New findings may alter the way ACL deficient knees are treated

Orthopedic community debates structure, function of anterolateral knee ligament.

For several decades, the anterolateral ligament of the knee has been scrutinized by orthopedic surgeons and researchers, leading to a wide-scale debate on the existence of the ligament, its function and best treatment methods.

Wolf Orthopaedic Biomechanics Lab, WOBL. Fowler Kennedy Sports Medicine Clinic, London Ontario

Healio Orthopedics Today March 2017

“One of the biggest issues with the anterolateral ligament, ALL, is that the name anterolateral ligament has been used for a number of different structures over the years, so the nomenclature is not as concise or as consistent to the literature as one would want,” Alan Getgood, MPhil, MD, FRCS (Tr&Orth), complex knee surgeon at Fowler Kennedy Sports Medicine Clinic, University of Western Ontario, in London, Ontario, Canada, told Orthopedics Today. “Therefore, that often leads to some discussions to whether this truly is a structure or not. I think with the number of studies that have come through now, it is shown that there is a structure there.”

Bone and Joint Research, Western University

The believers define the ALL as a structure that may tear in conjunction with ACL tears, especially when the knee is subjected to extreme internal rotation that may occur in high-level athletes who ski or play soccer, for instance. Proponents of the ALL also say it possibly plays a role in Segond fractures, a small tibial plateau bone chip identified in the late 1800s by French surgeon Paul Ferdinand Segond, that may occur in high-energy rotatory knee injuries.

Non-believers in the ALL contend it is most likely the iliotibial (IT) band, or a deep layer of the IT band, that is affected in these situations, along with other structures in what they call the anterolateral complex. Opponents to the ALL concept say those are the areas that must be addressed in conjunction with these knee injuries, especially when the ACL is torn.

“I think [the debate] is because there are different ways of looking at [the ALL],” Robert F. LaPrade, MD, PhD, complex knee surgeon at the Steadman Clinic, in Vail, Colo., said. “If you look at some of our European colleagues, they have looked at cadaver specimens that are preserved in formalin, the old-fashioned way, and when you look at it that way it obliterates the tissue planes. It is a little bit harder to see exactly what happens when you flex and extend the knee, so it can look a little bit thicker probably than what we see with fresh cadavers.”

To do no harm, Freddie H. Fu, MD, DSc(Hon), DPs(Hon), calls for caution before proceeding with widespread clinical trials of the anterolateral knee complex. UPMC Photo

The existence debate
Recently, the existence of the ALL was debated at the European Society of Sports Traumatology, Knee Surgery and Arthroscopy Congress by Steven Claes, MD, PhD, of Belgium, and Freddie H. Fu, MD, DSc(Hon), DPs(Hon), of Pittsburgh.

Claes, who contends the ALL exists and whose anatomical research with colleagues on embalmed cadavers in support of that claim was published in the Journal of Anatomy, said during the debate, “I think it is better to join forces in this field for the best of our patients.”

Source Healio Orthopedics Today

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