Background:Reconstruction of the anterior cruciate ligament (ACL) is one of the most common procedures in orthopaedic surgery. However, even with advances in surgical techniques and implants, some patients still have residual anterolateral rotatory laxity after reconstruction. A thorough study of the anatomy of the anterolateral region of the knee is needed.Purpose:To study the anterolateral region and determine the measurements and points of attachments of the anterolateral ligament (ALL).Study Design:Descriptive laboratory study.Methods:Dissections of the anterolateral structures of the knee were performed in 20 human cadavers. After isolating the ALL, its length, thickness, width, and points of attachments were determined. The femoral attachment of the ALL was based on the anterior-posterior and proximal-distal distances from the attachment of the lateral collateral ligament (LCL). The tibial attachment point was based on the distance from the Gerdy tubercle to the fibular head and the distance from the lateral tibial plateau. The ligaments from the first 10 dissections were sent for histological analysis.Results:The ALL was found in all 20 knees. The femoral attachment of the ALL at the lateral epicondyle averaged 3.5 mm distal and 2.2 mm anterior to the attachment of the LCL. Two distal attachments were observed: one inserts into the lateral meniscus, the other between the Gerdy tubercle and the fibular head, approximately 4.4 mm distal to the tibial articular cartilage. The mean measurements for the ligament were 37.3 mm (length), 7.4 mm (width), and 2.7 mm (thickness). The histological analysis of the ligaments revealed dense connective tissue.Conclusion:The ALL is consistently present in the anterolateral region of the knee. Its attachment to the femur is anterior and distal to the attachment of the LCL. Moving distally, it bifurcates at close to half of its length. The ALL features 2 distal attachments, one at the lateral meniscus and the other between the Gerdy tubercle and the fibular head.Clinical Relevance:The ALL may be important in maintaining normal rotatory limits of knee motion; ALL rupture could be responsible for rotatory laxity after isolated intra-articular reconstruction of the ACL.
We present a new technique for the combined intra-and extra-articular reconstruction of the anterior cruciate ligament. Intra-articular reconstruction is performed in an outside-in manner according to the precepts of the anatomic femoral tunnel technique. Extra-articular reconstruction is performed with the gracilis tendon while respecting the anatomic parameters of the origin and insertion points and the path described for the knee anterolateral ligament.
Combined injuries involving the anterior cruciate ligament (ACL) and posterolateral corner (PLC) occur in approximately 10% of complex knee injuries. The current tendency is to reconstruct both the ACL and the structures of the PLC. In injuries involving multiple ligaments, a potential problem in the reconstruction is the convergence of tunnels in the lateral walls of the femur. As a solution to this problem, we propose a combined technique for reconstruction of the ACL and PLC with a single tunnel in the lateral femoral wall. Combined ACL/PLC reconstruction is performed with 2 semitendinosus tendons and 1 gracilis tendon. The technique consists of making a tunnel in the lateral wall of the femur, from the outside in, at the isometric point, for reconstruction of the collateral ligament and popliteus tendon, and emerging in the joint region at the anatomic point of the ACL reconstruction. The graft is passed from the tibia to the femur with the double gracilis tendon and the simple semitendinosus tendon; the remaining portions are left for reconstruction of the structures of the PLC. This technique is very effective in terms of minimizing the number of tunnels, but it does rely on having grafts of adequate size.C ombined injuries involving the anterior cruciate ligament (ACL) and posterolateral corner (PLC) occur in approximately 10% of complex knee injuries. Patients with these injuries have a high level of knee instability, even for day-to-day activities, and tend to place too much burden on the medial compartment. This problem can be resolved with surgical treatment. The current tendency is to reconstruct both the ACL and the structures of the PLC, rather than repairing the latter. [1][2][3][4] In injuries involving multiple segments, a potential problem with reconstruction is the convergence of femoral tunnels in the lateral walls in the case of ACL and PLC reconstruction and in the medial walls in the case of posterior cruciate ligament and medial collateral ligament reconstruction. 5,6 As a solution to this problem, we propose a combined technique for reconstruction of the ACL and PLC with a single tunnel in the lateral femoral wall.
Background:No consensus exists regarding the anatomic characteristics of the knee anterolateral ligament (ALL). A critical analysis of the dissections described in previous studies allows the division of the ALL into 2 groups with similar characteristics. The presence of considerable variability suggests that the authors may not be referring to the same structure.Purpose/Hypothesis:To perform a lateral anatomic dissection, by layers, seeking to characterize the 2 variants described for the ALL on the same knee. We hypothesized that we would identify the 2 variants described for the ALL and that these variants would have distinct characteristics.Study Design:Descriptive laboratory study.Methods:Thirteen unpaired cadaveric knees were used in this study. The dissection protocol followed the parameters described in previous studies. Immediately below the iliotibial tract, we isolated a structure designated as the superficial ALL, whereas between this structure and the articular capsule, we isolated a structure designated as the deep ALL. The 2 structures were measured for length at full extension and at 90° of flexion and for distance from the tibial insertion relative to the Gerdy tubercle. Potential contact with the lateral meniscus was also evaluated. After measurements were obtained, the 2 dissected structures underwent histologic analysis.Results:The superficial ALL presented a posterior and proximal origin to the center of the lateral epicondyle, its length increased on knee extension, and it exhibited no contact with the lateral meniscus. The deep ALL was located in the center of the lateral epicondyle, its length increased on knee flexion, and it presented a meniscal insertion. Both structures had a similar tibial insertion site; however, the insertion site of the deep ALL was located more posteriorly. The analysis of the histological sections for both structures indicated the presence of dense and well-organized collagen fibers.Conclusion:This anatomic study clearly identified 2 structures, described as the superficial and deep ALL, which were consistent with previous but conflicting descriptions of the ALL.Clinical Relevance:This study clarifies numerous controversies encountered in anatomic studies of the ALL. Knowledge regarding the existence of 2 distinct structures in the anterolateral knee will allow more accurate evaluation of their functions and characteristics.
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