Abstract
Background
The earlier studies did not assess the associated factors of anterolateral ligament injury, comprehensively. We sought to evaluate the independent predictive factors of anterolateral ligament injury in the patients with anterior cruciate ligament tear. Ultrasound scan has an emerging role in the diagnosis of anterolateral ligament injury.
Materials and Methods
We included 198 patients with anterior cruciate ligament tear in this study. All the patients underwent knee ultrasound scan to diagnose the anterolateral ligament injury. The potential predictive factors of anterolateral ligament injury were compared between the patients with anterolateral ligament injury and the patients with the intact anterolateral ligament.
Results
In all the patients, the anterolateral ligament was seen in the tibial and femoral portions using the ultrasound scan. One hundred and ten patients (55.6%) had anterolateral ligament injury and the anterolateral ligament was intact in 88 patients (44.4%). The lateral collateral ligament injury was significantly associated with the anterolateral ligament injury (p < 0.001). In addition, the iliotibial band injury had a significant relationship with the anterolateral ligament injury (p = 0.001). An increased lateral tibial slope was significantly associated with the anterolateral ligament injury (p = 0.031). Furthermore, the bone contusion of the lateral femoral condyle had a significant relationship with the anterolateral ligament injury (p = 0.004).
Conclusion
The independent predictors of anterolateral ligament injury included the lateral collateral ligament injury, iliotibial band injury, bone contusion of the lateral femoral condyle, and an increased lateral tibial slope.
Keywords: Anterolateral ligament, Predictive factors, Ultrasound scan, Anterior cruciate ligament
Introduction
The anterolateral ligament (ALL) of the knee was probably investigated for the first time by Segond. He introduced an avulsed segment of the tibia that was attached to a fibrous band [1]. Claes et al. [1] rediscovered the ALL in the anterolateral part of the knee as a distinct ligament. They found that ALL was responsible for the Segond fracture [2]. Also, the anatomical and histological investigations indicated that the ALL was distinguishable from the anterolateral joint capsule [1, 3, 4]. This ligament would help in rotational stability in high degrees of knee flexion [5]. Moreover, a positive pivot shift test is associated with the ALL injury in the patients with anterior cruciate ligament (ACL) tear [6].
The proximal origin of the ALL is near to the lateral epicondyle of the femur. However, there is disagreement about the exact point of attachment [7]. The distal insertion site of the ligament is at a point between the Gerdy’s tubercle and the head of the fibula [7]. It has attachments to the lateral meniscus too [7]. Nevertheless, a few authors believe that there is no attachment to the lateral meniscus [8]. Also, the lateral inferior geniculate artery (LIGA) passes near to the ALL [1].
Magnetic resonance imaging (MRI) and ultrasound scan were used to identify the ALL, and to evaluate the ligament injuries [9–14]. Most of the researchers could identify the distal part of the ligament more than the proximal part [7]. Cavaignac et al. [13] could identify the ALL in the whole length in all of their patients using the ultrasound scan. The rate of ALL injury was reported from 11 to 79% in different studies [15]. The ultrasound scan-based studies had better inter-observer agreement compared with the MRI-based studies [15]. Sonography is real time and has better axial resolution [16].
Some groups evaluated a few associated factors of the ALL injury. However, those factors were limited to some anatomical parameters [17–19]. Most of these studies were retrospective, and all of them used MRI to evaluate the ALL injury [17–19]. Therefore, we decided to recognize the attributed factors of the ALL injury comprehensively.
There are many ambiguities about the ALL. For example, the mechanisms of injury, associated anatomical factors and musculoskeletal health status have not been investigated properly in the patients with ALL injury in the previous studies. In this study, we sought to rectify parts of these ambiguities. This helps us to better understand the pathoanatomy of the ALL injury in the patients with ACL tear.
In this study, we aimed to comprehensively evaluate the predictive factors of the ALL injury in the patients with ACL tear. There is a gap in the literature in this regard. This helps the orthopedic surgeon to consider concomitant ALL injury as a possibility in the patients with ACL tear [18]. In addition, this adds more information about the possibility of the ALL injury in the patients with residual laxity after isolated ACL reconstruction [20].
Materials and Methods
The study was approved by the Ethics Committee of our university, and informed consent was obtained from all participants. We enrolled the patients with ACL tear diagnosed using MRI from October 2018 to May 2019. The exclusion criteria included the former knee injury, former knee surgery, considerable degenerative changes of the injured knee, time from injury more than 3 months, age less than 19 years and more than 49 years.
We performed the ultrasound examination of the injured knee joint to detect the ALL injury. Then, we categorized the patients into two groups based on the ALL condition (patients with ALL injury and patients with intact ALL). We compared multiple factors between these two groups to identify the predictive factors and associated factors of the ALL injury. We attained parts of the data using the questionnaire, interview, and measurement. We used the ultrasound scan and MRI to achieve the other parts of the data.
In the following, we explain how we chose the predictive factors. The demographic data [age, gender, height, weight and body mass index (BMI)], smoking status, anatomical factors [lateral tibial slope (LTS), lateral compartment translation (LCT), lateral femoral notch (LFN) and femoral notch shape], dominant leg and level of activity were added based on the previous studies regarding the predictive factors of sports injuries and high-grade pivot shift [20, 21]. Some factors including the bone bruise, meniscus tear, medial collateral ligament (MCL) injury, lateral collateral ligament (LCL) injury, iliotibial band (ITB) injury and popliteus muscle injury were added based on the previous studies about the ALL injuries [17–19]. Other factors including the mechanism of injury, pattern of injury and musculoskeletal health status were added based on the experience of the authors and potential associations of these factors with the ALL injury. In the following, we explain each one of these factors in detail as well as the method of ALL evaluation.
We collected information about the status of smoking, age and gender. Also, we measured the patients’ height and weight, and calculated their BMI. The determination of the dominant leg was done by questioning the patient [22]. Furthermore, we asked the patients about the type of activity at the time of injury. The classification of the injury mechanism was done using the classification approach introduced by Kobayashi et al. [23]. We distributed the patients into four groups:
Noncontact: there was no physical contact between the patient and other individuals.
Contact: there was physical contact with other individual in the parts of the body other than the injured leg.
Collision: there was physical contact with other individual in the injured leg.
Accident: the patients who had motor vehicle accidents were placed in this group [23].
We considered the patients’ activity level as a potential predictive factor of ALL injury. We used the Marx Activity Rating Scale (MARS) to assess the patients’ activity level [24, 25].
All the patients had a knee MRI and underwent the knee ultrasound examination to evaluate the ALL injury. Ultrasound scan was performed by two radiologists independently. If there was disagreement between the opinions, the more experienced radiologist’s opinion was considered. We used the linear probes with a maximum frequency of 12 MHz. The patient reclined on the supine position and the knee was flexed about 70 degrees with subtle internal rotation during the sonography [13]. The sonography technique for the evaluation of the ALL was validated earlier [13].
Some reasons for using ultrasound examination in addition to MRI for the evaluation of ALL injury included:
Anterolateral ligament is a thin structure (mean thickness of 1.4 mm), and routine knee MRI has a slice thickness of 3 mm. This may cause a partial volume effect and be problematic in the diagnosis of ALL injuries [26].
Anterolateral ligament has an oblique course in the anterolateral part of the knee, and we usually need oblique MRI slices for visualization of it in entire length which are not provided routinely, [9] while ultrasound examination is dynamic and we can place the probe parallel to the oblique structures.
Anterolateral ligament is a superficial structure, and it is easy to be visualized with high-resolution linear probes even in obese or muscular patients.
At first, the lateral epicondyle of the femur and the Gerdy’s tubercle were investigated using the physical exam. Then, the linear probe was placed in the direction of the line that connected these two points. After translating the probe posteriorly, it was rotated clockwise in the right knee (anticlockwise in the left knee) until the ligament was seen in its longitudinal axis [13]. The ALL was seen as a slightly echogenic and fairly thin ligamentous structure (Fig. 1a, b) [14]. We considered the anechoic or hypoechoic areas with ligament discontinuity as ligament injury (Fig. 1c, d) [14]. The Segond fracture was considered as a type of ALL injury [2].
Fig. 1.
Evaluation of ALL injury using ultrasonography and MRI. a ALL tibial portion, b ALL femoral portion, c, d ALL injuries in sonography, e normal ALL in MRI, f ALL injury in MRI
We considered the musculoskeletal health status as a potential predictive factor of ALL injury. The ultrasound scan was used to evaluate the musculoskeletal health status indirectly [27]. We measured the anterior thigh muscle thickness in the uninjured lower extremity for this purpose. The distance of the measurement point from the anterior superior iliac spine was twice the distance from the patella [27].
The knee MRI was done using 1.5 T MRI scanner. The imaging included fat-saturated proton density-weighted fast spin-echo (FS PD FSE) sequences on axial, coronal, and sagittal planes, also T1 weighted fast spin-echo sequences on sagittal planes, and T2 weighted fast spin-echo sequences on sagittal planes. The slice thickness was 3 mm, and the patient reclined on the supine position.
Although we used the ultrasound scan to detect the ALL injury, we evaluated the ALL using the MRI too. We used coronal FS PD FSE images to evaluate the ALL. We considered the ligament edema, irregularity and discontinuity as injury (Fig. 1e, f) [15]. The ALL condition in MRI was evaluated by two radiologists independently.
We evaluated the injuries of the LCL, MCL, popliteus muscle or tendon, posterior cruciate ligament (PCL), and bone bruises using MRI [28, 29]. We considered the ligament edema, irregularity and discontinuity, as well as the periligamentous edema, as injury [28, 29]. We registered the bone contusions of the medial and lateral plateaus of the tibia as well as the medial and lateral condyles of the femur, separately. We considered the ligament edema, irregularity and disruption as an injury for ITB [30]. We used the accepted MRI criteria to diagnose the meniscus tear [28, 29].
The bone impaction of the lateral femoral condyle may be created because of the pivot shift mechanism in some patients with ACL tear [31]. We measured the depth of the LFN using the MRI sagittal slices, and the LFN with a more than 2 mm depth was considered as abnormal (Fig. 2a) [31, 32].
Fig. 2.
Special measurements using MRI. a Lateral femoral notch depth, b lateral tibial slope, c lateral compartment translation, d Type U femoral notch, e Type A femoral notch, f Type W femoral notch
An increased LTS is associated with the peak anterior tibial shear force [33]. We measured the LTS using the method introduced by Hashemi et al. [34] (Fig. 2b). After drawing a line vertical to the longitudinal axis of the tibia, the angle between this line and the superior rim of the lateral tibial plateau was measured [34]. There is not a defined cut point for abnormal LTS in the patients with ACL tear. Therefore, we used the measurements of the control group to define the cut-off point for the LTS, similar to the earlier studies [20, 35]. After calculating the mean and the standard deviation (SD) for the control group, the mean plus 2SD was considered as cut off point (LTS ≥ 10.9 degrees) [20, 35].
Lateral compartment translation is associated with a positive pivot shift test [36]. We measured the LCT in the sagittal slices using a previously introduced approach (Fig. 2c) [37]. We measured the distance between the posterior rim of the lateral tibial plateau and the posterior rim of the lateral femoral condyle [37]. We considered the LCT greater than 6 mm as abnormal based on the earlier studies [36, 38].
Femoral notch shape has a relationship with the ACL tear [39]. We sought to evaluate its relationship with the ALL injury. We determined the femoral notch shape using MRI [39]. We classified the notch shape into three groups including type A, type U and type W according to the earlier studies (Fig. 2d–f) [39, 40].
We used the classification approach introduced by Hayes et al. to classify the injury patterns in MRI [41].
Table 1 summarizes all of the selected factors.
Table 1.
The potential predictive factors of ALL injury and the method of achieving the data
| The method of achieving the data | Parameter |
|---|---|
| Interview | Age |
| Gender (male/female) | |
| Injured knee (right/left) | |
| Injured leg (dominant/non dominant) | |
| Smoking status | |
| Mechanism of injury | |
| (a) Noncontact | |
| (b) Contact | |
| (c) Collision | |
| (d) Accident | |
| Questionnaire | Marx activity rating scale |
| Measurement | Weight |
| Height | |
| BMI | |
| Sonography | Anterior thigh muscle thickness (mm) |
| MRI | Lateral tibial plateau bone bruise |
| Medial tibial plateau bone bruise | |
| Lateral femoral condyle bone bruise | |
| Medial femoral condyle bone bruise | |
| LCL injury | |
| MCL injury | |
| PCL injury | |
| ITB injury | |
| Popliteus muscle injury | |
| Lateral meniscus tear | |
| Medial meniscus tear | |
| Abnormal LTS | |
| Abnormal LCT | |
| Abnormal LFN | |
| Femoral notch shape | |
| Pattern of injury | |
| (a) Flexion valgus, external rotation | |
| (b) Flexion varus, internal rotation | |
| (c) Other patterns (hyperextension, pure valgus, flexion with posterior tibial translation, flexion and internal rotation of femur on fixed tibia) |
BMI body mass index, MRI magnetic resonance imaging, LCL lateral collateral ligament, MCL medial collateral ligament, PCL posterior cruciate ligament, ITB iliotibial band, LTS lateral tibial slope, LCT lateral compartment translation, LFN lateral femoral notch
We performed statistical analysis using SPSS 25 software. A p value below 0.05 was considered significant. We used the chi-square test and Fisher’s exact test to compare the categorical variables. Also, we used the independent samples t test and Mann–Whitney test to compare the quantitative variables. Multivariable binary logistic regression analysis was used to discover the independent predictors of ALL injury. The inter-observer agreements were measured using Cohen’s kappa coefficient [42]. According to the calculation performed with G-power software, with a type one error of 0.05 and a power of 80% (type two error of 0.20), a required sample size for each group was estimated 82 subjects, and at least 164 subjects would be necessary totally.
Results
Finally, 198 patients were included in this study after excluding 49 patients. In these 49 patients, exclusion criteria were chronic knee injuries (> 3 months) (34 patients), former knee injuries (11 patients), age under 19 or above 49 years (3 patients) and considerable degenerative changes of the injured knee (1 patient). All of the included patients (198 ones) had acute knee injuries (≤ 3 months). The mean time interval from injury was 5.2 ± 3.0 weeks.
One hundred and seventy-three patients (87.4%) were male, and 25 patients (12.6%) were female. The mean age of the patients was 30.8 ± 7.0 years (19–49). The ALL was seen in entire length in all the patients using ultrasound scan (ƙ = 1). In four patients (2.0%) the LIGA crossed the ALL fibers. One hundred and ten patients (55.6%) had the ALL injury, and the ALL was intact in 88 patients (44.4%), according to the sonography evaluation. All the injuries were seen in the tibial portion. Twenty-two patients (11.1%) had a Segond fracture. The inter-observer agreement was almost perfect for diagnosing the ALL injury by ultrasound scan (ƙ = 0.95). In MRI, we could see the ligament in 159 patients (80.3%, ƙ = 0.65). The ALL was seen in the whole length in 24 patients (12.1%), and it was seen partially in 135 patients (68.2%). The ALL injury was diagnosed for 69 patients using MRI (43.4%, ƙ = 0.55). The inter-observer agreement was weak for diagnosing the ALL injury by MRI.
In regard to the mechanism of injury, 142 patients (71.7%) were in the noncontact group, 21 patients (10.6%) were in the collision group, 18 patients (9.1%) were in the accident group, and 17 patients (8.6%) were in the contact group. The most common sports activity at the time of injury was futsal (97 patients).
Tables 2 and 3 display the results of the comparison of variables between the patients with ALL injury and the patients without ALL injury.
Table 2.
Comparison of variables between the patients with and without ALL injury (part 1)
| Variable | ALL injury group (n = 110) | Control group (n = 88) |
p value |
|---|---|---|---|
| Age | 31.0 (± 7.1) | 30.5 (± 6.9) | 0.581 |
| Gender (male/female) | 99/11 | 74/14 | 0.214 |
| Injured knee (right/left) | 71/39 | 57/31 | 0.973 |
| Injured leg (dominant/non dominant) | 68/42 | 61/27 | 0.271 |
| Height (cm) | 174.4 (± 9.1) | 173.1 (± 9.2) | 0.340 |
| Weight (kg) | 73.8 (± 10.4) | 75.4 (± 14.2) | 0.373 |
| BMI | 24.2 (± 2.7) | 25.1 (± 4.2) | 0.095 |
| Smoking | 23 (20.9%) | 16 (18.2%) | 0.632 |
| Marx activity scale score | 11.2 (± 4.4) | 10.5 (± 4.7) | 0.237 |
| Anterior thigh muscle thickness (mm) | 35.3 (± 6.3) | 34.5 (± 6.9) | 0.361 |
| Anterior thigh subcutaneous fat thickness (mm) | 5.1 (± 2.1) | 5.7 (± 2.8) | 0.110 |
| Mechanism of injury | 0.083 | ||
| (a) Noncontact | 75 (68.2%) | 67 (76.1%) | |
| (b) Contact | 10 (9.1%) | 7 (8.0%) | |
| (c) Collision | 10 (9.1%) | 11 (12.5%) | |
| (d) Accident | 15 (13.6%) | 3 (3.4%) |
ALL anterolateral ligament, BMI body mass index
Table 3.
Comparison of variables between the patients with and without ALL injury (part 2)
| Variable | ALL injury group (n = 110) | Control group (n = 88) |
p value |
|---|---|---|---|
| Lateral tibial plateau bone bruise | 96 (87.3%) | 71 (80.7%) | 0.205 |
| Medial tibial plateau bone bruise | 58 (52.7%) | 39 (44.3%) | 0.240 |
| Lateral femoral condyle bone bruise | 86 (78.2%) | 52 (59.1%) | 0.004 |
| Medial femoral condyle bone bruise | 33 (30.0%) | 21 (23.9%) | 0.335 |
| LCL injury | 33 (30.0%) | 7 (8.0%) | < 0.001 |
| MCL injury | 48 (43.6%) | 37 (42%) | 0.822 |
| PCL injury | 3 (2.7%) | 4 (4.5%) | 0.702 |
| ITB injury (high grade) | 23 (20.1%) | 4 (4.5%) | 0.001 |
| Popliteus muscle injury | 16 (14.5%) | 6 (6.8%) | 0.086 |
| Lateral meniscus tear | 49 (44.5%) | 30 (34.1%) | 0.136 |
| Medial meniscus tear | 38 (34.5%) | 37 (42.0%) | 0.280 |
| Abnormal LTS | 13 (11.8%) | 3 (3.4%) | 0.031 |
| Abnormal LCT | 15 (13.6%) | 7 (8.0%) | 0.206 |
| Abnormal LFN | 17 (15.5%) | 7 (8.0%) | 0.108 |
| Femoral notch shape | 0.255 | ||
| U shape | 39 (35.5%) | 35 (39.8%) | |
| A shape | 59 (53.6%) | 49 (55.7%) | |
| W shape | 12 (10.9%) | 4 (4.5%) | |
| Pattern of injury | 0.145 | ||
| (a) Flexion valgus, external rotation | 33 (30%) | 41 (46.6%) | |
| (b) Flexion varus, internal rotation | 15 (13.6%) | 7 (8.0%) | |
| (c) Other patterns | 5 (4.5%) | 6 (6.8%) | |
| (d) None of the defined patterns (was excluded from calculation) | 57 (51.9%) | 34 (38.6%) |
ALL anterolateral ligament, LCL lateral collateral ligament, MCL medial collateral ligament, PCL posterior cruciate ligament, ITB iliotibial band, LTS lateral tibial slope, LCT lateral compartment translation, LFN lateral femoral notch
The LCL injury had a significant relationship with the ALL injury (p < 0.001, odds ratio = 5.0, 95% CI 2.1–11.9). Also, the ITB injury was more frequent in the patients with ALL injury significantly (p = 0.001, odds ratio = 5.6, 95% CI 1.8–16.7). Bone bruise of the lateral femoral condyle had a significant relationship with the ALL injury (p = 0.004, odds ratio = 2.5, 95% CI 1.3–4.6).
The ALL injury did not have any significant relationship with the status of smoking, age, gender, the dominance of the injured leg, height, weight, BMI, MARS, and anterior thigh muscle thickness.
The ALL injury had no significant relationship with the MCL injury, meniscus tear, depth of LFN, LCT, and femoral notch shape. However, an increased LTS was associated with the ALL injury significantly (p = 0.031, odds ratio = 3.8, 95% CI 1.1–13.8).
We used the multivariable binary logistic regression analysis to identify the ALL injury predictors by considering the confounding factors. The LCL injury, ITB injury, lateral femoral condyle bone contusion, LTS, popliteus muscle injury, mechanism of injury, BMI, age, and gender were included in the model (Table 4). The independent predictors of ALL injury were the ITB injury, LCL injury, bone bruise of the lateral femoral condyle, and an increased LTS.
Table 4.
Results of multivariable binary logistic regression analysis
| Variable | p value | Odds ratio (95% CI) |
|---|---|---|
| Age | 0.289 | 1.0 (0.9–1.1) |
| Gender | 0.261 | 1.8 (0.6–5.2) |
| BMI | 0.146 | 0.9 (0.8–1.1) |
| Mechanism of injury | 0.406 | – |
| Lateral femoral condyle bone contusion | 0.004 | 3.0 (1.4–6.3) |
| LCL injury | 0.001 | 5.0 (1.9–12.9) |
| ITB injury | 0.006 | 5.6 (1.7–18.8) |
| Popliteus muscle/tendon injury | 0.165 | 2.1 (0.7–6.1) |
| Abnormal LTS | 0.030 | 5.0 (1.2–21.6) |
CI confidence interval, BMI body mass index, LCL lateral collateral ligament, ITB iliotibial band, LTS lateral tibial slope
Discussion
We used the ultrasound examination to evaluate the ALL. Essentially, the tibial attachment site of the ALL is a good landmark for identifying the ALL. After identifying the distal attachment, it is enough to follow the ligament proximally to find it in the whole length.
The inter-observer agreement was almost perfect for ultrasonography and it was weak for MRI in our study. The partial volume effect may be problematic in routine MRI for thin structures. Sonography has better axial resolution and more ability in identifying the small abnormalities within the ligament [16].
Argento et al. [12] reported that the LIGA crossed the ALL in 3.6% of their patients. In our experience, the LIGA crossed the ALL in 2.0% of our patients. The sparing of the LIGA during surgery may help to improve the healing process [43].
We recognized all the injuries in the distal part. There is controversy about the most common site of injury [7, 15]. However, the distal injuries were reported more frequent in comparison with the proximal injuries [7, 15]. The origin of the ALL is near to the optimal flexion axis of the knee [44]. Therefore, Claes et al. [10] assumed that the distal portion of the ligament was the larger lever. This may cause more tension on the distal part of the ligament compared with the proximal part. The existence of the Segond fracture in the distal part confirms this hypothesis. Cavaignac et al. [13] identified all the injuries in the distal part, similar to the present study.
There is a controversy about the role of 3 T MRI in the detection of ALL injury [9, 15, 45]. Muramatsu et al. used three-dimensional MRI (3D MRI) to evaluate the ALL. They concluded that 3D MRI was suitable for visualizing the ligament [26]. Three-dimensional MRI has good ability in the detection of the structures with an oblique course in entire length [26]. However, there is no access to the 3D MRI technique and 3 T MRI in many regions, while sonography is more accessible in many areas. However, special training in musculoskeletal sonography for the radiologists should be taken into consideration.
A universally accepted cut point does not exist for the definition of acute ACL tear [46]. It was considered from 3 weeks to 1 year in different studies [18, 46]. In this study, the time period between the injury and the knee joint sonography was fewer than 3 months, similar to some studies [47].
Some authors suggested that concomitant ALL reconstruction could reduce ACL reconstruction failures [7]. Therefore, the recognition of ALL injury risk factors is important. A few studies evaluated the associated factors of the ALL injury [17–19]. They assessed mostly some anatomical variables. To our knowledge, this study is the first one to evaluate the attributed factors of the ALL injury comprehensively.
Van Dyck et al. [17] and Helito et al. [18] concluded that the bone bruises of the medial and lateral compartments had significant relationships with the ALL injury. Lee et al. [19] indicated that the bone bruise of the lateral compartment was significantly associated with the ALL injury. We found that only the bone bruise of the lateral femoral condyle was associated with the ALL injury.
There was a controversy between the earlier studies about the association between the ALL injury and the lateral meniscus tear [15]. Lee et al. found an association between the injuries of these two structures while the other two studies did not find such an association [17–19]. We did not find a significant association between the ALL injury and the lateral meniscus tear. However, the rate of meniscus injury is attributed to the time of evaluation [48].
Van Dyck et al. [17] as well as Helito et al. [18] found associations between the ALL injury and the injury of the knee collateral ligaments. We found a significant relationship only between the LCL injury and the ALL injury. The mechanism of MCL injury is mainly different from the mechanism of LCL injury [41].
The pattern of injury in MRI did not have any relationship with the ALL injury. There is a hypothesis that the Segond fracture occurs mostly in flexion with varus, and internal rotation [41]. However, according to the present study, ALL injuries occurred while the different mechanisms of injury existed. Not a simple mechanism could justify ALL injuries.
Similar to the present study, Van Dyck et al. [17] and Helito et al. [18] found a significant association between the ITB injury and the ALL injury. Helito et al. [18] were the only group that reported a significant association between the ALL injury and the popliteus tendon injury. However, we did not find such an association. Additionally, Helito et al. [18] indicated that ALL injuries were more common in older patients significantly. In our study, the age was not associated with the ALL injury.
An increased LTS is significantly related to the high-grade pivot shift test [20]. To the best of our knowledge, no other study has assessed the relationship between the increased LTS and the ALL injury. We indicated that an increased LTS is the independent predictor of ALL injury. The increased LTS would increase the anterior translation of the tibia and tibio-femoral rotation during the sports activities [49]. This may produce tension on the distal insertion site of the ALL.
The accident was the second most common mechanism in patients with ALL injury. However, no significant relationship was found between the mechanism of injury and the ligament injury.
This study had some limitations. We evaluated different patients from the time of injury up to three months after the injury. This might cause some healings and some delayed changes. Furthermore, the diagnosis of meniscus tear was made using MRI. Magnetic resonance imaging has lesser accuracy compared with arthroscopy for detecting meniscus tear [28, 29]. Another limitation of this study was using MRI for the detection of ACL tear. In addition, the data about the mechanism of injury were achieved using the interview with the patients, which may have been influenced by recall bias. Another limitation of our study was the small number of cases.
Conclusion
We found that the LCL injury, ITB injury, bone contusion of the lateral femoral condyle, and an increased LTS were the independent predictors of ALL injury. When we encounter these pathologies in routine MRI in a patient with ACL tear, additional knee ultrasound scan is reasonable for the evaluation of ALL injury.
Funding
None.
Compliance with ethical standards
Conflict of interest
There are no conflicts of interest.
Informed consent in studies with human subjects
All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008. Informed consent was obtained from all patients for being included in the study. The study was approved by Ethics Committee of AJA University of Medical Sciences, Tehran, Iran (Approval ID: IR.AJAUMS.REC.1397.035).
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity.
Footnotes
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