Anterolateral Ligament Injury Research Articles

Tibial-sided Anterolateral Ligament Injuries Are Associated With Poor Healing and Residual Pivot Shift Testing After Anterior Cruciate Ligament Reconstruction

Purpose; to investigate if tibial sided anterolateral ligament (ALL) injuries are associated with poor healing and residual pivot shift. Methods; Patients who underwent anterior cruciate ligament reconstructions within postinjury 6 weeks from January 2008 to March 2021 were included. They had concomitant ALL injury confirmed by preoperative magnetic resonance imaging (MRI) and were followed minimum 20 months. Preoperative ALL injury was graded by the Muramatsu classification and postoperative ALL healing were graded by a modification of the Lee classification (good, partial, and non-visualized). The patients were allocated to an improved group (IG) and an unimproved group (UG) based on a comparison of pre- and postoperative MRI. ALL tear site, postoperative knee stability, Lysholm score, and Tegner activity scale (PROs) were compared between the two groups. Results; 128 patients were enrolled. 94.5 % patients achieved the minimal clinically important difference (MCID) for PROs, respectively. The ALL was torn at the femoral side in 46.9% patients, at mid-substance in 31.2.%, and at tibial side in 21.9%, Preoperatively, 86 (67.2%) patients had a partial tear and 42 (32.8%) patients had a complete tear. Based on the postoperative MRI appearances, 38 (29.7%) and 90 (70.3%) patients were allocated to the IG and UG, respectively. The tibial side tears were significantly frequent in UG (p= .032). Pivot shift showed a significantly higher incidence in UG than IG (p=.004). Lachman test and PROs did not differ between the two groups. Conclusions; Tibial-sided ALL tears occurred in 18.7% of the UG compared to 3.2% of the IG, and 45.6% of the UG had a postoperative grade 1 or 2 pivot shift, compared to 15.8% of the IG. Percentages of patients with the MCID for PROs did not differ between the two groups. However, the clinical relevance is limited by a high transfer bias.

Outcomes of Anterior Cruciate Ligament Reconstruction in Patients with Associated Anterolateral Ligament Injury.

Objective To evaluate if there is a significant difference in the outcomes of isolated anterior cruciate ligament (ACL) reconstruction in patients with or without associated anterolateral ligament (ALL) injury. Methods We conducted a retrospective cross-sectional study through the analysis of medical records and the application of the questionnaires of the Lysholm Knee Scoring Scale and the International Knee Documentation Committee (IKDC) Subjective Knee Form to patients undergoing isolated ACL reconstruction. Results The 52 participants included were divided into two groups: 19 with associated ALL injury and 33 with no associated ALL injury. None of the patients with associated ALL injury suffered an ACL rerupture, and 21.1% presented injuries to other knee structures after surgery. Among the patients with no associated injury, 6.1% suffered ACL rerupture, and 18.2% presented injuries to other structures after surgery ( p = 0.544). Return to activities at the same level as that of the preoperative period occurred in 60% of the patients with associated ALL injury and in 72% of those with no associated injury ( p = 0.309). The mean score on the Lysholm Knee Scoring Scale was of 81.6 points in patients with associated ALL injury, and of 90.1 in those with no associated injury ( p = 0.032). The mean score on the IKDC Subjective Knee Form was of 70.3 points in patients with associated ALL injury and of 76.7 in those with no associated injury ( p = 0.112). Conclusion There was no statistically significant difference regarding graft injuries or new injuries to other structures, satisfaction with the operated knee, or the score on the IKDC Subjective Knee Form. Return to activity was similar in the groups with and without associated ALL injuries. The scores on the Lysholm Knee Scoring Scale were better, with a statistically significant difference in the group with no associated ALL injuries.

Anterolateral Ligament and Kaplan Fiber Injury Both Occur Frequently in Acute Anterior Cruciate Ligament-Injured Knees.

The association of ALL and KF injuries in anterior cruciate ligament (ACL)-deficient knees remain topics of conflicting research despite improved magnetic resonance imaging (MRI). We aimed to evaluate the rate of the anterolateral ligament (ALL) and Kaplan fibers (KF) injuries in adults with acute ACL injuries using MRI. We retrospectively reviewed 64 patients with clinical and MRI diagnoses of acute ACL tears. Two radiologists analyzed and categorized the status of the ALL and KF in all patients as intact, partially injured, or completely injured. Interobserver agreement was assessed. Injuries to the collateral ligaments, ITB and posterior cruciate ligament (PCL) were also evaluated. The mean age of the patients was 33 years. ALL injuries were observed in 46 (71%) patients, among whom 33 (71%) had partial and 13 (28%) had complete injuries. KF injuries were identified in 32 (50%) patients, with 28 (87.5%) of them having partial and 4 (12.5%) having complete injuries. Combined injuries of both ALL and KF were found in 25 (32.4%) patients (p-value of 0.266). The agreement between the examiners ranged from moderate to substantial (Kappa between 0.55 and 0.75), with the highest agreement observed in cases of KF injuries (Kappa = 0.75). ALL and KF injuries were prevalent in acute ACL-injured knees with rates of injury of 71% and 50%, respectively. ALL injuries were more frequent and more frequently severe compared to KF injuries.

Increased knee torsional misalignment associated with femoral torsion is related to non-contact anterior cruciate ligament injury: a case-control study.

Altered axial biomechanics of the knee are recognized as a risk factor for non-contact anterior cruciate ligament (ACL) injury. However, the relationship of knee and segmental torsion to non-contact ACL and combined anterolateral ligament (ALL) injury is unclear. This study aims to determine the relationship of knee and segmental torsion to non-contact ACL injury and to explore their relationship with ALL injuries. We divided 122 patients with arthroscopically confirmed non-contact ACL injuries into an ACL injury group (isolated ACL injury, 63 patients) and an ACL + ALL injury group (ACL combined with ALL injury,59 patients). Additionally, 90 normal patients with similar age, gender and body mass index (BMI) were matched as a control group. The tibial tubercle-trochlear groove (TT-TG) distance, distal femoral torsion (DFT), posterior femoral condylar torsion (PFCT) and proximal tibial torsion (PTT) were measured using magnetic resonance imaging (MRI). We assessed the differences between the groups using an independent samples t test and utilized receiver operating characteristic (ROC) curves to determine the cut-off value for the increased risk of ACL injury. In patients with ACL injury, the measurements of the TT-TG (11.8 ± 3.1mm), DFT (7.7° ± 3.5°) and PFCT (3.6° ± 1.3°) were significantly higher compared to the control group (9.1 ± 2.4mm, 6.3° ± 2.7° and 2.8° ± 1.3°, respectively; P < 0.05), but the PTT did not differ between the two groups. The TT-TG, DFT and PFCT were not significantly larger in patients combined with ALL injury. ROC curve analysis revealed ACL injury is associated with TT-TG, DFT and PFCT. Knee torsional alignment is associated with ACL injury, predominantly in the distal femur rather than the proximal tibia. However, its correlation with ALL injury remains unclear. These findings may help identify patients at high risk for non-contact ACL injury and inform the development of targeted prevention and treatment strategies.

Correlation of tibial tuberosity–trochlear groove distance, anterolateral ligament injury, and the type of trochlear dysplasia with the grade of anterior cruciate ligaments tear

BackgroundThe anterior cruciate ligament (ACL) is the most frequently injured ligament. The grade of ACL tear on magnetic resonance imaging (MRI) can help determine the ACL injury treatment. Lateralization of the tibial tubercle is indicated by an increase in the distance of the tibial tuberosity–trochlear groove (TT-TG). Anterolateral ligament (ALL) injury affects a high degree of pivot shift in the knee joint with ACL deficiency. Trochlear dysplasia (TD) is a congenital morphological deformity of the femoral trochlea. An increase in the TT-TG distance, as well as the presence of ALL injuries and TD, can elevate the likelihood of experiencing ACL injuries. This study aims to analyze the correlation of TT-TG distance, ALL injury, and type of TD with the grade of ACL tear through MRI.MethodsThis analytical cross-sectional study was conducted from November 2021 to June 2022 at RSUP Dr. Kariadi Hospital, Semarang. The ACL tear was divided into three degrees. The Schoettle or the Nizić method was used to measure the TT-TG distance. ALL injuries were evaluated by looking at the integrity of the ligament. TD assessment was according to the Dejour classification.ResultsA total of 50 subjects participated in the study. The TT-TG distance for grade I ACL tears was 5.90–14.6 mm (22%), 1.69–18.30 mm (44%) for grade II, and 1.01–14.10 mm (34%) for grade III. The ANOVA test showed no significant relationship between the TT-TG distance and the degree of ACL tear (p = 0.146). ALL injuries were found in six study subjects: One subject (16.7%) had grade I ACL tear, three subjects (50%) had grade II, and two subjects (33.3%) had grade III. The Chi-square test showed no significant correlation between ALL injuries and the degree of ACL tear (p = 0.930). Most subjects did not experience TD (78%), while 20% experienced TD type A and 2% experienced TD type B. In type A TD, 50% of ACL tears were grade I, 30% grade II, and 20% grade III. Among all subjects with TD type B, only one was found to have a grade III ACL tear. Based on the Chi-square test, there was no significant correlation between TD type and the degree of ACL tear (p = 0.110).ConclusionsThere is no significant correlation between the tibial tuberosity–trochlear groove distance, ALL injury, and type of trochlear dysplasia with the grade of ACL tear.

Evaluation of the anterolateral ligament of the knee with high resolution ultrasound

Objectives: To determine whether high-resolution ultrasound is an exam that contributes to the identification and assessment of the integrity of the anterolateral ligament of the knee in patients with anterior cruciate ligament injury. Methods: 41 patients, 16 to 55 years old, with primary lesion of the anterior cruciate ligament were evaluated. Demographic data were collected, and a Pivot Shift test was performed. An ultrasound examination was performed, with a high- resolution probe, on both patients' knees, initially, seeking the visualization of the anterolateral ligament in all its extension and later assessing its integrity, ending with an assessment of the lateral meniscus. Results: 100% of the evaluated cases, it was possible to visualize the anterolateral ligament through ultrasound with 46.3% of injuries, with the tibial portion being the most injured. 19 patients (46.3%) had anterolateral ligament injury on the same side as the anterior cruciate ligament injury, while in 19 cases (46.3%) no anterolateral ligament injury was observed on either side. 5 patients had a pivot shift test considered positive with 80% of associated anterolateral ligament injury. 31 patients had lateral meniscus injury by magnetic resonance imaging. Of the 31 patients, 25 were confirmed by ultrasound. Of the 11 patients without lesion of the lateral meniscus by MRI, none had an ultrasound lesion. Adding these two groups, 92.6% of results favorable to ultrasound, (p &lt;0.001). Conclusion: The data obtained suggest that ultrasound contributes to the identification and assessment of the integrity of the knee anterolateral ligament in patients with anterior cruciate ligament injury. Level of Evidence IV.

Greater Knee Rotatory Instability After Posterior Meniscocapsular Injury Versus Anterolateral Ligament Injury: A Proposed Mechanism of High-Grade Pivot Shift.

For anterolateral rotatory instability as a result of secondary soft tissue injuries in anterior cruciate ligament (ACL)-deficient knees, there is increasing interest in secondary stabilizers to prevent internal rotation (IR) of the tibia. To determine which secondary stabilizer is more important in anterolateral rotatory instability in ACL-deficient knees. Controlled laboratory study. The lower extremities of 10 fresh-frozen cadavers (20 extremities) without anterior-posterior or rotational instability were included. Matched-pair randomization was performed, with each side per specimen assigned to 1 of 2 groups. In group 1, the ACL was sectioned, followed by the anterolateral ligament (ALL); in group 2, the ACL was sectioned, followed by sequential sectioning of the posterolateral meniscocapsular complex (PLMCC) and posteromedial meniscocapsular complex (PMMCC). The primary outcome was the change in relative tibial IR during a simulated pivot-shift test with 5 N·m of IR torque and 8.9 N of valgus force. The secondary outcomes were the International Knee Documentation Committee grade in the pivot-shift test and the incidence of the grade 3 pivot shift. In group 1, compared with baseline, the change in relative tibial IR at 0° of knee flexion was 1.4° (95% CI, -0.1° to 2.9°; P = .052) after ALL release. In group 2, it was 2.5° (95% CI, 0.4° to 4.8°; P = .007) after PLMCC release and 4.1° (95% CI, 0.5° to 7.8°; P = .017) after combined PLMCC and PMMCC release. Combined PLMCC and PMMCC release resulted in greater change of tibial IR with statistical significance at 0°, 15°, and 30° of knee flexion (P = .008, .057, and .004, respectively) compared with ALL release. The incidence of grade 3 pivot shifts was 10% in group 1 and 90% in group 2. Posterior meniscocapsular laxity caused an increase in relative tibial IR as much as ALL injury in ACL-deficient knees in our simulated laboratory test, and greater anterolateral rotatory instability occurred with posterior meniscocapsular injury compared with ALL injury. Repair of the injured posterior meniscocapsular complex may be an important treatment option for reducing anterolateral rotatory instability in the ACL-deficient knee.

Distal Kaplan fibers and anterolateral ligament injuries are associated with greater intra-articular internal tibial rotation in ACL-deficient knees based on magnetic resonance imaging

PurposeThe purpose of the present study was to assess the internal rotation of the tibia on Magnetic Resonance Imaging (MRI) in a series of consecutive athletes with Anterior cruciate Ligament (ACL) tears.MethodsRetrospective analysis of prospectively collected data was performed to include all consecutive patients who had undergone primary ACL reconstruction between January 2022 and June 2022. The angle between surgical epicondylar axes (SEA) of the knee and posterior tibial condyles (PTC) was measured. A negative value was defined as internal torsion. KFs and ALL injuries were reported. Analysis of covariance (ANCOVA) was performed to examine the independent associations between SEA-PTC angle and injuries of KFs and ALL adjusted for physical variables (age, gender and body mass index [BMI]). Statistical significance was set at a p-value of < 0.05.ResultsA total of 83 eligible patients were included. The result of multiple linear regression analysis showed that internal tibial rotation was associated with KFs and ALL injuries. The estimated average of SEA-PTC angle in relation to ALL injuries controlling the other variables was -5.49 [95%CI -6.79 – (-4.18)] versus -2.99 [95%CI -4.55 – (-1.44)] without ALL injuries. On the other hand, the estimated average of SEA-PTC angle in relation to KFs lesions controlling the other variables was -5.73 [95%CI -7.04 – (-4.43)] versus -2.75 [95%CI -4.31 – (-1.18)] without KFs injuries.ConclusionsKFs and ALL injuries were associated with an increased intra-articular internal tibial rotation in ACL-deficient knees. The measurement of femorotibial rotation on axial MRI could be useful to detect indirect signs of anterolateral complex (ALC) injuries.

Combined Anterolateral Ligament and Anterior Cruciate Ligament Injury Is Associated With Increased Lateral Femoral Condyle Ratio

to investigate the association between the lateral femoral condylar ratio (LFCR), the posterior tibial slope (PTS), and injury of the anterolateral ligament (ALL). Inclusion criteria were patients with acute anterior cruciate ligament (ACL) tear after noncontact injury during sports from October 1997 to May 2021. The LFCR and PTS were measured, and injury of the ALL was evaluated. Patients were divided into 2 groups: isolated ACL tear (isolated group) and combined ACL with ALL tear (combined group). The LFCR and PTS were compared between the isolated and combined groups. For each risk factor, the receiver operating characteristic curve, the area under the curve (AUC), and its 95% confidence interval (CI) were calculated to determine the cutoff for detecting increased risk of ALL injury. There were 83 patients in the isolated group and 176 patients in the combined group. Demographics of the 2groups did not differ significantly. The LFCR was significantly larger in the combined group than in the isolated group (P= .000). The PTS did not differ between the two groups (P= .405). The LFCR (odds ratio [OR]= 1.58; P= .000) was a significant factor. Age, body mass index, and PTS were not associated with an ALL injury. The AUC (0.79; 95% CI, 0.74-0.85) for the LFCR had a sensitivity of 73% and specificity of 76% to predict an ALL rupture. The calculated cutoff of 64.5 was associated with an increased risk for ALL rupture (OR= 8.65; 95% CI, 4.73-15.81) when compared with the isolated group. An increased LFCR was associated with the ALL injury. However, increased PTS was not associated with ALL injury. These findings need to be considered for clinicians in treating ACL tear patients at risk for an ALL injury. III, retrospective comparative prognostic trial.

Influence of Injury to the Kaplan Fibers of the Iliotibial Band on Anterolateral Rotatory Knee Laxity in Anterior Cruciate Ligament Injury: A Retrospective Cohort Study

Background: Biomechanical cadaveric studies have shown that Kaplan fibers (KFs) of the iliotibial band play a role in controlling anterolateral rotatory knee laxity in anterior cruciate ligament (ACL) injury. However, in the clinical setting, the contribution of injury to KFs on anterolateral rotatory laxity remains unclear. Purpose: To use magnetic resonance imaging (MRI) scans to detect concomitant KF injury in ACL-injured knees and to then examine the effect of KF injury on anterolateral rotatory laxity as measured by the pivot-shift test in a clinical setting. Study Design: Cross-sectional study; Level of evidence, 3. Methods: The study enrolled 91 patients with primary ACL tears (mean age 25 ± 11 years; 46 male and 45 female) whose MRI was conducted within 90 days after injury. KF injury was assessed by MRI according to previously reported criteria, and the patients were allocated to a KF injury group and a no–KF injury group. At the time of ACL reconstruction, the pivot-shift test was performed with the patient under anesthesia and quantitatively evaluated by tibial acceleration using an electromagnetic measurement system. Manual grading of the pivot-shift test was assessed according to guidelines of the International Knee Documentation Committee. The data were statistically compared between the 2 groups using Mann-Whitney U test and Fisher exact test (P < .05). Results: KFs were identified in 85 patients (93.4%), and KF injury was detected in 20 of the 85 patients (23.5%). No significant differences were observed between the KF injury group (n = 20) and the no–KF injury group (n = 65) in demographic characteristics, the period from injury to MRI (8.0 ± 14.0 days vs 8.9 ± 12.1 days, respectively), the rate of meniscal injury (50.0% vs 53.8%), or the rate of anterolateral ligament injury (45.0% vs 44.6%). Regarding the pivot-shift test, no significant differences were observed in tibial acceleration (1.2 m/s2 [interquartile range, 0.5-2.1 m/s2] vs 1.0 m/s2 [interquartile range, 0.6-1.7 m/s2], respectively) or manual grading between the 2 groups. Conclusion: Concomitant KF injury did not significantly affect the pivot-shift phenomenon in acute ACL-injured knees. The findings suggest that the contribution of KF injury to anterolateral rotatory knee laxity may be limited in the clinical setting.

Effet synergique du ligament antérolatéral et de la capsule sur le contrôle de la laxité du genou dans les lésions traumatiques du ligament croisé antérieur : une étude cadavérique

IntroductionThere is much controversy about the practical role of the anterolateral ligament (ALL) and its relation to other anterolateral knee structures including the anterolateral capsule (ALC) and iliotibial band (ITB). The purpose of this cadaveric study was to investigate the effect of the ALL and ALC injuries on knee laxity with the iliotibial band (ITB) preserved in the anterior cruciate ligament (ACL)-injured knee. HypothesisThe ALL and ALC would contribute to knee joint stability during anterior translation and internal rotation of the tibia in an ACL-injured knee. Material and methodsFor 10 fresh-frozen cadaveric knees, we measured knee laxity with the following state of knee injuries with ITB preserved: (1) intact knee, (2) ACL-sectioned knee (ACL-), (3) additional sectioning of the ALL (ACL-/ALL-), and (4) additional sectioning of the ALC (ACL-/ALL-/ALC-). We did biomechanical measurements in internal-external rotation, anterior-posterior translation, and varus-valgus angulation for each condition at knee flexion angles of 0°, 30°, 60°, and 90°. ResultsAfter we sectioned the ALL (ACL-/ALL-), the mean IR at 0°, 30°, 60°, and 90° of knee flexion were significantly increased, compared to the intact knee (P=<0.001, <0.001, <0.001, and 0.002) and ACL- (p=<0.001, <0.001, <0.001, and 0.002). The additional transection of the ALC (ACL-/ALL-/ALC-) significantly increased IR laxity from the ACL-/ALL- at 30°, 60°, and 90° (p=0.005, 0.003, and 0.047). For anterior laxity, ACL-/ALL- resulted in significantly increased anterior laxity from the ACL- at 30° and 60° (P=0.003 and 0.019), and ACL-/ALL-/ALC- significantly increased anterior laxity even from the ACL-/ALL- at 30° and 60° (p=0.007 and 0.011). For varus laxity, ACL-/ALL- resulted in significantly increased varus laxity from both the intact knee and ACL- at 60° (P=0.004 and 0.007) and 90° (p=<0.001 and <0.001). ACL-/ALL-/ALC- resulted in significantly increased varus from ACL-/ALL- at 60° and 90° (p=<0.001 and 0.003). ConclusionThe anterolateral ligament and anterolateral capsule injuries in ACL-injured knees even with ITB preserved had a synergistic effect on knee laxity in the aspects of internal rotation, anterior translation, and varus angulation. Level of evidenceII, Controlled laboratory study.

Tibial internal rotation in combined anterior cruciate ligament and high-grade anterolateral ligament injury and its influence on ACL length

BackgroundAssessment of combined anterolateral ligament (ALL) and anterior cruciate ligament (ACL) injury remains challenging but of high importance as the ALL is a contributing stabilizer of tibial internal rotation. The effect of preoperative static tibial internal rotation on ACL -length remains unknown. The aim of the study was analyze the effect of tibial internal rotation on ACL length in single-bundle ACL reconstructions and to quantify tibial internal rotation in combined ACL and ALL injuries.MethodsThe effect of tibial internal rotation on ACL length was computed in a three-dimensional (3D) model of 10 healthy knees with 5° increments of tibial internal rotation from 0 to 30° resulting in 70 simulations. For each step ACL length was measured. ALL injury severity was graded by a blinded musculoskeletal radiologist in a retrospective analysis of 61 patients who underwent single-bundle ACL reconstruction. Preoperative tibial internal rotation was measured in magnetic resonance imaging (MRI) and its diagnostic performance was analyzed.ResultsACL length linearly increased 0.7 ± 0.1 mm (2.1 ± 0.5% of initial length) per 5° of tibial internal rotation from 0 to 30° in each patient.Seventeen patients (27.9%) had an intact ALL (grade 0), 10 (16.4%) a grade 1, 21 (34.4%) a grade 2 and 13 (21.3%) a grade 3 injury of the ALL. Patients with a combined ACL and ALL injury grade 3 had a median static tibial internal rotation of 8.8° (interquartile range (IQR): 8.3) compared to 5.6° (IQR: 6.6) in patients with an ALL injury (grade 0–2) (p = 0.03). A cut-off > 13.3° of tibial internal rotation predicted a high-grade ALL injury with a specificity of 92%, a sensitivity of 30%; area under the curve (AUC) 0.70 (95% CI: 0.54–0.85) (p = 0.03) and an accuracy of 79%.ConclusionACL length linearly increases with tibial internal rotation from 0 to 30°. A combined ACL and high-grade ALL injury was associated with greater preoperative tibial internal rotation. This potentially contributes to unintentional graft laxity in ACL reconstructed patients, in particular with concomitant high-grade ALL tears.Study designCohort study; Level of evidence, 3.

Synergistic effect of the anterolateral ligament and capsule injuries on the knee laxity in anterior cruciate ligament injured knees: A cadaveric study

IntroductionThere is much controversy about the practical role of the anterolateral ligament (ALL) and its relation to other anterolateral knee structures including the anterolateral capsule (ALC) and iliotibial band (ITB). The purpose of this cadaveric study was to investigate the effect of the ALL and ALC injuries on knee laxity with the iliotibial band (ITB) preserved in the anterior cruciate ligament (ACL)-injured knee. HypothesisThe ALL and ALC would contribute to knee joint stability during anterior translation and internal rotation of the tibia in an ACL-injured knee. Material and methodsFor 10 fresh-frozen cadaveric knees, we measured knee laxity with the following state of knee injuries with ITB preserved: (1) intact knee, (2) ACL-sectioned knee (ACL-), (3) additional sectioning of the ALL (ACL-/ALL-), and (4) additional sectioning of the ALC (ACL-/ALL-/ALC-). We did biomechanical measurements in internal-external rotation, anterior-posterior translation, and varus-valgus angulation for each condition at knee flexion angles of 0°, 30°, 60°, and 90°. ResultsAfter we sectioned the ALL (ACL-/ALL-), the mean IR at 0°, 30°, 60°, and 90° of knee flexion were significantly increased, compared to the intact knee (p=<0.001, <0.001, <0.001, and 0.002) and ACL- (p=<0.001, <0.001, <0.001, and 0.002). The additional transection of the ALC (ACL-/ALL-/ALC-) significantly increased IR laxity from the ACL-/ALL- at 30°, 60°, and 90° (p=0.005, 0.003, and 0.047). For anterior laxity, ACL-/ALL- resulted in significantly increased anterior laxity from the ACL- at 30° and 60° (p=0.003 and 0.019), and ACL-/ALL-/ALC- significantly increased anterior laxity even from the ACL-/ALL- at 30° and 60° (p=0.007 and 0.011). For varus laxity, ACL-/ALL- resulted in significantly increased varus laxity from both the intact knee and ACL- at 60° (p=0.004 and 0.007) and 90° (p=<0.001 and<0.001). ACL-/ALL-/ALC- resulted in significantly increased varus from ACL-/ALL- at 60° and 90° (p=<0.001 and 0.003). ConclusionThe anterolateral ligament and anterolateral capsule injuries in ACL-injured knees even with ITB preserved had a synergistic effect on knee laxity in the aspects of internal rotation, anterior translation, and varus angulation. Level of evidenceII, Controlled laboratory study.

Prevalence of anterolateral ligament injuries and lateral meniscus tear on MR imaging in patients with both-bundle tear vs. selective bundle incomplete tear of the anterior cruciate ligament.

We investigated the prevalence of anterolateral ligament (ALL) injury and lateral meniscus (LM) tear in cases with both-bundle tear and selective bundle incomplete tear of the anterior cruciate ligament (ACL). A total of 174 cases of magnetic resonance (MR) images that had an ACL tear and underwent arthroscopic ACL reconstruction were retrospectively reviewed. ACL injury was classified into both bundle, anteromedial bundle, and posterolateral bundle (PL) on arthroscopic finding. The ALL was divided into three portions: femoral, meniscal, and tibial. ALL injury was scored into three groups: grade 0 is intact; grade 1 is stranding and edema surrounds the expected location of the ALL; grade 2 is clear discontinuity of the ALL consistent with rupture. Traumatic LM tear was also assessed on MR images. The total prevalence of ALL injury was 36.2% (reader 1) and 42.0% (reader 2). ALL injury was statistically related to the selective bundle tear (p = 0.002 and 0.004, readers 1 and 2). PL bundle tear was significantly correlated with the ALL injury (p value < 0.001, readers 1 and 2, both). The location and grade of ALL injury were not significantly correlated with the type of ACL injury. LM tear was not significantly related to the types of ACL tear (p = 0.208 and 0.907, readers 1 and 2) and ALL injury (p value = 0.096 and 0.383, readers 1 and 2). ALL injury was significantly related to the PL bundle tear of the ACL. LM tear was not significantly correlated with the types of ACL injury and ALL injury. • Anterolateral ligament (ALL) injury was significantly related to the posterolateral bundle (PL) tear of the anterior cruciate ligament (ACL). • Lateral meniscus (LM) tear was not significantly correlated with the types of ACL injury and ALL injury. • Clinicians and radiologists should be aware of these relationships and scrutinize ALL injury in cases with PL bundle tears, even with an incomplete ACL injury.

The Modifications of the Anterior Cruciate Ligament Rupture Physical Therapy Caused by the Anterolateral Ligament Injury

The anterolateral ligament (ALL) is a rotational stabilizer of the knee joint widely investigated the last 13 years as the possible cause of some anterior cruciate ligament (ACL) reconstructions failure. ALL injuries accompany 64% of ACL ruptures. Nevertheless, there are still no publications concerning changes in the ACL rehabilitation process due to the ALL concomitant rupture. We evaluated rotational stability in 12 athletes with the ACL rupture and concomitant ALL injury or Segond fracture treated conservatively before the treatment and 3 months later. The physical therapy comprised the range of motions and strengthening exercises during the immobilization period and thereafter. As only the knee joint was immobilized the physical therapy was conducted to the adjacent joints and muscles at the very beginning. A total of 83.33% of patients became pivot-shift negative in three months. In 16.67% pivot-shift test was questionable. Lachman test remained positive in 91.67%. The ACL is a more important structure than the ALL. So, our treatment strategy focuses mainly on it. Most changes in physical therapy are the immobilization and postponed axial loading with internal rotation. But even these minor changes may influence greatly the overall stability of the knee, particularly rotational stability. It seems to be the single case series as- sessing the rotational stability recovery after the ALL rupture conservative treatment we found in the scientific literature. Immobilization and non-weightbearing for up to 6 weeks may decrease the rotational instability in con- servatively treated ALL injuries concomitant to the ACL ruptures. Further investigations of the physical therapy and rehabilitation of the anterolateral ligament injuries and Segond fractures are necessary.

A Surgical Algorithm According to Pivot-Shift Grade in Patients With ACL Injury: A Prospective Clinical and Radiological Evaluation

Background:Some patients have a positive pivot-shift finding and rotational instability after anterior cruciate ligament (ACL) reconstruction (ACLR). Three major pathologies known to affect the pivot-shift examination include ACL tear, anterolateral ligament injury, and loss of posterior lateral meniscus root function.Purpose:To describe a surgical algorithm determining indications for lateral extra-articular tenodesis (LET) based on intraoperative pivot-shift examination to prevent postoperative pivot shift and rotational instability and to evaluate the 2-year clinical and functional outcomes.Study Design:Case series; Level of evidence, 4.Methods:The study included 47 consecutive patients (39 men and 8 women) who underwent operative treatment for ACL injury between 2016 and 2017. Pivot-shift examination was performed under anesthesia, and the pivot shift was graded as grade 1 (glide), grade 2 (clunk), or grade 3 (gross). According to the surgical algorithm, single-bundle ACLR was performed in patients with grade 1 pivot shift. In patients with grade 2 with loss of posterior lateral meniscus root function, concurrent lateral meniscal repair was performed, and in patients with grade 2 with an intact lateral meniscus posterior root, concurrent extra-articular iliotibial band tenodesis was performed. Patients with grade 3 underwent ACLR, lateral meniscal repair, and LET. Clinical and radiographic evaluations were performed.Results:The mean age was 27.2 years (range, 16-56 years). In total, 26 (55.3%) patients were evaluated as having pivot-shift grade 1; 16 (34%) patients, grade 2; and 5 (10.6%) patients, grade 3. A total of 7 (14.9%) patients underwent LET in addition to ACLR. Two of these patients had pivot-shift grade 2, and LET was performed since the lateral meniscus posterior root was intact. In 14 of 16 patients with grade 2, lateral meniscus root disruption was detected, and lateral meniscal repair was performed. One patient was excluded from the further follow-up because of graft failure. At a mean postoperative follow-up of 29 months in 46 patients, the pivot-shift examination was negative in all patients. The mean Lysholm and International Knee Documentation Committee subjective scores were 95.35 ± 4.40 and 82.87 ± 9.36, respectively. Radiographic evidence of osteoarthritis was not detected.Conclusion:Only 14.9% of patients needed LET. With proper ACL, lateral meniscal, and anterolateral ligament surgery, it was possible to prevent positive pivot-shift findings postoperatively.

Does anterolateral ligament injury change the treatment option in patients with partial ACL tears?

Patients with ACL tears with ALL injury have more clinical complaints (instability, feeling of the pop on the knee or knee sliding). patients have ALL injury with partial ACL tears, It is unclear whether the choice of treatment will be conservative or surgical. This study aimed to determine the effect of anterolateral ligament (ALL) status, whether intact or ruptured, on the choice of conservative or surgical treatment in patients with partial anterior cruciate ligament (ACL) tears. Between 2015 and 2019, patients with suspected partial ACL tears were identified on both physical examination and MR imaging. 122 patients who had partial ACL tears and also status of patient's ALL could be evaluated by radiologist were included in the study, retrospectively. Sixty-two patients who underwent ACL reconstruction were determined as group 1, and 60 patients who did not undergo ACL reconstruction were defined as group 2. In patients with partial ACL rupture with or without ACL reconstruction, it was evaluated whether a ruptured or non- ruptured ALL was effective in this decision of conservative or surgically. The MRIs of patients with partial ACL tears were evaluated by a radiologist and it was concluded that the ALLs of 50 patients were ruptured, and 72 were intact. The ALLs of 36 patients in group 1 were ruptured, and 26 patients were intact. Fourteen patients in group 2 had ruptured ALLs, 46 patient's ALLs were intact. Seventy-two percent of the patients with partial ACL tears who had ruptured ALLs in MRI underwent ACL reconstruction. It was found that ACL reconstruction was performed more frequently in patients with partial ACL tears with ALL rupture. Therefore, we believe that preoperative evaluations of ALLs using MRI in patients with partial ACL tears are essential for surgical planning.

Injuries of Kaplan fibers in ACL deficient and reconstructed knees – redefining the structure and risk assessment on MRI using injury patterns

Objectives:To determine an injury pattern of knee structures along torn Kaplan fibers in ACL deficient knees and to observe the healing process of Kaplan fibers in ACL reconstructed knees.Methods:A total of 101 knee MRIs obtained between January 2004 and April 2020 with full-thickness ACL tears were retrospectively assessed for visibility and impairment of three Kaplan bundles (proximal, distal and epicondylar band) and for associated injuries by two fellowship-trained independent musculoskeletal radiologists. A subgroup of 33 follow-up knee MRIs after ACL reconstruction was assessed to observe the natural evolution of Kaplan fibers injury. Descriptive statistics and Spearman correlation coefficients (P<.05) were used to determine injury patterns.Results:Kaplan fibers were injured in 43 of 101 (43%) acute ACL deficient knees. Proximal Kaplan fibers were visible in less than 48 of 101 (50%) knees as opposed to the distal Kaplan fibers and epicondylar Kaplan band which were both visible in 98 of 101 (97%) knees. Injury to the Kaplan complex was significantly associated with anterolateral (rho, 0.36; P<.001) and lateral collateral ligament impairment (rho, 0.21;P<.05) and medial femoral bone marrow edema (rho, 0.21;P<.05). After ACL reconstruction, only two of 33 (6%) patients showed torn Kaplan and 13 of 33 (39%) distal Kaplan fibers were scarred.Conclusion:Torn Kaplan fibers are associated with anterolateral and lateral collateral ligament injuries in ACL deficiency, indicating a more severe anterolateral and rotatory instability. Injury patterns in ACL deficient knees can eliminate the uncertainty of proximal Kaplan fibers identification. Kaplan fiber tears tend to heal following ACL reconstruction.

Adolescents show a lower healing rate of anterolateral ligament injury and a higher rotational laxity than adults after anterior cruciate ligament reconstruction

BackgroundThis study aimed to compare anterolateral ligament (ALL) injuries in anterior cruciate ligament (ACL) ruptures, as well as ALL healing and clinical outcomes following ACL reconstruction between adolescents and adults. MethodsThis retrospective study involved 98 patients who underwent ACL reconstruction. They were divided into two groups according to age: group A (adolescents, 16–20 years of age; n = 49) and group B (adults, 21–45 years of age; n = 49). Subjective scores including ACL-Return to Sport after Injury (ACL-RSI) scale and objective tests were assessed. Follow up magnetic resonance imaging (MRI) and second-look arthroscopy was conducted at 1-year and 2-year follow up, respectively. ResultsGood healing rate of ALL was higher in adults than in adolescents (P = 0.048). Graft tension and synovial coverage showed no significant differences between two groups. Group A showed a higher rate of high-grade pivot shift and a lower ACL-RSI at last follow up than group B (P = 0.126 and P = 0.016). Poor healing of ALL was significantly associated with lower ACL-RSI and failure to return to sports (P < 0.001 and P = 0.001). Re-rupture of the ACL graft was found in four (8.2%) and one (2.0%) of group A and B, respectively. ConclusionsAdolescents showed a lower healing rate of ALL, a lower ACL-RSI, a higher rate of high-grade pivot shift than adults. Moreover, poor healing of ALL was significantly associated with a lower ACL-RSI and failure to return to sports. We suggest that adolescents need to pay more attention to the presence of ALL injury.

Age, activity level and meniscus injury, but not tear location, tibial slope or anterolateral ligament injury predict coping with anterior cruciate ligament injury

IntroductionEarly recognition of potential predictors on the success of conservative treatment of anterior cruciate ligament (ACL) is important, as appropriate treatment can be applied to each individual patient. The goal of this study is to assess the patient demographic and radiological parameters that predict coping with ACL injuries. MethodsAll patients presenting with a complete ACL injury between 2014 and 2018 at our clinic were included. The role of patient demographics (age, gender, activity level, meniscus injury and time from injury to clinic), and ACL tear location, bone bruises, tibial slope, and anterolateral ligament (ALL) injury were assessed on the success of conservative treatment using univariate and multivariate analyses. ResultsSixty-five patients (32%) were copers and 141 (68%) were non-copers. Univariate analysis showed that copers were significantly older (40 vs. 27 years, P < 0.001), had lower preinjury activity level (Tegner 5.7 vs. 6.5, P < 0.001) and less often lateral meniscus tears (16% vs. 5%, P = 0.019) but not medial meniscus tears (17% vs. 14%, P = 0.609) than non-copers. Multivariate analysis revealed that increasing age (P < 0.001), Tegner level ≤ 6 (P = 0.003) and no meniscus injury (P = 0.045) were independent predictors of coping with ACL deficiency. ConclusionsOlder age, participation in lower activity sports levels and absence of meniscus injury were predictive of coping with ACL deficiency, whereas there was no such role for tear location, tibial slope, lateral bone bruise presence, ALL injury or gender. These findings might help to identify potential copers and guide surgeons early in the optimal treatment for patients with ACL injury.