Rezende FC, Neto AM, Fayard JM, Thaunat M. Arthroscopic identification of the anterolateral ligament of the knee. Arthrosc Tech. 2014;3(3):e389-e392.
16. Helito CP, Helito PV, Costa HP, et al. MRI evaluation of the anterolateral ligament of the knee: assessment in routine 1.5-T scans. Skeletal Radiol. 2014;43(10):1421-1427.
17. Helito CP, Demange MK, Helito PV, et al. Evaluation of the anterolateral ligament of the knee by means of magnetic resonance examination. Rev Bras Orthop. 2015;50(2):214-219.
18. Helito CP, Demange MK, Bonadio MB, et al. Radiographic landmarks for locating the femoral origin and tibial insertion of the knee anterolateral ligament. Am J Sports Med. 2014;42(10):2356-2362.
