The anterolateral capsule is infrequently damaged as evaluated arthroscopically in patients undergoing anatomic ACL reconstruction

Abstract

ObjectivesConcomitant anterolateral complex (ALC) injury may contribute to persistent rotatory knee instability following anterior cruciate ligament (ACL) reconstruction. There is no consensus on how to best identify concomitant ALC injury preoperatively, nor how well ALC injury identified on imaging modalities correlates with clinical examination of knee instability.The purpose of this retrospective study was to determine the incidence of concomitant ALC injury in ACL-injured knees, as determined by arthroscopy to preoperative radiography, ultrasound, and MRI. MethodsA total of 117 patients with a unilateral primary ACL injury who underwent individualized anatomic ACLR between June 2016 and May 2019 were enrolled. Preoperative imaging modalities, including X-ray, ultrasound, and MRI, were evaluated for concomitant ALC injury. Clinical examination under anesthesia, including the anterior drawer, Lachman, and pivot shift tests were performed. Anterolateral capsule injury, as defined by hemorrhage and/or capsular tearing on diagnostic arthroscopy, was also determined. Correlative analyses of ALC injury incidence and severity were performed across imaging modalities and against clinical examination grades. ResultsALC injury incidence across imaging modalities was as follows: X-ray (3%), arthroscopy (19%), MRI (53%), and US (63%). The ALC injury rate on arthroscopy was significantly less than MRI (p < 0.001) or ultrasound (p < 0.001). ALC injury incidence and severity were significantly correlated between MRI and US grading scales (p = 0.02), but no correlations among other imaging modalities were found. Similarly, no imaging modality meaningfully correlated with physical examination maneuvers. ConclusionThe incidence of ALC injury varies across imaging modalities, with lower injury rates found on arthroscopy (19%) compared to MRI (53%) and US (63%). Increasing ALC injury severity grades on imaging does not predict increasing anterolateral knee laxity on clinical examination. Level of evidenceV, retrospective case series.