Abstract
Antero-lateral ligament complex (ALC) is a vital structure for maintaining rotational stability of the knee. Evaluation of ALC radiologically (MRI) is still unpopular in setting of anterior cruciate ligament injury. A dire necessity exists for the orthopedic surgeons in outdoor patient department settings to rule out involvement of ALC. So, that it can be addressed during operating for Anterior Cruciate Ligament injury. The authors have formulated an algorithm on a personal level and have implemented this screening program and initiated screening of young to middle aged patients reporting with rotational knee instability for ALC involvement before recommending final operative plan. This screening program which uses specifically devised physical tests have significantly reduced the number of underdiagnosed Antero Lateral Ligament tear.
Introduction
Antero-lateral ligament complex (ALC) is a novel area of focus in patients having ACL tear with anterior and rotational knee instability since it is essential for maintaining rotational knee stability (1-4). Anterolateral augmentation (ALA) may be advantageous for patients who are undergone anterior cruciate ligament (ACL) reconstruction (ACLR), but this is still debatable (5).
Materials and methods
Scenario in developing countries
Evaluation of Antero-lateral ligament complex (ALC) radiologically (MRI) is still unpopular in setting of anterior cruciate ligament injury. Orthopedic surgeons are left with no choice but assessing the ALC intraoperatively and fix the excessive antero-lateral laxity by conducting additional procedures like lateral extraarticular tenodesis (LET) or antero-lateral reconstruction.
Anatomy of Antero-lateral ligament complex
Below the ilio-tibial band, the antero-lateral ligament is a triangular structure (6). The iliotibial band and its superficial, deep, and capsulo-osseous layers, as well as the Antero-lateral ligament, constitute the Antero-lateral ligament complex (7). Please refer to Fig. 1 for anatomy of Antero-lateral ligament complex.
Screening program
The authors wish to propose a program in which patients of young to middle age presenting with anterior and rotational instability of knee joint will be screened using physical tests to detect or suspect involvement/injury to antero-lateral complex (ALC) of knee joint. This screening targets early evaluation of integrity of ALC, before finalizing management plan of Anterior Cruciate ligament (ACL), Tibial collateral ligament (Medial Collateral Ligament), Fibular collateral ligament (Lateral Collateral Ligament), Posterior cruciate ligament (PCL) in patients presenting with instability of knee joint. The objective behind this screening of ALC is a consideration that approximately 20 percent of ACL injury invariably involves ALC. A detailed algorithm of this screening process is mentioned in Fig. 2.
Radiological evaluation of Antero-lateral ligament
Ultrasound may increase the likelihood of ALL-reconstruction indications because it has a higher spatial resolution and can detect Segond fractures that radiography and MRI cannot (8). Since ultrasonography is a low-cost, real-time imaging modality with excellent spatial resolution, when identifying the Antero-lateral ligament, ultrasound is more sensitive and specific than MRI (9).
Conclusions
Integrity of Antero-lateral complex is of vital importance in maintaining the rotational instability of knee joint and should be always evaluated first before intervening for ACL tear. Ultrasound is a better diagnostic modality than MRI for identifying the ALL injuries.
Figure 1.
Anatomy of Antero-lateral ligament complex.
Figure 2.
Algorithm for screening of patients presenting with antero-lateral instability of Knee joint.
Acknowledgments
We extend our sincere gratitude towards our Respected Executive Director, Prof. Dr. Colonel. CDS Katoch Sir who has constantly encouraged us to conduct research work.
References
- 1.Kim SH: Editorial commentary: Knee anterolateral ligament cadaveric, biomechanical analysis should include tensioning of all knee dynamic structures. Arthroscopy 37: 1192-1193, 2021. [DOI] [PubMed] [Google Scholar]
- 2.Santoso A, Anwar IB, Sibarani T, Soetjahjo B, Utomo DN, Mustamsir E, Budhiparama NC: Research on the anterolateral ligament of the knee: An evaluation of PubMed articles from 2010 to 2019. Orthop J Sports Med 8: 2325967120973645, 2020. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Littlefield CP, Belk JW, Houck DA, Kraeutler MJ, LaPrade RF, Chahla J, McCarty EC: The anterolateral ligament of the knee: An updated systematic review of anatomy, biomechanics, and clinical outcomes. Arthroscopy 37: 1654-1666, 2021. [DOI] [PubMed] [Google Scholar]
- 4.Musahl V, Rahnemai-Azar AA, van Eck CF, Guenther D, Fu FH: Anterolateral ligament of the knee, fact or fiction? Knee Surg Sports Traumatol Arthrosc 24: 2-3, 2016. [DOI] [PubMed] [Google Scholar]
- 5.Lai S, Zhang Z, Li J, Fu WL: Comparison of anterior cruciate ligament reconstruction with versus without anterolateral augmentation: A systematic review and meta-analysis of randomized controlled trials. Orthop J Sports Med 11: 23259671221149403, 2023. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Sonnery-Cottet B, Daggett M, Fayard JM, Ferretti A, Helito CP, Lind M, Monaco E, de Pádua VBC, Thaunat M, Wilson A, et al. : Anterolateral Ligament Expert Group consensus paper on the management of internal rotation and instability of the anterior cruciate ligament-deficient knee. J Orthop Traumatol 18: 91-106, 2017. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Garcia-Mansilla I, Zicaro JP, Martinez EF, Astoul J, Yacuzzi C, Costa-Paz M: Overview of the anterolateral complex of the knee. World J Clin Cases 10: 8474-8481, 2022. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Cavaignac E, Faruch M, Wytrykowski K, Constant O, Murgier J, Berard E, Chiron P: Ultrasonographic evaluation of anterolateral ligament injuries: Correlation with magnetic resonance imaging and pivot-shift testing. Arthroscopy 33: 1384-1390, 2017. [DOI] [PubMed] [Google Scholar]
- 9.Panda S, et al. : Evaluation of ALL of Knee using USG and MRI in cases of ACL tear. Int J Anat Radiol Surg 9: RO16-RO19, 2020. [Google Scholar]