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Function and strain of the anterolateral ligament part II: reconstruction

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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

Anterolateral rotatory instability (ALRI) may result from isolated ruptures of the anterior cruciate ligament (ACL) or combined lesions with the anterolateral ligament (ALL). Biomechanical studies have demonstrated that the ALL contributes to the overall rotational stability of the knee. The purpose of this study was to investigate the biomechanical function of anatomic ALL reconstruction (ALLrec) in the setting of a combined ACL and ALL injury and reconstruction. The hypothesis was that combined ACL reconstruction (ACLrec) and ALLrec (ACL/ALLrec) significantly reduces internal rotation and shows load sharing between both reconstructions compared with isolated ACLrec.

Methods

Eight fresh-frozen cadaveric knees were evaluated using a six degrees of freedom knee simulator. Continuous passive motion and external loads were tested. Kinematic differences between ACLrec and combined ACL/ALLrec were compared. Additionally, ACL graft tension and ALL graft strain were measured continuously throughout the testing protocol.

Results

Combined anatomic ACL/ALLrec significantly improved the internal rotatory stability compared with isolated ACLrec at 30°–90° under an internal rotation moment. During a static pivot-shift test, additional ALLrec showed no significant reduction of ap-translation. ALLrec resulted in an increase in ACL graft tension during continuous passive motion and with additional internal rotation moment.

Conclusion

In the case of a combined ACL and ALL deficiency, concurrent ACLrec and ALLrec significantly improved the rotatory stability of the knee compared with solely reconstructing the ACL at flexion angles ≥ 30°. Nevertheless, additional ALLrec with fixation at 60° and with low tension could not restore extension-near rotatory stability. For that reason, ALLrec with fixation at 60° flexion cannot be recommended in clinical application.

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References

  1. Andrews JR, Sanders RA, Morin B (1985) Surgical treatment of anterolateral rotatory instability. A follow-up study. Am J Sports Med 13:112–119

    Article  CAS  Google Scholar 

  2. Benum P (1982) Anterolateral rotary instability of the knee joint. Results after stabilization by extraarticular transposition of the lateral part of the patellar ligament. A preliminary report. Acta Orthop Scand 53:613–617

    Article  CAS  Google Scholar 

  3. Bonanzinga T, Signorelli C, Grassi A, Lopomo N, Jain M, Mosca M, Iacono F, Marcacci M, Zaffagnini S (2017) Kinematics of ACL and anterolateral ligament. Part II: anterolateral and anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 25:1062–1067

    Article  CAS  Google Scholar 

  4. Chahla J, Menge TJ, Mitchell JJ, Dean CS, Laprade RF (2016) Anterolateral ligament reconstruction technique: an anatomic-based approach. Arthrosc Techn 5:e453–e457

    Article  Google Scholar 

  5. Claes S, Vereecke E, Maes M, Victor J, Verdonk P, Bellemans J (2013) Anatomy of the anterolateral ligament of the knee. J Anat 223:321–328

    Article  Google Scholar 

  6. Clancy WG, Nelson DA, Reider B, Narechania RG (1982) Anterior cruciate ligament reconstruction using one-third of the patellar ligament, augmented by extra-articular tendon transfers. J Bone Jt Surg Am 64:352–359

    Article  Google Scholar 

  7. Delaloye J-R, Hartog C, Blatter S, Schläppi M, Müller D, Denzler D, Murar J, Koch P (2020) Anterolateral ligament reconstruction and modified lemaire lateral extra-articular tenodesis improve knee stability after anterior cruciate ligament reconstruction: a biomechanical study. Arthroscopy. https://doi.org/10.1016/j.arthro.2020.03.027

    Article  Google Scholar 

  8. DePhillipo NN, Cinque ME, Chahla J, Geeslin AG, Laprade RF (2017) Anterolateral ligament reconstruction techniques, biomechanics, and clinical outcomes: a systematic review. Arthroscopy 33:1575–1583

    Article  Google Scholar 

  9. Drews BH, Kessler O, Franz W, Dürselen L, Freutel M (2017) Function and strain of the anterolateral ligament part I: biomechanical analysis. Knee Surg Sports Traumatol Arthrosc 25:1132–1139

    Article  Google Scholar 

  10. Drews BH, Seitz AM, Huth J, Bauer G, Ignatius A, Dürselen L (2017) ACL double-bundle reconstruction with one tibial tunnel provides equal stability compared to two tibial tunnels. Knee Surg Sports Traumatol Arthrosc 25:1646–1652

    Article  Google Scholar 

  11. Dürselen L, Vögele S, Seitz AM, Ignatius A, Friederich NF, Bauer G, Majewski M (2011) Anterior knee laxity increases gapping of posterior horn medial meniscal tears. Am J Sports Med 39:1749–1755

    Article  Google Scholar 

  12. Ellison AE (1979) Distal iliotibial-band transfer for anterolateral rotatory instability of the knee. J Bone Joint Surg Am 61:330–337

    Article  CAS  Google Scholar 

  13. Fleming RE, Blatz DJ, McCarroll JR (1983) Lateral reconstruction for anterolateral rotatory instability of the knee. Am J Sports Med 11:303–307

    Article  Google Scholar 

  14. Fu FH, van Eck CF, Tashman S, Irrgang JJ, Moreland MS (2015) Anatomic anterior cruciate ligament reconstruction: a changing paradigm. Knee Surg Sports Traumatol Arthrosc 23:640–648

    Article  Google Scholar 

  15. Getgood A, Brown C, Lording T, Amis A, Claes S, Geeslin A, Musahl V, ALC Consensus Group (2019) The anterolateral complex of the knee: results from the International ALC Consensus Group Meeting. Knee Surg Sports Traumatol Arthrosc 27(1):166–176

    Article  Google Scholar 

  16. Godin JA, Chahla J, Moatshe G, Kruckeberg BM, Muckenhirn KJ, Vap AR, Geeslin AG, Laprade RF (2017) A comprehensive reanalysis of the distal iliotibial band: quantitative anatomy, radiographic markers, and biomechanical properties. Am J Sports Med 45:2595–2603

    Article  Google Scholar 

  17. Helito CP, Bonadio MB, Gobbi RG, da Mota E, Albuquerque RF, Pecora JR, Camanho GL, Demange MK (2015) Combined intra- and extra-articular reconstruction of the anterior cruciate ligament: the reconstruction of the knee anterolateral ligament. Arthrosc Techn 4:e239–e244

    Article  Google Scholar 

  18. Helito CP, Sobrado MF, Giglio PN, Bonadio MB, Pecora JR, Camanho GL, Demange MK (2019) Combined reconstruction of the anterolateral ligament in patients with anterior cruciate ligament injury and ligamentous hyperlaxity leads to better clinical stability and a lower failure rate than isolated anterior cruciate ligament reconstruction. Arthroscopy 35:2648–2654

    Article  Google Scholar 

  19. Herbst E, Albers M, Burnham JM, Fu FH, Musahl V (2017) The anterolateral complex of the knee. Orthop J Sports Med 5:2325967117730805

    Article  Google Scholar 

  20. Ibrahim SA, Shohdy EM, Marwan Y, Ramadan SA, Almisfer AK, Mohammad MW, Abdulsattar WS, Khirat S (2017) Anatomic reconstruction of the anterior cruciate ligament of the knee with or without reconstruction of the anterolateral ligament: a randomized clinical trial. Am J Sports Med 45:1558–1566

    Article  Google Scholar 

  21. Inderhaug E, Stephen JM, Williams A, Amis AA (2017) Biomechanical comparison of anterolateral procedures combined with anterior cruciate ligament reconstruction. Am J Sports Med 45:347–354

    Article  Google Scholar 

  22. Inderhaug E, Stephen JM, Williams A, Amis AA (2017) Anterolateral tenodesis or anterolateral ligament complex reconstruction: effect of flexion angle at graft fixation when combined with acl reconstruction. Am J Sports Med 45:3089–3097

    Article  Google Scholar 

  23. Jenny J-Y, Puliero B, Schockmel G, Harnoist S, Clavert P (2017) Minimal influence of the anterolateral knee ligament on anterior and rotational laxity of the knee: a cadaveric study. Eur J Orthop Surg Traumatol 23:3186

    Google Scholar 

  24. Kanamori A, Zeminski J, Rudy TW, Li G, Fu FH, Woo SL-Y (2002) The effect of axial tibial torque on the function of the anterior cruciate ligament: a biomechanical study of a simulated pivot shift test. Arthroscopy 18:394–398

    Article  Google Scholar 

  25. Kennedy MI, Claes S, Fuso FAF, Williams BT, Goldsmith MT, Turnbull TL, Wijdicks CA, Laprade RF (2015) The anterolateral ligament: an anatomic, radiographic, and biomechanical analysis. Am J Sports Med 43:1606–1615

    Article  Google Scholar 

  26. Kernkamp WA, Van de Velde SK, Bakker EWP, van Arkel ERA (2015) Anterolateral extra-articular soft tissue reconstruction in anterolateral rotatory instability of the knee. Arthrosc Techn 4:e863–e867

    Article  Google Scholar 

  27. Kittl C, El-Daou H, Athwal KK, Gupte CM, Weiler A, Williams A, Amis AA (2015) The role of the anterolateral structures and the ACL in controlling laxity of the intact and ACL-deficient knee. Am J Sports Med 44:345–354

    Article  Google Scholar 

  28. Lee DW, Kim JG, Cho SI, Kim DH (2019) Clinical outcomes of isolated revision anterior cruciate ligament reconstruction or in combination with anatomic anterolateral ligament reconstruction. Am J Sports Med 47:324–333

    Article  Google Scholar 

  29. Li X, Xu C-P, Song J-Q, Jiang N, Yu B (2013) Single-bundle versus double-bundle anterior cruciate ligament reconstruction: an up-to-date meta-analysis. Int Orthop 37:213–226

    Article  Google Scholar 

  30. Losee RE, Johnson TR, Southwick WO (1978) Anterior subluxation of the lateral tibial plateau. A diagnostic test and operative repair. J Bone Jt Surg Am 60:1015–1030

    Article  CAS  Google Scholar 

  31. Meredick RB, Vance KJ, Appleby D, Lubowitz JH (2008) Outcome of single-bundle versus double-bundle reconstruction of the anterior cruciate ligament: a meta-analysis. Am J Sports Med 36:1414–1421

    Article  Google Scholar 

  32. Musahl V, Getgood A, Neyret P, Claes S, Burnham JM, Batailler C, Sonnery-Cottet B, Williams A, Amis A, Zaffagnini S, Karlsson J (2017) Contributions of the anterolateral complex and the anterolateral ligament to rotatory knee stability in the setting of ACL Injury: a roundtable discussion. Knee Surg Sports Traumatol Arthrosc 25(4):997–1008

    Article  Google Scholar 

  33. Nitri M, Rasmussen MT, Williams BT, Moulton SG, Cruz RS, Dornan GJ, Goldsmith MT, Laprade RF (2016) An in vitro robotic assessment of the anterolateral ligament, part 2: anterolateral ligament reconstruction combined with anterior cruciate ligament reconstruction. Am J Sports Med 44:593–601

    Article  Google Scholar 

  34. Nurmi JT, Kannus P, Sievänen H, Järvelä T, Järvinen M, Järvinen TLN (2004) Interference screw fixation of soft tissue grafts in anterior cruciate ligament reconstruction: part 2: effect of preconditioning on graft tension during and after screw insertion. Am J Sports Med 32:418–424

    Article  Google Scholar 

  35. Rasmussen MT, Nitri M, Williams BT, Moulton SG, Cruz RS, Dornan GJ, Goldsmith MT, Laprade RF (2015) An in vitro robotic assessment of the anterolateral ligament, part 1: secondary role of the anterolateral ligament in the setting of an anterior cruciate ligament injury. Am J Sports Med 44:585–592

    Article  Google Scholar 

  36. Rosenstiel N, Praz C, Ouanezar H, Saithna A, Fournier Y, Hager J-P, Thaunat M, Sonnery-Cottet B (2019) Combined anterior cruciate and anterolateral ligament reconstruction in the professional athlete: clinical outcomes from the scientific anterior cruciate ligament network international study group in a series of 70 patients with a minimum follow-up of 2 years. Arthroscopy 35:885–892

    Article  Google Scholar 

  37. Runer A, Birkmaier S, Pamminger M, Reider S, Herbst E, Künzel K-H, Brenner E, Fink C (2016) The anterolateral ligament of the knee: a dissection study. Knee 23:8–12

    Article  Google Scholar 

  38. Schon JM, Moatshe G, Brady AW, Serra Cruz R, Chahla J, Dornan GJ, Turnbull TL, Engebretsen L, Laprade RF (2016) Anatomic anterolateral ligament reconstruction of the knee leads to overconstraint at any fixation angle. Am J Sports Med 44:2546–2556

    Article  Google Scholar 

  39. Smith JO, Yasen SK, Lord B, Wilson AJ (2015) Combined anterolateral ligament and anatomic anterior cruciate ligament reconstruction of the knee. Knee Surg Sports Traumatol Arthrosc 23:3151–3156

    Article  Google Scholar 

  40. Sonnery-Cottet B, Lutz C, Daggett M, Dalmay F, Freychet B, Niglis L, Imbert P (2016) The involvement of the anterolateral ligament in rotational control of the knee. Am J Sports Med 44:1209–1214

    Article  Google Scholar 

  41. Sonnery-Cottet B, Saithna A, Cavalier M, Kajetanek C, Temponi EF, Daggett M, Helito CP, Thaunat M (2017) Anterolateral ligament reconstruction is associated with significantly reduced ACL graft rupture rates at a minimum follow-up of 2 years: a prospective comparative study of 502 patients from the SANTI Study Group. Am J Sports Med 45:1547–1557

    Article  Google Scholar 

  42. Sonnery-Cottet B, Thaunat M, Freychet B, Pupim BHB, Murphy CG, Claes S (2015) Outcome of a combined anterior cruciate ligament and anterolateral ligament reconstruction technique with a minimum 2-year follow-up. Am J Sports Med 43:1598–1605

    Article  Google Scholar 

  43. Spencer L, Burkhart TA, Tran MN, Rezansoff AJ, Deo S, Caterine S, Getgood AM (2015) Biomechanical analysis of simulated clinical testing and reconstruction of the anterolateral ligament of the knee. Am J Sports Med 43:2189–2197

    Article  Google Scholar 

  44. Tavlo M, Eljaja S, Jensen JT, Siersma VD, Krogsgaard MR (2016) The role of the anterolateral ligament in ACL insufficient and reconstructed knees on rotatory stability: A biomechanical study on human cadavers. Scand J Med Sci Sports 26:960–966

    Article  CAS  Google Scholar 

  45. Thein R, Boorman-Padgett J, Stone K, Wickiewicz TL, Imhauser CW, Pearle AD (2016) Biomechanical assessment of the anterolateral ligament of the knee: a secondary restraint in simulated tests of the pivot shift and of anterior stability. J Bone Jt Surg Am 98:937–943

    Article  Google Scholar 

  46. Ueki H, Nakagawa Y, Ohara T, Watanabe T, Horie M, Katagiri H, Otabe K, Katagiri K, Hiyama K, Katakura M, Hoshino T, Inomata K, Araya N, Sekiya I, Muneta T, Koga H (2018) Risk factors for residual pivot shift after anterior cruciate ligament reconstruction: data from the MAKS group. Knee Surg Sports Traumatol Arthrosc 24:2936–2937

    Google Scholar 

  47. Yasuma S, Nozaki M, Murase A, Kobayashi M, Kawanishi Y, Fukushima H, Takenaga T, Yoshida M, Kuroyanagi G, Kawaguchi Y, Nagaya Y, Murakami H (2020) Anterolateral ligament reconstruction as an augmented procedure for double-bundle anterior cruciate ligament reconstruction restores rotational stability: Quantitative evaluation of the pivot shift test using an inertial sensor. Knee 27:397–405

    Article  Google Scholar 

  48. Yoon KH, Hwang IU, Kim EJ, Kwon YB, Kim S-G (2020) Anterolateral Ligament Reconstruction Improves Anteroposterior Stability As Well As Rotational Stability in Revision Anterior Cruciate Ligament Reconstruction with High-Grade Pivot Shift. J Knee Surg. https://doi.org/10.1055/s-0040-1708055

    Article  Google Scholar 

  49. Zhu Y, Tang R-K, Zhao P, Zhu S-S, Li Y-G, Li J-B (2013) Double-bundle reconstruction results in superior clinical outcome than single-bundle reconstruction. Knee Surg Sports Traumatol Arthrosc 21:1085–1096. https://doi.org/10.1007/s00167-012-2073-8

    Article  Google Scholar 

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Acknowledgements

This study was funded by the Alwin-Jäger-Foundation. The instruments for the surgical preparation were provided by Arthrex (München, Germany). W.F. is a consultant to Arthrex and receives royalties from Arthrex. B.H.D. is a consultant to Arthrex. M.F. is an employee of ZF Friedrichshafen AG. No author has received any financial benefit from the research in this study.

Funding

This study was funded by the Alwin-Jäger-Foundation.

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Author notes

  1. Björn Holger Drews and O. Kessler equally contributed.

Authors and Affiliations

  1. St. Vinzenz Clinic Allgäu, Kirchenweg 15, 87459, Pfronten, Germany

    Björn H. Drews

  2. Centre for Orthopaedics and Sports, Albisriederstrasse 243 A, 8047, Zürich, Switzerland

    Oliver Kessler

  3. University Hospital for Orthopaedic Surgery, Leipziger Str. 44, 39120, Magdeburg, Germany

    Oliver Kessler

  4. Lutrina Clinic, Pfaffplatz 10, 67655, Kaiserslautern, Germany

    Wolfgang Franz

  5. Institute of Orthopaedic Research and Biomechanics, Trauma Research Centre, University of Ulm, Medical Centre, Helmholtzstraße 14, 89081, Ulm, Germany

    Maren Freutel & Lutz Dürselen

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  1. Björn H. Drews
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  2. Oliver Kessler
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  3. Wolfgang Franz
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  5. Lutz Dürselen
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Correspondence to Björn H. Drews.

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The authors declare that they have no conflict of interest.

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The Institutional Review Board of the University of Ulm approved this study (approval number 51/15).

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Drews, B.H., Kessler, O., Franz, W. et al. Function and strain of the anterolateral ligament part II: reconstruction. Knee Surg Sports Traumatol Arthrosc 31, 390–398 (2023). https://doi.org/10.1007/s00167-020-06137-8

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  • DOI: https://doi.org/10.1007/s00167-020-06137-8

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