High Interspecimen Variability in Engagement of the Anterolateral Ligament: An In Vitro Cadaveric Study

Kent, Robert N.; Boorman-Padgett, James; Thein, Ran; List, Jelle P. van der; Nawabi, Danyal H.; Wickiewicz, Thomas L.; Imhauser, Carl W.; Pearle, Andrew D.

doi:10.1007/s11999-017-5375-9

Cited by 8 publications

(9 citation statements)

References 34 publications

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“…The systematic search generated 85 abstracts from Pub-Med, 115 from Scopus, 21 from WOS and 10 from Cochrane. Out of the 231 abstracts, 187 were not relevant and 30 studies were excluded because they did not meet the inclusion criteria (6 anatomic studies [5,20,25,40,42,46], 3 biomechanical studies [23,34,37], 5 reviews [9,14,15,29,44], 8 surgical techniques [12,13,24,30,31,33,35,43] and 8 primary ACL reconstructions [3,10,18,19,21,22,36,47,50]). Of the remaining 14, 2 were further excluded: one [8], because the authors published on the same population with recent results and the other [7] because it only analyzed intraoperative tibial translation and internal rotation using a navigation system and had no clinical outcomes.…”

Section: Resultsmentioning

confidence: 99%

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Good mid-term outcomes and low rates of residual rotatory laxity, complications and failures after revision anterior cruciate ligament reconstruction (ACL) and lateral extra-articular tenodesis (LET)

Grassi

Zicaro

Paz

et al. 2019

Knee Surg Sports Traumatol Arthrosc

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Background Residual rotational instability remains a controversial factor when analysing failure rates of anterior cruciate ligament (ACL) reconstruction. Anatomical and biomechanical studies have demonstrated a very important role of anterolateral structures for rotational control. Revision ACL is considered one of the main indications for a lateral extra‐articular tenodesis (LET). Yet, few series evaluating these procedures are published. Purpose To perform a systematic review of studies that assessed outcomes in patients treated with revision ACL surgery associated with a lateral extra‐articular procedure. Study design Systematic review. Methods A comprehensive literature search was performed in February 2018 using PubMed, Scopus, Web of Search and Cochrane. Inclusion criteria were series of ACL revision reconstructions associated with lateral extra‐articular procedures. Clinical outcomes (Lysholm, subjective IKDC, KOOS, Cincinnati and WOMAC), joint stability measures (Lachman test, pivot‐shift, arthrometer assessment and navigation assessment), graft type, reported chondral and meniscal injury, radiographic outcomes, complications and failures were recorded. Articles were assessed for level of evidence and methodology using a modification of the ACL Methodology Score (AMS) system. Results Twelve studies met the inclusion criteria out of the 231 abstracts; 9 retrospective evaluations, two prospective cohorts and one combination of two populations (a retrospective and prospective series). A total of 851 patients evaluated with a mean age of 28.8 years (range 16–68 years) and a weighted mean follow‐up of 4.9 years (range 1–10 years). The mean time from primary ACL reconstruction to revision was 5.3 years (reported in 7 studies, including 710 patients). The Lysholm, IKDC, and KOOS scores indicated favorable results in studies that reported these outcomes. Objective evaluations reported 86% objective A and B IKDC results, 2.6 mm mean side‐to‐side arthrometric difference and 80% negative pivot‐shift. About 74% of patients returned to their previous sport (evaluated in six studies). Few studies reported radiological evaluation. Fifty‐nine complications (8.0%) and 24 failures (3.6%) were reported. The mean modified ACL Methodology Score was 55.5 (range 32–72). Conclusion Good mid‐term results were obtained for combined revision ACL reconstruction and lateral extra‐articular procedures. Despite the fact that in clinical practice LET are a common indication associated with revision ACL, there are no high‐level studies supporting this technique. Level of evidence IV.

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Section: Resultsmentioning

confidence: 99%

“…These included: three studies which used the original or modified Lemaire technique (Fig. 2a, b) [1,25,37], three studies that used the Cocker-Arnold technique (Fig. 2c) [1,11,39], three studies that used the remnant of the intra-articular graft through the over-the-top technique (Fig.…”

Section: Surgical Techniques (Table 2)mentioning

confidence: 99%

Good mid-term outcomes and low rates of residual rotatory laxity, complications and failures after revision anterior cruciate ligament reconstruction (ACL) and lateral extra-articular tenodesis (LET)

Grassi

Zicaro

Paz

et al. 2019

Knee Surg Sports Traumatol Arthrosc

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“…29,41,53 The presence of a distinct ALL in 3 of our specimens suggests that there is variability in the thickness or ''ligamentous'' quality of the ALL region throughout the population. In a cadaveric study, Kent et al 26 found interspecimen variability in the ALL based on biomechanical properties. The authors also found that the ALL engaged in half of ACL-intact knees.…”

Section: Discussionmentioning

confidence: 99%

Microstructural and Mechanical Properties of the Anterolateral Ligament of the Knee

et al. 2020

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Background: The variable anatomy and controversy of the anterolateral ligament (ALL) reflect the complex relationship among the anterolateral knee structures. Purpose/Hypothesis: The purpose was to quantify the microstructural and mechanical properties of the ALL as compared with the anterolateral capsule (ALC) and lateral collateral ligament (LCL). The primary hypotheses were that (1) there is no difference in these properties between the ALL and ALC and (2) the LCL has significantly different properties from the ALL and ALC. Study Design: Descriptive laboratory study. Methods: The LCL, ALL, and ALC were harvested from 25 cadaveric knees. Mechanical testing and microstructural analyses were performed using quantitative polarized light imaging. The average degree of linear polarization (AVG DoLP; mean strength of collagen alignment) and standard deviation of the angle of polarization (STD AoP; degree of variation in collagen angle orientation) were calculated. Results: Linear region moduli were not different between the ALC and ALL (3.75 vs 3.66 MPa, respectively; P > .99). AVG DoLP values were not different between the ALC and ALL in the linear region (0.10 vs 0.10; P > .99). Similarly, STD AoP values were not different between the ALC and ALL (24.2 vs 21.7; P > .99). The LCL had larger modulus, larger AVG DoLP, and smaller STD AoP values than the ALL and ALC. Of 25 knee specimens, 3 were observed to have a distinct ALL, which exhibited larger modulus, larger AVG DoLP, and smaller STD AoP values as compared with nondistinct ALL samples. Conclusion: There were no differences in the mechanical and microstructural properties between the ALL and ALC. The ALC and ALL exhibited comparably weak and disperse collagen alignment. However, when a distinct ALL was present, the properties were suggestive of a ligamentous structure. Clinical Relevance: The properties of the ALL are similar to those of a ligament only when a distinct ALL is present, but otherwise, for the majority of specimens, ALL properties are closer to those of the capsule. Variability in the ligamentous structure of the ALL suggests that it may be more important in some patients than others and reconstruction may be considered in selective patients. Further study is needed to better understand its selective role and optimal indications for reconstruction.

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“…As a speculative example, our findings might suggest that during extra-articular augmentation, one should pay particular attention to where within the envelope of anterior translation the lateral tissue becomes taut, or engages, since the engagement point predicts the resulting knee motion. 18 Further work is needed to determine how individual ligaments engage and how surgical parameters as well as biological remodeling of graft tissues modulate relative tissue engagement.…”

Section: Discussionmentioning

confidence: 99%

Engagement of the Secondary Ligamentous and Meniscal Restraints Relative to the Anterior Cruciate Ligament Predicts Anterior Knee Laxity

et al. 2019

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Background: Patients with high-grade preoperative side-to-side differences in anterior laxity as assessed via the Lachman test after unilateral anterior cruciate ligament (ACL) rupture are at heightened risk of early ACL graft failure. Biomechanical factors that predict preoperative side-to-side differences in anterior laxity are poorly understood. Purpose: To assess, in a cadaveric model, whether the increase in anterior laxity caused by sectioning the ACL (a surrogate for preoperative side-to-side differences in anterior laxity) during a simulated Lachman test is associated with two biomechanical factors: (1) the tibial translation at which the secondary anterior stabilizers, including the remaining ligaments and the menisci, begin to carry force, or engage, relative to that of the ACL or (2) the forces carried by the ACL and secondary stabilizers at the peak applied anterior load. Study Design: Controlled laboratory study. Methods: Seventeen fresh-frozen human cadaveric knees underwent Lachman tests simulated through a robotic manipulator with the ACL intact and sectioned. The net forces carried by the ACL and secondary soft tissue stabilizers (the medial meniscus and all remaining ligaments, measured as a whole) were characterized as a function of anterior tibial translation. The engagement points of the ACL (with the ACL intact) and each secondary stabilizer (with the ACL sectioned) were defined as the anterior translation at which they began to carry force, or engaged, during a simulated Lachman test. Then, the relative engagement point of each secondary stabilizer was defined as the difference between the engagement point of each secondary stabilizer and that of the ACL. Linear regressions were performed to test each association ( P < .05). Results: The increase in anterior laxity caused by ACL sectioning was associated with increased relative engagement points of both the secondary ligaments (β = 0.87; P < .001; R2 = 0.75) and the medial meniscus (β = 0.66; P < .001; R2 = 0.58). Smaller changes in anterior laxity were also associated with increased in situ medial meniscal force at the peak applied load when the ACL was intact (β = −0.06; P < .001; R2 = 0.53). Conclusion: The secondary ligaments and the medial meniscus require greater anterior tibial translation to engage (ie, begin to carry force) relative to the ACL in knees with greater changes in anterior laxity after ACL sectioning. Moreover, with the ACL intact, the medial meniscus carries more force in knees with smaller changes in anterior laxity after ACL sectioning. Clinical Relevance: Relative tissue engagement is a new biomechanical measure to characterize in situ function of the ligaments and menisci. This measure may aid in developing more personalized surgical approaches to reduce high rates of ACL graft revision in patients with high-grade laxity.

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High Interspecimen Variability in Engagement of the Anterolateral Ligament: An In Vitro Cadaveric Study

Cited by 8 publications

References 34 publications

Good mid-term outcomes and low rates of residual rotatory laxity, complications and failures after revision anterior cruciate ligament reconstruction (ACL) and lateral extra-articular tenodesis (LET)

Good mid-term outcomes and low rates of residual rotatory laxity, complications and failures after revision anterior cruciate ligament reconstruction (ACL) and lateral extra-articular tenodesis (LET)

Microstructural and Mechanical Properties of the Anterolateral Ligament of the Knee

Engagement of the Secondary Ligamentous and Meniscal Restraints Relative to the Anterior Cruciate Ligament Predicts Anterior Knee Laxity

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