Biomechanical Analysis of Simulated Clinical Testing and Reconstruction of the Anterolateral Ligament of the Knee

Abstract

Background: Anatomic anterolateral ligament (ALL) reconstruction has been proposed to assist anterior cruciate ligament (ACL) reconstruction in controlling anterolateral rotational laxity of the knee. However, the biomechanical effects have not been reported. Purpose: (1) To investigate the effect of ALL transection on rotational knee kinematics and (2) to determine the effect on knee biomechanics of ALL reconstruction procedures compared with lateral extra-articular tenodesis (LET). Study Design: Controlled laboratory study. Methods: A total of 12 cadaveric knee specimens were tested in the following sequence: (1) ACLintact, (2) anteromedial bundle of ACL sectioned (ACLamb), (3) complete ACL sectioned (ACLfull), (4) ALL sectioned (ALLsec), (5) anatomic ALL reconstruction (ALLanat), and (6) LET. Biomechanical anterior drawer and Lachman tests were performed in which a 90-N load was applied to the posterior tibia, and anterior translation was measured. A combined load to simulate the early phase of the pivot-shift test was executed in which a 5-N·m internal rotation moment was applied to a fully extended knee; anterior translation and internal rotation were measured. Results: Anterior translation increased across conditions for the biomechanical tests. Internal rotation during the simulated early-phase pivot-shift test was significantly different between ACLfull and ALLsec. Anatomic ALL reconstruction did not significantly reduce internal rotation or anterior translation during the simulated early-phase pivot-shift test. After LET, a significant decrease in anterior translation was found. There was no evidence of overconstraint of the knee with either anatomic ALL reconstruction or LET. Conclusion:The ALL demonstrated a role in controlling anterolateral laxity. LET had a composite effect in governing both anterior and rotational laxity. Anatomic ALL reconstruction did not reduce anterolateral rotational laxity. Clinical Relevance: Profiling the biomechanical characteristics of anterolateral reconstruction is integral to understanding the implications and potential benefit of such an additional procedure to ACL reconstruction.

The anterolateral ligament: A cadaveric study in fetuses

“…The ALL, unlike the ACL, shows greater restrictive force during knee flexion, providing greater resistance with degrees of flexion between 608 and 908 (Helito et al, 2014;Zens et al, 2015). Therefore, the ALL can act as a secondary restrictor against internal rotation at flexion angles >358 (Parsons et al, 2015;Spencer et al, 2015), when the ACL loses its restraining force. However, unlike the ACL, the ALL does not seem to be involved in controlling the anterior drawer test (Parsons et al, 2015).…”

Combined Intra-articular and Extra-articular Reconstruction in Anterior Cruciate Ligament–Deficient Knee: 25 Years Later

“…[1][2][3] Although current literature provides varying description, 4-7 most authors agree that the capsule contains a true ligament (i.e., the anterolateral ligament [ALL]) or at least a robust thickening whose biomechanical effect, already described in the past, has been emphasized again. 8,9 Improper healing, a lack of recognition, or inadequate treatment of injury of these structures could explain the persistence of residual pivot-shift often observed after a successful anterior cruciate ligament (ACL) reconstruction. Extra-articular reconstruction, either isolated or in association with ACL intra-articular reconstruction, was popular since the beginning of modern ACL surgery with the aim to improve rotational control in ACL-deficient knees.…”

Comparison of reaction forces on the anterior cruciate and anterolateral ligaments during internal rotation and anterior drawer forces at different flexion angles of the knee joint

“…There are three performance tests in orthopedics clinics. The first of these is a pivotshifttest, second is an anterior drawer test, third is a Lachman test . 5 Nm and 10 Nm internal rotation momenta were applied to obtained the models as seen in Figure .…”