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(Anterolateral Structure) Ryosuke Kuroda Anterior Cruciate

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(Anterolateral Structure) Ryosuke Kuroda Anterior Cruciate Facts about ALS (anterolateral structure) Ryosuke Kuroda Anterior cruciate ligament (ACL) reconstruction aims to restore normal knee kinematics. It is widely performed and yields good clinical outcomes; however, residual instability with positive pivot shift test is noted in several cases. The recent increased interest in residual anterolateral rotatory instability after ACL reconstruction has focused on the presence, anatomy, and biomechanical function of the anterolateral ligament (ALL) of the knee, which was reintroduced in 2013. The causes of rotatory instability are multifactorial, but recent studies have focused on the anatomy and biomechanical function of the anterolateral knee structure (ALS), which is speculated to include the ALL. The ALL was reported to be a secondary restraint against rotatory instability in ACL-deficient knees1,2. The structure and function of the ALS of the knee has created much controversy since the ‘re-discovery’ of the ALL and its proposed role in aiding control of anterolateral rotatory laxity in the ACL injured knee. Whether the ALL is a distinct structure in the ALS remains controversial. There have been conflicting findings about the anatomical and functional descriptions of the ALL. A recent anatomic report by Herbst et al. has provided a detailed layer-by layer description of the anterolateral complex of the knee 8. This anterolateral complex consists of the iliotibial band (ITB) with its superficial, middle, deep, and capsulo-osseous layers, as well as the anterolateral joint capsule. They suggested t 76 hat the recent descriptions of the ALL either refer to the capsulo-osseous layer according to Terry et al. 30 or the mid third capsular ligament Furthermore, they also demonstrated that the confluence of the superficial and deep lateral joint capsule anterior to the lateral collateral ligament (LCL) is misinterpreted as a ligament in embalmed specimens. In addition, Dodds et al. reported that the ALL is below the deep capsulo-osseous layer of the ITB but superficial to the capsule. Noyes et al. also reported the effect of the ALL and ITB on knee rotational stability using a robotic simulator. They proved that sectioning both the ALL and ITB is required to produce major increases in pivot-shift translations and internal tibial rotations, and the results show variability in the magnitude of rotational instability. Therefore, ITB may play an important role for knee stability. However, most of the previous biomechanical studies on the function of the ALL removed the ITB. Preservation of the ITB seems to be crucial for the cutting study on the function of the ALL. A recent biomechanical study has reported the important mechanical property of ITB. The study found that ITB has a greater mechanical property than ALS, because rupture of the ALS occurs at almost 2 times higher ultimate elongation than the ITB. This finding indicates that injury to the ALS only happens after enough elongation has occurred during the first stretch and causes injury to the ITB. With 94 regard to ALS anatomy, ITB preservation seems to be crucial for biomechanical testing on the function of the ALL. It enabled to preserve the ITB and other soft tissues by using whole hemi-pelvis lower limbs. Fourteen fresh-frozen hemi-pelvis lower limbs were employed. Biomechanical functions of the ALS were quantitatively analyzed using the electromagnetic measurement system (EMS) under both ACL-intact and ACL-deficient status. With the ITB intact, the intra-articular dissection of the ALS increased neither the anterior tibial translation during the Lachman test nor the acceleration of posterior translations during the pivot shift test, regardless of the ACL-intact or ACL-deficient status. The ALS may not play a significant role in either anterior or dynamic rotatory knee stability whereas the ACL does. 1. Hughston JC, Andrews JR, Cross MJ, et al. Classification of knee ligament instabilities. Part I. The medial compartment and cruciate ligaments. J Bone Joint Surg Am. 1976;58(2):159-172. 2. Hughston JC, Andrews JR, Cross MJ, et al. Classification 416 of knee ligament instabilities. Part II. The lateral compartment. J Bone Joint Surg Am. 1976;58(2):173-179. 3. Hoshino Y, Kuroda R, Nagamune K, et al. In vivo measurement of the pivot-shift test in the anterior cruciate ligament-deficient knee using an electromagnetic device. Am J Sports Med. 2007;35(7):1098-1104. 4. Claes S, Vereecke E, Maes M, et al. Anatomy of the anterolateral ligament of the knee. J Anat. 2013;223(4):321-328. 5. Vincent JP, Magnussen RA, Gezmez F, et al. The anterolateral ligament of the human knee: an anatomic and histologic study. Knee Surg Sports Traumatol Arthrosc. 2012;20(1):147-152. 6. Dombrowski ME, Costello JM, Ohashi B, et al. Macroscopic anatomical, histological and magnetic resonance imaging correlation of the lateral capsule of the knee. Knee Surg Sports Traumatol Arthrosc. 2016;24(9):2854-2860. 7. Musahl V, Rahnemai-Azar AA, Costello J, et al. The Influence of Meniscal and Anterolateral Capsular Injury on Knee Laxity in Patients With Anterior Cruciate Ligament Injuries. Am J Sports Med. 2016;44(12):3126-3131. 8. Rahnemai-Azar AA, Miller RM, Guenther D, et al. Structural Properties of the Anterolateral Capsule and Iliotibial Band of the Knee. Am J Sports Med. 2016;44(4):892-897. 9. Herbst E, Albers M, Burnham JM, et al. The anterolateral complex of the knee: a pictorial essay. Knee Surg Sports Traumatol Arthrosc. 2017. 10. Noyes FR, Huser LE, Levy MS. Rotational Knee Instability in ACL-Deficient Knees: Role of the Anterolateral Ligament and Iliotibial Band as Defined by Tibiofemoral Compartment Translations and Rotations. J Bone Joint Surg Am. 2017;99(4):305- 314. .
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