Authors: .uk
Biomechanics of the anterolateral structures of the knee.Authors:Christoph Kittl MD1, Eivind Inderhaug MD PhD2, Andy Williams FRCS(Orth)3, Andrew A Amis FREng, DSc4,5.1. Department of Trauma, Hand and Reconstructive Surgery, Westphalian Wilhelms University Muenster, Muenster, Germany. Christoph.kittl@2. Orthopaedic Surgery Department, Haraldsplass Hospital, Bergen, Norway. Eivind.inderhaug@3. Fortius Clinic, Fitzhardinge Street, London, UK. Andy.williams@4. Biomechanics Group, Mechanical Engineering Department, Imperial College London, London, UK. a.amis@imperial.ac.uk (corresponding author)5. Musculoskeletal Surgery Group, Imperial College School of Medicine, Charing Cross Hospital London, UK. Disclosures: the authors declare that they have no conflicts of interest relating to this article. However, work which led up to this article was supported as follows: C.K.: AGA (Arthroscopy Association of the German-speaking countries); E.I.: Bergen Regional Health Authority; A.W. and A.A.A.: Smith & Nephew Co supported research studies at Imperial College London and educational lectures at conferences.Synopsis: This paper describes the complex anatomical structures which pass across the lateral aspect of the knee, particularly the ilio-tibial tract and the underlying anterolateral ligament and capsule. It provides data on their strength and roles in controlling tibiofemoral joint laxity and stability. These findings are discussed in relation to surgery to repair or reconstruct the anatomical structures, or to create tenodeses with similar effect.Keywords: anterolateral, tenodesis, ligament, ilio tibial tract, rotatory instability, pivot-shift.Key points:The primary soft-tissue restraint to tibial internal rotation has been found to be the deep layer of the ilio- tibial tract, connecting from Kaplan’s fibers on the femur to Gerdy’s tubercle on the tibia.The anterolateral ligament has been found to be relatively weak and poorly aligned to resist tibial internal rotation, but damage here does increase laxity and may be a sign of other structures being damaged.Although lateral tenodeses are not anatomical, they are effective in controlling tibial internal rotation.AbstractThis article describes the anatomical structures on the anterolateral aspect of the knee, with the several layers of tissue which form the ilio-tibial tract (ITT) and the capsular structures. Among the capsular fibres is found the localised thickening which has been called the anterolateral ligament (ALL), which separates from the capsule and passes superficially over the lateral (fibular) collateral ligament. The ALL has been found to have differing strengths in several studies, typically below 200 N, whereas a graft taken from the ITT was several times stronger. Robotic methods have found that the ALL made a small contribution to resisting tibial internal rotation, while the larger overlying layers of the ITT were found to be the primary restraint. It was also reported that the isometry of the ALL depended on its femoral attachment, and that a point proximal and slightly posterior to the lateral femoral epcondyle gave close to isometric behaviour. Background:Previously, the term anterolateral rotatory instability (ALRI) was synonymous for the instability caused by an isolated anterior cruciate ligament (ACL) injury. Hughston et al. ADDIN EN.CITE <EndNote><Cite><Author>Hughston</Author><Year>1976</Year><RecNum>10</RecNum><DisplayText><style face="superscript">1</style></DisplayText><record><rec-number>10</rec-number><foreign-keys><key app="EN" db-id="rapw0xaz5e22wqepzdavr2tf2f2sxftp5xzf" timestamp="1445164168">10</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Hughston, JC</author><author>Andrews, JR</author><author>Cross, MJ</author><author>Moschi, A</author></authors></contributors><titles><title>Classification of knee ligament instabilities. Part II. The lateral compartment</title><secondary-title>Journal of bone and joint surgery (American volume)</secondary-title></titles><periodical><full-title>Journal of bone and joint surgery (American volume)</full-title></periodical><pages>173</pages><volume>58</volume><number>2</number><dates><year>1976</year></dates><isbn>0021-9355</isbn><urls></urls></record></Cite></EndNote>1, was the first to popularize the idea that only a concomitant anterolateral capsular injury can induce this excessive anterior subluxation of the lateral tibial plateau. With the introduction of arthroscopic ACL surgery, these peripheral injuries fell out of focus. Although intra-articular reconstruction of the ACL restored knee kinematics in the anterior/posterior direction, it failed to completely abolish the pivot-shift phenomenon in some knees. ADDIN EN.CITE <EndNote><Cite><Author>Lie</Author><Year>2007</Year><RecNum>108</RecNum><DisplayText><style face="superscript">2</style></DisplayText><record><rec-number>108</rec-number><foreign-keys><key app="EN" db-id="rapw0xaz5e22wqepzdavr2tf2f2sxftp5xzf" timestamp="1496178902">108</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Lie, Denny TT</author><author>Bull, Anthony MJ</author><author>Amis, Andrew A</author></authors></contributors><titles><title>Persistence of the mini pivot shift after anatomically placed anterior cruciate ligament reconstruction</title><secondary-title>Clinical orthopaedics and related research</secondary-title></titles><periodical><full-title>Clin Orthop Relat Res</full-title><abbr-1>Clinical orthopaedics and related research</abbr-1></periodical><pages>203-209</pages><volume>457</volume><dates><year>2007</year></dates><urls></urls></record></Cite></EndNote>2 This led to a more anatomical approach of intra-articular ACL reconstruction reproducing its oblique course to the posterior aspect of the femur using the medial portal technique. ADDIN EN.CITE <EndNote><Cite><Author>Harner</Author><Year>2008</Year><RecNum>109</RecNum><DisplayText><style face="superscript">3</style></DisplayText><record><rec-number>109</rec-number><foreign-keys><key app="EN" db-id="rapw0xaz5e22wqepzdavr2tf2f2sxftp5xzf" timestamp="1496178977">109</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Harner, Christopher D</author><author>Honkamp, Nicholas J</author><author>Ranawat, Anil S</author></authors></contributors><titles><title>Anteromedial portal technique for creating the anterior cruciate ligament femoral tunnel</title><secondary-title>Arthroscopy: The Journal of Arthroscopic & Related Surgery</secondary-title></titles><periodical><full-title>Arthroscopy: The Journal of Arthroscopic & Related Surgery</full-title></periodical><pages>113-115</pages><volume>24</volume><number>1</number><dates><year>2008</year></dates><isbn>0749-8063</isbn><urls></urls></record></Cite></EndNote>3 However, despite many efforts to improve tunnel positioning, graft tensioning, and after care protocols, still rotational laxity has not been completely abolished. ADDIN EN.CITE <EndNote><Cite><Author>Amis</Author><Year>1998</Year><RecNum>110</RecNum><DisplayText><style face="superscript">4</style></DisplayText><record><rec-number>110</rec-number><foreign-keys><key app="EN" db-id="rapw0xaz5e22wqepzdavr2tf2f2sxftp5xzf" timestamp="1496179046">110</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Amis, Andrew A</author><author>Jakob, Roland P</author></authors></contributors><titles><title>Anterior cruciate ligament graft positioning, tensioning and twisting</title><secondary-title>Knee Surgery, Sports Traumatology, Arthroscopy</secondary-title></titles><periodical><full-title>Knee Surgery, Sports Traumatology, Arthroscopy</full-title></periodical><pages>S2-S12</pages><volume>6</volume><number>1</number><dates><year>1998</year></dates><isbn>0942-2056</isbn><urls></urls></record></Cite></EndNote>4 This residual rotational laxity after ACL reconstruction may come from additional injury of the peripheral structures, which gained broad interest after anatomical description of the anterolateral ligament (ALL) in 2013. ADDIN EN.CITE <EndNote><Cite><Author>Claes</Author><Year>2013</Year><RecNum>26</RecNum><DisplayText><style face="superscript">5</style></DisplayText><record><rec-number>26</rec-number><foreign-keys><key app="EN" db-id="rapw0xaz5e22wqepzdavr2tf2f2sxftp5xzf" timestamp="1445164168">26</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Claes, Steven</author><author>Vereecke, Evie</author><author>Maes, Michael</author><author>Victor, Jan</author><author>Verdonk, Peter</author><author>Bellemans, Johan</author></authors></contributors><titles><title>Anatomy of the anterolateral ligament of the knee</title><secondary-title>Journal of Anatomy</secondary-title></titles><periodical><full-title>Journal of Anatomy</full-title></periodical><pages>321–328</pages><volume>223</volume><keywords><keyword>anatomy</keyword><keyword>Anterior Cruciate Ligament</keyword><keyword>anterolateral ligament</keyword><keyword>pivot-shift</keyword><keyword>Segond fracture</keyword></keywords><dates><year>2013</year><pub-dates><date>2013</date></pub-dates></dates><isbn>1469-7580</isbn><urls><related-urls><url> et al. - 2013 - Anatomy of the anterolateral ligament of the knee.pdf</url></pdf-urls></urls><electronic-resource-num>10.1111/joa.12087</electronic-resource-num><remote-database-name>Wiley Online Library</remote-database-name><language>en</language><access-date>2013-11-13 16:01:32</access-date></record></Cite></EndNote>5 Since then, many studies regarding anatomy, biomechanics and possible reconstructions have been conducted.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DYXRlcmluZTwvQXV0aG9yPjxZZWFyPjIwMTU8L1llYXI+
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ADDIN EN.CITE.DATA 6-10 However, there is still a lack of evidence on how to diagnose these injuries and more importantly which patients will benefit from an additional lateral extra-articular procedure.Although this work has given promising biomechanical and clinical results, these questions must be clarified by level I studies. Similar to the medial side, anterolateral capsular structures may have a high healing potential, when the primary restraint to anterior tibial translation is reconstructed, so routine use of anterolateral procedures may place the patient at unnecessary risk of an additional extra-articular procedure. Conversely, undiagnosed anterolateral structure injuries may ?stretch-out’ over time in chronic cases and impose abnormal loads on the ACL graft, preventing it from healing in the bone tunnel. ADDIN EN.CITE <EndNote><Cite><Author>Carson</Author><Year>1985</Year><RecNum>19</RecNum><DisplayText><style face="superscript">11</style></DisplayText><record><rec-number>19</rec-number><foreign-keys><key app="EN" db-id="rapw0xaz5e22wqepzdavr2tf2f2sxftp5xzf" timestamp="1445164168">19</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Carson, W G, Jr</author></authors></contributors><titles><title>Extra-articular reconstruction of the anterior cruciate ligament: lateral procedures</title><secondary-title>The Orthopedic clinics of North America</secondary-title><short-title>Extra-articular reconstruction of the anterior cruciate ligament</short-title></titles><periodical><full-title>The Orthopedic clinics of North America</full-title></periodical><pages>191-211</pages><volume>16</volume><keywords><keyword>Acute Disease</keyword><keyword>Chronic Disease</keyword><keyword>Follow-Up Studies</keyword><keyword>Humans</keyword><keyword>Joint Instability</keyword><keyword>Knee Injuries</keyword><keyword>Ligaments, Articular</keyword><keyword>Methods</keyword><keyword>Suture Techniques</keyword><keyword>Tendon Transfer</keyword></keywords><dates><year>1985</year><pub-dates><date>Apr 1985</date></pub-dates></dates><isbn>0030-5898</isbn><urls></urls><remote-database-name>NCBI PubMed</remote-database-name><language>eng</language></record></Cite></EndNote>11 The purpose of the following review is to provide a biomechanical rationale regarding the anterolateral structures of the knee.Anatomy of the anterolateral structures:The anatomy on the anterolateral side of the knee can best be described in a layer-by-layer fashion. The first relevant layer is the iliotibial tract (ITT), which inserts onto the tibia at Gerdy’s tubercle and extents proximally as the fascia lata, merging into the gluteus maximus, gluteus medius, and tensor fascia lata muscle. The second layer is formed by the posterior fibre region of the superficial tract, which merges with the deep and capsulo-osseous structures of the ITT. ADDIN EN.CITE <EndNote><Cite><Author>Terry</Author><Year>1986</Year><RecNum>41</RecNum><DisplayText><style face="superscript">12</style></DisplayText><record><rec-number>41</rec-number><foreign-keys><key app="EN" db-id="rapw0xaz5e22wqepzdavr2tf2f2sxftp5xzf" timestamp="1445164169">41</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Terry, Glenn C.</author><author>Hughston, Jack C.</author><author>Norwood, Lyle A.</author></authors></contributors><titles><title>The anatomy of the iliopatellar band and iliotibial tract</title><secondary-title>American Journal of Sports Medicine</secondary-title></titles><periodical><full-title>American journal of sports medicine</full-title></periodical><pages>39-45</pages><volume>14</volume><dates><year>1986</year><pub-dates><date>01/01/1986</date></pub-dates></dates><isbn>0363-5465, 1552-3365</isbn><urls><related-urls><url> 14:39:20</access-date></record></Cite></EndNote>12 (Figure 1)The deep layer of the ITT becomes visible approximately 60 mm proximal to the lateral femoral epicondyle. ADDIN EN.CITE <EndNote><Cite><Author>Terry</Author><Year>1986</Year><RecNum>2</RecNum><DisplayText><style face="superscript">13</style></DisplayText><record><rec-number>2</rec-number><foreign-keys><key app="EN" db-id="5zspvaw9sezss9evfa5pfswwww2d259xwevd" timestamp="1395241091">2</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Terry, Glenn C.</author><author>Hughston, Jack C.</author><author>Norwood, Lyle A.</author></authors></contributors><titles><title>The anatomy of the iliopatellar band and iliotibial tract</title><secondary-title>The American Journal of Sports Medicine</secondary-title></titles><periodical><full-title>The American Journal of Sports Medicine</full-title></periodical><pages>39-45</pages><volume>14</volume><dates><year>1986</year><pub-dates><date>01/01/1986</date></pub-dates></dates><isbn>0363-5465, 1552-3365</isbn><urls><related-urls><url> 14:39:20</access-date></record></Cite></EndNote>12 A triangular area at the distal termination of the lateral intermuscular septum is formed by strong fibres (Kaplan-fibres) connecting the superficial ITT layer to the femur. The capsulo-osseous layer was described as the deepest layer of the ITT and provides a lateral capsular strengthening. ADDIN EN.CITE <EndNote><Cite><Author>Vieira</Author><Year>2007</Year><RecNum>135</RecNum><DisplayText><style face="superscript">14</style></DisplayText><record><rec-number>135</rec-number><foreign-keys><key app="EN" db-id="5zspvaw9sezss9evfa5pfswwww2d259xwevd" timestamp="1397217148">135</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Vieira, E. L.</author><author>Vieira, E. A.</author><author>da Silva, R. T.</author><author>Berlfein, P. A.</author><author>Abdalla, R. J.</author><author>Cohen, M.</author></authors></contributors><auth-address>Sports Traumatology Center (Cete), Department of Orthopedics and Traumatology, Federal University of Sao Paulo (UNIFESP-EPM), Sao Paulo, Brazil. eduardolvieira@</auth-address><titles><title>An anatomic study of the iliotibial tract</title><secondary-title>Arthroscopy</secondary-title><alt-title>Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association</alt-title></titles><periodical><full-title>Arthroscopy-the Journal of Arthroscopic and Related Surgery</full-title><abbr-1>Arthroscopy</abbr-1></periodical><pages>269-74</pages><volume>23</volume><number>3</number><keywords><keyword>Adult</keyword><keyword>Cadaver</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Knee Joint/*anatomy & histology</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword></keywords><dates><year>2007</year><pub-dates><date>Mar</date></pub-dates></dates><isbn>1526-3231 (Electronic)
0749-8063 (Linking)</isbn><accession-num>17349469</accession-num><urls><related-urls><url> This layer is also known as the retrograde tract insertion ADDIN EN.CITE <EndNote><Cite><Author>Lobenhoffer</Author><Year>1987</Year><RecNum>81</RecNum><DisplayText><style face="superscript">15</style></DisplayText><record><rec-number>81</rec-number><foreign-keys><key app="EN" db-id="rapw0xaz5e22wqepzdavr2tf2f2sxftp5xzf" timestamp="1445164252">81</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Lobenhoffer, P.</author><author>Posel, P.</author><author>Witt, S.</author><author>Piehler, J.</author><author>Wirth, C. J.</author></authors></contributors><titles><title>Distal femoral fixation of the iliotibial tract</title><secondary-title>Archives of orthopaedic and traumatic surgery</secondary-title></titles><periodical><full-title>Archives of orthopaedic and traumatic surgery</full-title></periodical><pages>285-290</pages><volume>106</volume><keywords><keyword>Orthopedics</keyword></keywords><dates><year>1987</year><pub-dates><date>1987/08/01</date></pub-dates></dates><isbn>0344-8444, 1434-3916</isbn><urls><related-urls><url> et al. - 1987 - Distal femoral fixation of the iliotibial tract.pdf</url></pdf-urls></urls><electronic-resource-num>10.1007/BF00454335</electronic-resource-num><remote-database-name>link.</remote-database-name><language>en</language><access-date>2013-11-15 12:32:58</access-date></record></Cite></EndNote>14 and attaches at the lateral femoral supracondylar region and passes distal, where it inserts slightly posterior to Gerdy’s tubercle. This ligament-like unit is composed of the deep and capsulo-osseous layers of the ITT, and forms a sling around the posterolateral aspect of the femur, inserting posterior to Gerdy’s tubercle and was described as “acting as an anterolateral ligament” by Terry et al.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5UZXJyeTwvQXV0aG9yPjxZZWFyPjE5ODY8L1llYXI+PFJl
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ADDIN EN.CITE.DATA 12,15 (Figure 2)The next layer is formed by the mid-third lateral capsular ligament, which can be divided into a meniscotibial portion and a meniscofemoral portion. ADDIN EN.CITE <EndNote><Cite><Author>Hughston</Author><Year>1976</Year><RecNum>10</RecNum><DisplayText><style face="superscript">1</style></DisplayText><record><rec-number>10</rec-number><foreign-keys><key app="EN" db-id="rapw0xaz5e22wqepzdavr2tf2f2sxftp5xzf" timestamp="1445164168">10</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Hughston, JC</author><author>Andrews, JR</author><author>Cross, MJ</author><author>Moschi, A</author></authors></contributors><titles><title>Classification of knee ligament instabilities. Part II. The lateral compartment</title><secondary-title>Journal of bone and joint surgery (American volume)</secondary-title></titles><periodical><full-title>Journal of bone and joint surgery (American volume)</full-title></periodical><pages>173</pages><volume>58</volume><number>2</number><dates><year>1976</year></dates><isbn>0021-9355</isbn><urls></urls></record></Cite></EndNote>1 On the tibia it attaches between the anteroinferior popliteomeniscal fascicle (popliteus hiatus) and the posterior border of Gerdy’s tubercle approximately 6-9 mm distal from the joint line.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5SZWlkPC9BdXRob3I+PFllYXI+MjAwMTwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA 17,19 with several other attachments on the posterior aspect of the popliteus attachment and at the lateral gastrocnemius tendon attachment. ADDIN EN.CITE <EndNote><Cite><Author>LaPrade</Author><Year>2006</Year><RecNum>134</RecNum><DisplayText><style face="superscript">23</style></DisplayText><record><rec-number>134</rec-number><foreign-keys><key app="EN" db-id="5zspvaw9sezss9evfa5pfswwww2d259xwevd" timestamp="1396524910">134</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>LaPrade, Robert F</author></authors></contributors><titles><title>Posterolateral knee injuries: anatomy, evaluation, and treatment</title></titles><dates><year>2006</year></dates><publisher>Thieme</publisher><isbn>313140311X</isbn><urls></urls></record></Cite></EndNote>21 The recently re-discovered ALL, first published by Vincent et al.10, does not really fit in this layered anatomy. Depending on the author this ligament is either described as a capsular thickening or as part of the capsulo-osseous layer of the ITT. Claes et al. ADDIN EN.CITE <EndNote><Cite><Author>Claes</Author><Year>2013</Year><RecNum>26</RecNum><DisplayText><style face="superscript">5</style></DisplayText><record><rec-number>26</rec-number><foreign-keys><key app="EN" db-id="rapw0xaz5e22wqepzdavr2tf2f2sxftp5xzf" timestamp="1445164168">26</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Claes, Steven</author><author>Vereecke, Evie</author><author>Maes, Michael</author><author>Victor, Jan</author><author>Verdonk, Peter</author><author>Bellemans, Johan</author></authors></contributors><titles><title>Anatomy of the anterolateral ligament of the knee</title><secondary-title>Journal of Anatomy</secondary-title></titles><periodical><full-title>Journal of Anatomy</full-title></periodical><pages>321–328</pages><volume>223</volume><keywords><keyword>anatomy</keyword><keyword>Anterior Cruciate Ligament</keyword><keyword>anterolateral ligament</keyword><keyword>pivot-shift</keyword><keyword>Segond fracture</keyword></keywords><dates><year>2013</year><pub-dates><date>2013</date></pub-dates></dates><isbn>1469-7580</isbn><urls><related-urls><url> et al. - 2013 - Anatomy of the anterolateral ligament of the knee.pdf</url></pdf-urls></urls><electronic-resource-num>10.1111/joa.12087</electronic-resource-num><remote-database-name>Wiley Online Library</remote-database-name><language>en</language><access-date>2013-11-13 16:01:32</access-date></record></Cite></EndNote>5 described a capsular ligament with a femoral insertion on the tip of the lateral femoral epicondyle, which was present in 97% of their dissected knees and an intimidate connection to the lateral meniscus was observed. Their description is very similar to the midthird lateral capsular ligament popularized by Hughston et al.1 Anterolateral rotatory instability of the kneeIt is well-known that the ACL is the primary restraint to anterior tibial translation (ATT) and the PCL to posterior tibial translation (PTT). ADDIN EN.CITE <EndNote><Cite><Author>Butler</Author><Year>1980</Year><RecNum>30</RecNum><DisplayText><style face="superscript">25</style></DisplayText><record><rec-number>30</rec-number><foreign-keys><key app="EN" db-id="rapw0xaz5e22wqepzdavr2tf2f2sxftp5xzf" timestamp="1445164168">30</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Butler, D. L.</author><author>Noyes, F. R.</author><author>Grood, E. S.</author></authors></contributors><titles><title>Ligamentous restraints to anterior-posterior drawer in the human knee. A biomechanical study</title><secondary-title>J Bone Joint Surg Am</secondary-title><alt-title>The Journal of bone and joint surgery. American volume</alt-title></titles><periodical><full-title>J Bone Joint Surg Am</full-title></periodical><alt-periodical><full-title>The Journal of bone and joint surgery. American volume</full-title></alt-periodical><pages>259-70</pages><volume>62</volume><number>2</number><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Biomechanical Phenomena</keyword><keyword>Cadaver</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Knee Joint/*physiology</keyword><keyword>Ligaments, Articular/*physiology</keyword><keyword>Male</keyword><keyword>Movement</keyword></keywords><dates><year>1980</year><pub-dates><date>Mar</date></pub-dates></dates><isbn>0021-9355 (Print)</isbn><accession-num>7358757</accession-num><urls><related-urls><url> It has been found that the tibia can be translated 30% more if it is free to rotate. ADDIN EN.CITE <EndNote><Cite><Author>Amis</Author><Year>2005</Year><RecNum>5</RecNum><DisplayText><style face="superscript">26</style></DisplayText><record><rec-number>5</rec-number><foreign-keys><key app="EN" db-id="rapw0xaz5e22wqepzdavr2tf2f2sxftp5xzf" timestamp="1445164168">5</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Amis, Andrew A</author><author>Bull, Anthony MJ</author><author>Lie, Denny TT</author></authors></contributors><titles><title>Biomechanics of rotational instability and anatomic anterior cruciate ligament reconstruction</title><secondary-title>Operative Techniques in Orthopaedics</secondary-title></titles><periodical><full-title>Operative Techniques in Orthopaedics</full-title></periodical><pages>29-35</pages><volume>15</volume><number>1</number><dates><year>2005</year></dates><isbn>1048-6666</isbn><urls></urls></record></Cite></EndNote>23 This ‘coupled’ rotation in response to an anterior translation of the tibia results in a 3-10° internal rotation when examined by hand and slightly more in an ACL rupture. This is due to the more mobile lateral knee compartment, caused by the convex articular surfaces, the loose meniscocapsular attachment, and the less pronounced posterior wedge-effect of the relatively more mobile lateral meniscus.From video analysis studies ADDIN EN.CITE <EndNote><Cite><Author>Olsen</Author><Year>2004</Year><RecNum>112</RecNum><DisplayText><style face="superscript">27</style></DisplayText><record><rec-number>112</rec-number><foreign-keys><key app="EN" db-id="rapw0xaz5e22wqepzdavr2tf2f2sxftp5xzf" timestamp="1496179533">112</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Olsen, Odd-Egil</author><author>Myklebust, Grethe</author><author>Engebretsen, Lars</author><author>Bahr, Roald</author></authors></contributors><titles><title>Injury mechanisms for anterior cruciate ligament injuries in team handball a systematic video analysis</title><secondary-title>The American journal of sports medicine</secondary-title></titles><periodical><full-title>Am J Sports Med</full-title><abbr-1>The American journal of sports medicine</abbr-1></periodical><pages>1002-1012</pages><volume>32</volume><number>4</number><dates><year>2004</year></dates><isbn>0363-5465</isbn><urls></urls></record></Cite></EndNote>24, it is known that the trauma mechanism for non- contact ACL rupture involves a tibial internal rotational component. This is reinforced by the fact that the bone bruise found after a typical ACL rupture occurs at the posterolateral aspect of the tibia, which indicates this internal rotation movement. ADDIN EN.CITE <EndNote><Cite><Author>Herbst</Author><Year>2015</Year><RecNum>113</RecNum><DisplayText><style face="superscript">28</style></DisplayText><record><rec-number>113</rec-number><foreign-keys><key app="EN" db-id="rapw0xaz5e22wqepzdavr2tf2f2sxftp5xzf" timestamp="1496179618">113</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Herbst, Elmar</author><author>Hoser, Christian</author><author>Tecklenburg, Katja</author><author>Filipovic, Marcel</author><author>Dallapozza, Christian</author><author>Herbort, Mirco</author><author>Fink, Christian</author></authors></contributors><titles><title>The lateral femoral notch sign following ACL injury: frequency, morphology and relation to meniscal injury and sports activity</title><secondary-title>Knee Surgery, Sports Traumatology, Arthroscopy</secondary-title></titles><periodical><full-title>Knee Surgery, Sports Traumatology, Arthroscopy</full-title></periodical><pages>2250-2258</pages><volume>23</volume><number>8</number><dates><year>2015</year></dates><isbn>0942-2056</isbn><urls></urls></record></Cite></EndNote>25 In the actual injury situation, however, the abduction moment of the knee forces the lateral femoral condyle to slide posterior on the convex lateral tibial slope. This anterior subluxation of the lateral tibial plateau or the posterior subluxation of the femur, has been shown to put the ACL under excessive load, which may eventually cause the ACL rupture. ADDIN EN.CITE <EndNote><Cite><Author>Kanamori</Author><Year>2000</Year><RecNum>114</RecNum><DisplayText><style face="superscript">29</style></DisplayText><record><rec-number>114</rec-number><foreign-keys><key app="EN" db-id="rapw0xaz5e22wqepzdavr2tf2f2sxftp5xzf" timestamp="1496179751">114</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Kanamori, Akihiro</author><author>Woo, Savio LY</author><author>Ma, C Benjamin</author><author>Zeminski, Jennifer</author><author>Rudy, Theodore W</author><author>Li, Guoan</author><author>Livesay, Glen A</author></authors></contributors><titles><title>The forces in the anterior cruciate ligament and knee kinematics during a simulated pivot shift test: a human cadaveric study using robotic technology</title><secondary-title>Arthroscopy: The Journal of Arthroscopic & Related Surgery</secondary-title></titles><periodical><full-title>Arthroscopy: The Journal of Arthroscopic & Related Surgery</full-title></periodical><pages>633-639</pages><volume>16</volume><number>6</number><dates><year>2000</year></dates><isbn>0749-8063</isbn><urls></urls></record></Cite></EndNote>26 Although the central position of the ACL does not suggest a potential restraint to internal tibial rotation, it has been shown that it has a significant impact at early flexion angles. At these flexion angles, the tightening of the ACL forces the tibia to rotate externally and locks the knee at full extension. This principle of the ‘screw home’ mechanism is lost in an ACL-deficient knee leaving the tibia to rotate internally.27The ACL rupture mechanism also implies stretching or rupturing of the anterolateral structures, which cross the anterolateral joint line and are oriented in an oblique direction similar to the ACL.28 In the event of excessive anterior translation of the lateral tibial plateau, the anterolateral structures will have a much greater lever arm than the ACL to resist the combined anterior translation plus internal rotation motion. This is best shown by the Segond fracture, which is a bony avulsion of the lateral tibial rim caused by the anterolateral structures.29 (Figure 3) A combined injury of the ACL and the anterolateral structures will therefore lead to a high-grade translatory (anterior translation) and rotatory (internal rotation) instability, which may induce a high-grade pivot shift test.28The pivot-shift test imitates this typical anterior subluxation mechanism of an ACL rupture and correlates best with functional and subjective patient outcome after ACL reconstruction. ADDIN EN.CITE <EndNote><Cite><Author>Kocher</Author><Year>2004</Year><RecNum>117</RecNum><DisplayText><style face="superscript">33</style></DisplayText><record><rec-number>117</rec-number><foreign-keys><key app="EN" db-id="rapw0xaz5e22wqepzdavr2tf2f2sxftp5xzf" timestamp="1496180046">117</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Kocher, Mininder S</author><author>Steadman, J Richard</author><author>Briggs, Karen K</author><author>Sterett, William I</author><author>Hawkins, Richard J</author></authors></contributors><titles><title>Relationships between objective assessment of ligament stability and subjective assessment of symptoms and function after anterior cruciate ligament reconstruction</title><secondary-title>The American journal of sports medicine</secondary-title></titles><periodical><full-title>Am J Sports Med</full-title><abbr-1>The American journal of sports medicine</abbr-1></periodical><pages>629-634</pages><volume>32</volume><number>3</number><dates><year>2004</year></dates><isbn>0363-5465</isbn><urls></urls></record></Cite></EndNote>30 However, due to different bony geometry, integrity of the anterolateral and medial soft tissues, and hip abduction this test has a large inter-, and intraobserver variability. ADDIN EN.CITE <EndNote><Cite><Author>Noyes</Author><Year>1991</Year><RecNum>118</RecNum><DisplayText><style face="superscript">34,35</style></DisplayText><record><rec-number>118</rec-number><foreign-keys><key app="EN" db-id="rapw0xaz5e22wqepzdavr2tf2f2sxftp5xzf" timestamp="1496180128">118</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Noyes, Frank R</author><author>Grood, Edward S</author><author>Cummings, John F</author><author>Wroble, Randall R</author></authors></contributors><titles><title>An analysis of the pivot shift phenomenon: the knee motions and subluxations induced by different examiners</title><secondary-title>The American journal of sports medicine</secondary-title></titles><periodical><full-title>Am J Sports Med</full-title><abbr-1>The American journal of sports medicine</abbr-1></periodical><pages>148-155</pages><volume>19</volume><number>2</number><dates><year>1991</year></dates><isbn>0363-5465</isbn><urls></urls></record></Cite><Cite><Author>Bull</Author><Year>1999</Year><RecNum>119</RecNum><record><rec-number>119</rec-number><foreign-keys><key app="EN" db-id="rapw0xaz5e22wqepzdavr2tf2f2sxftp5xzf" timestamp="1496180158">119</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Bull, Anthony MJ</author><author>Andersen, Henrik N</author><author>Basso, Oreste</author><author>Targett, John</author><author>Amis, Andrew A</author></authors></contributors><titles><title>Incidence and Mechanism of the Pivot Shift: An In Vitro Study</title><secondary-title>Clinical orthopaedics and related research</secondary-title></titles><periodical><full-title>Clin Orthop Relat Res</full-title><abbr-1>Clinical orthopaedics and related research</abbr-1></periodical><pages>219-231</pages><volume>363</volume><dates><year>1999</year></dates><urls></urls></record></Cite></EndNote>31,32 Based on recent biomechanical data one may speculate that this subluxation of the lateral tibial plateau will increase when an additional anterolateral structure damage is present. ADDIN EN.CITE <EndNote><Cite><Author>Kittl</Author><Year>2015</Year><RecNum>93</RecNum><DisplayText><style face="superscript">36</style></DisplayText><record><rec-number>93</rec-number><foreign-keys><key app="EN" db-id="rapw0xaz5e22wqepzdavr2tf2f2sxftp5xzf" timestamp="1458390645">93</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Kittl, Christoph</author><author>El-Daou, Hadi</author><author>Athwal, Kiron K.</author><author>Gupte, Chinmay M.</author><author>Weiler, Andreas</author><author>Williams, Andy</author><author>Amis, Andrew A.</author></authors></contributors><titles><title>The Role of the Anterolateral Structures and the ACL in Controlling Laxity of the Intact and ACL-Deficient Knee</title><secondary-title>The American Journal of Sports Medicine</secondary-title></titles><periodical><full-title>Am J Sports Med</full-title><abbr-1>The American journal of sports medicine</abbr-1></periodical><dates><year>2015</year><pub-dates><date>December 10, 2015</date></pub-dates></dates><urls><related-urls><url> The reduction event in 30-60° of flexion, which is felt as the typical clunk, will then be pronounced similarly. In a clinical pivot-shift testing setup, however, it seems difficult to distinguish between a normal and a high-grade pivot shift, because of aforementioned variables. Thus, a specific clinical test to precisely identify ALRI is missing.Structural properties of the anterolateral structuresWhen Werner Müller ADDIN EN.CITE <EndNote><Cite><Author>Müller</Author><Year>2006</Year><RecNum>23</RecNum><DisplayText><style face="superscript">37</style></DisplayText><record><rec-number>23</rec-number><foreign-keys><key app="EN" db-id="rapw0xaz5e22wqepzdavr2tf2f2sxftp5xzf" timestamp="1445164168">23</key></foreign-keys><ref-type name="Audiovisual Material">3</ref-type><contributors><authors><author>Werner Müller</author></authors></contributors><titles><title>Anatomy of the knee</title></titles><dates><year>2006</year></dates><publisher>ESSKA DVD</publisher><urls></urls></record></Cite></EndNote>34 dissected the lateral knee structures in his ESSKA knee anatomy video he mentioned one basic biomechanical principle: “Big structures, big function, small structures, small function”. This does not necessarily mean that the bigger structures control anterior displacement of the lateral tibial plateau better than smaller structures. It strongly depends on fibre orientation (axis of alignment) to resist a certain displacement. The ITT, however, is tethered to the femoral metaphysis via the lateral intermuscular septum and the Kaplan fibres, therefore the capsulo-osseous layer forms a sling around the posterolateral aspect of the lateral femoral condyle, implying a potent role in restraining anterior subluxation of the lateral tibial plateau.13The ALL has been found to have a mean tensile strength of 49,9 – 319,7 N and a mean stiffness of 20 – 26 N/mm. These results come from differing descriptions of the anatomy of the ALL. Zens et al. ADDIN EN.CITE <EndNote><Cite><Author>Zens</Author><Year>2015</Year><RecNum>85</RecNum><DisplayText><style face="superscript">39</style></DisplayText><record><rec-number>85</rec-number><foreign-keys><key app="EN" db-id="rapw0xaz5e22wqepzdavr2tf2f2sxftp5xzf" timestamp="1445270155">85</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Zens, Martin</author><author>Feucht, Matthias J</author><author>Ruhhammer, Johannes</author><author>Bernstein, Anke</author><author>Mayr, Hermann O</author><author>Südkamp, Norbert P</author><author>Woias, Peter</author><author>Niemeyer, Philipp</author></authors></contributors><titles><title>Mechanical tensile properties of the anterolateral ligament</title><secondary-title>Journal of Experimental Orthopaedics</secondary-title></titles><periodical><full-title>Journal of Experimental Orthopaedics</full-title></periodical><pages>7</pages><volume>2</volume><number>1</number><dates><year>2015</year></dates><isbn>2197-1153</isbn><urls></urls></record></Cite></EndNote>35 separated an isolated ALL structure, according to only one available anatomic paper at this time, which only had an ultimate strength of 50 N. Other studies obviously included the capsulo-osseous layer of the ITB and found an ultimate tensile strength of 175 – 319N and a mean stiffness of 20 – 26 N/mm.36,37PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5SYWhuZW1haS1BemFyPC9BdXRob3I+PFllYXI+MjAxNjwv
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ADDIN EN.CITE.DATA This is similar to the structural properties of the deep MCL, which is protected by the superficial fibres of the MCL38, like the anterolateral capsule and the deep fibres of the ITT are sheltered by the superficial ITT. Conversely, an 18 mm wide strip of the ITT has been reported to have a mean tensile strength of 769 N.39Length change patterns of the anterolateral structures:In ligament surgery the term isometry indicates the constant length of a graft during range of motion. From ACL reconstruction studies we have learned that the effort to achieve true isometry will result in a non-anatomical graft placement, because isometry can only apply to a point to point connection and not to a graft or ligament attaching to an area of the bone. ADDIN EN.CITE <EndNote><Cite><Author>Zavras</Author><Year>2001</Year><RecNum>123</RecNum><DisplayText><style face="superscript">44</style></DisplayText><record><rec-number>123</rec-number><foreign-keys><key app="EN" db-id="rapw0xaz5e22wqepzdavr2tf2f2sxftp5xzf" timestamp="1496180681">123</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Zavras, TD</author><author>Race, A</author><author>Bull, AMJ</author><author>Amis, AA</author></authors></contributors><titles><title>A comparative study of'isometric'points for anterior cruciate ligament graft attachment</title><secondary-title>Knee Surgery, Sports Traumatology, Arthroscopy</secondary-title></titles><periodical><full-title>Knee Surgery, Sports Traumatology, Arthroscopy</full-title></periodical><pages>28-33</pages><volume>9</volume><number>1</number><dates><year>2001</year></dates><isbn>0942-2056</isbn><urls></urls></record></Cite></EndNote>40 This will cause different length change patterns for different fibre regions. In order to reduce excessive length changes at each end of an attachment area, a flat ligament like the ACL and the superficial MCL will be twisted about its axis. ADDIN EN.CITE <EndNote><Cite><Author>Müller</Author><Year>2013</Year><RecNum>99</RecNum><DisplayText><style face="superscript">45</style></DisplayText><record><rec-number>99</rec-number><foreign-keys><key app="EN" db-id="rapw0xaz5e22wqepzdavr2tf2f2sxftp5xzf" timestamp="1477845743">99</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>Müller, Werner</author></authors></contributors><titles><title>Das Knie: Form, Funktion und ligament?re Wiederherstellungschirurgie</title></titles><dates><year>2013</year></dates><publisher>Springer-Verlag</publisher><isbn>3662064758</isbn><urls></urls></record></Cite></EndNote>41 It has also been shown that isometry depends more on the femoral attachment than the tibial attachment.It seems logical that the area at the axis of knee flexion, the transepicondylar axis, will be near to isometric, because the posterior aspects of the femoral condyles are almost spherical. However, due to the knee’s roll-glide mechanism the lateral condyle rolls posteriorly on the increasing posterior tibial slope. This makes it impossible to find a perfect isometric tibiofemoral connection, which has been shown by Sidles et al. ADDIN EN.CITE <EndNote><Cite><Author>Sidles</Author><Year>1988</Year><RecNum>74</RecNum><DisplayText><style face="superscript">46</style></DisplayText><record><rec-number>74</rec-number><foreign-keys><key app="EN" db-id="rapw0xaz5e22wqepzdavr2tf2f2sxftp5xzf" timestamp="1445164252">74</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Sidles, John A.</author><author>Larson, Roger V.</author><author>Garbini, Joseph L.</author><author>Downey, Daniel J.</author><author>Matsen, Frederick A.</author></authors></contributors><titles><title>Ligament length relationships in the moving knee</title><secondary-title>Journal of Orthopaedic Research</secondary-title></titles><periodical><full-title>Journal of Orthopaedic Research</full-title></periodical><pages>593–610</pages><volume>6</volume><keywords><keyword>Biomechanics</keyword><keyword>Isometry</keyword><keyword>knee</keyword><keyword>Ligament</keyword></keywords><dates><year>1988</year><pub-dates><date>1988</date></pub-dates></dates><isbn>1554-527X</isbn><urls><related-urls><url> Online Library</remote-database-name><language>en</language><access-date>2013-11-15 16:44:49</access-date></record></Cite></EndNote>42. They also found that a structure attaching anterior to the epicondyle will stretch with knee flexion, while structures attaching posterior to the epicondyle will slacken with knee flexion. Looking at the ALL, two different attachment areas have been described. Vincent et al. ADDIN EN.CITE <EndNote><Cite><Author>Vincent</Author><Year>2012</Year><RecNum>111</RecNum><DisplayText><style face="superscript">10</style></DisplayText><record><rec-number>111</rec-number><foreign-keys><key app="EN" db-id="rapw0xaz5e22wqepzdavr2tf2f2sxftp5xzf" timestamp="1496179176">111</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Vincent, Jean-Philippe</author><author>Magnussen, Robert A</author><author>Gezmez, Ferittu</author><author>Uguen, Arnaud</author><author>Jacobi, Matthias</author><author>Weppe, Florent</author><author>Ma’ad, F</author><author>Lustig, Sébastien</author><author>Demey, Guillaume</author><author>Servien, Elvire</author></authors></contributors><titles><title>The anterolateral ligament of the human knee: an anatomic and histologic study</title><secondary-title>Knee Surgery, Sports Traumatology, Arthroscopy</secondary-title></titles><periodical><full-title>Knee Surgery, Sports Traumatology, Arthroscopy</full-title></periodical><pages>147-152</pages><volume>20</volume><number>1</number><dates><year>2012</year></dates><isbn>0942-2056</isbn><urls></urls></record></Cite></EndNote>10 and Claes et al. ADDIN EN.CITE <EndNote><Cite><Author>Claes</Author><Year>2013</Year><RecNum>26</RecNum><DisplayText><style face="superscript">5</style></DisplayText><record><rec-number>26</rec-number><foreign-keys><key app="EN" db-id="rapw0xaz5e22wqepzdavr2tf2f2sxftp5xzf" timestamp="1445164168">26</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Claes, Steven</author><author>Vereecke, Evie</author><author>Maes, Michael</author><author>Victor, Jan</author><author>Verdonk, Peter</author><author>Bellemans, Johan</author></authors></contributors><titles><title>Anatomy of the anterolateral ligament of the knee</title><secondary-title>Journal of Anatomy</secondary-title></titles><periodical><full-title>Journal of Anatomy</full-title></periodical><pages>321–328</pages><volume>223</volume><keywords><keyword>anatomy</keyword><keyword>Anterior Cruciate Ligament</keyword><keyword>anterolateral ligament</keyword><keyword>pivot-shift</keyword><keyword>Segond fracture</keyword></keywords><dates><year>2013</year><pub-dates><date>2013</date></pub-dates></dates><isbn>1469-7580</isbn><urls><related-urls><url> et al. - 2013 - Anatomy of the anterolateral ligament of the knee.pdf</url></pdf-urls></urls><electronic-resource-num>10.1111/joa.12087</electronic-resource-num><remote-database-name>Wiley Online Library</remote-database-name><language>en</language><access-date>2013-11-13 16:01:32</access-date></record></Cite></EndNote>5 described an insertion area of the ALL anterior to and at the epicondyle, while several other studies8,37 described an attachment area proximal and posterior to the epicondyle. The anterior attachment ALL has been found to increase in length from 0-90° flexion by almost 20%. ADDIN EN.CITE <EndNote><Cite><Author>Kittl</Author><Year>2015</Year><RecNum>95</RecNum><DisplayText><style face="superscript">47</style></DisplayText><record><rec-number>95</rec-number><foreign-keys><key app="EN" db-id="rapw0xaz5e22wqepzdavr2tf2f2sxftp5xzf" timestamp="1474801184">95</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Kittl, Cristoph</author><author>Halewood, Camilla</author><author>Stephen, Joanna M</author><author>Gupte, Chinmay M</author><author>Weiler, Andreas</author><author>Williams, Andy</author><author>Amis, Andrew A</author></authors></contributors><titles><title>Length change patterns in the lateral extra-articular structures of the knee and related reconstructions</title><secondary-title>The American journal of sports medicine</secondary-title></titles><periodical><full-title>Am J Sports Med</full-title><abbr-1>The American journal of sports medicine</abbr-1></periodical><pages>354-362</pages><volume>43</volume><number>2</number><dates><year>2015</year></dates><isbn>0363-5465</isbn><urls></urls></record></Cite></EndNote>43 This, however, means that it cannot be tight at early flexion angles and only control laxity at higher flexion angles. Conversely the ALL which attaches posterior to the epicondyle may only control laxity at early flexion angle, and then slacken with knee flexion. This principle of the knee capsule also applies to the ITB, which can be divided into anterior and posterior fibre regions which act reciprocally. The posterior fibre region is tight in extension, while the anterior fibre region is tight in flexion. (Figure 4) The separation distance of the posterior attachment has also been measured by Dodds et al. ADDIN EN.CITE <EndNote><Cite><Author>Dodds</Author><Year>2014</Year><RecNum>25</RecNum><DisplayText><style face="superscript">8</style></DisplayText><record><rec-number>25</rec-number><foreign-keys><key app="EN" db-id="rapw0xaz5e22wqepzdavr2tf2f2sxftp5xzf" timestamp="1445164168">25</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Dodds, AL</author><author>Halewood, C</author><author>Gupte, CM</author><author>Williams, A</author><author>Amis, AA</author></authors></contributors><titles><title>The anterolateral ligament Anatomy, length changes and association with the Segond fracture</title><secondary-title>Bone & Joint Journal</secondary-title></titles><periodical><full-title>Bone & Joint Journal</full-title></periodical><pages>325-331</pages><volume>96</volume><number>3</number><dates><year>2014</year></dates><isbn>2049-4394</isbn><urls></urls></record></Cite></EndNote>8, by threading a suture along the ligament fibres attaching it to the tibia and a transducer. If the tibia was rotated internally the separation distance increased (that is, the structure was stretched, causing tension to resist the tibial motion), while external rotation decreased the separation distance. Thus, anterolateral structures attaching posterior to the lateral femoral epicondyle are tight in early flexion angles and, due to their oblique course, are able to restrain the anterior subluxation of the lateral tibial plateau.Confusion surrounding the role of the anterolateral structures:Hughston et al ADDIN EN.CITE <EndNote><Cite><Author>Hughston</Author><Year>1976</Year><RecNum>10</RecNum><DisplayText><style face="superscript">1</style></DisplayText><record><rec-number>10</rec-number><foreign-keys><key app="EN" db-id="rapw0xaz5e22wqepzdavr2tf2f2sxftp5xzf" timestamp="1445164168">10</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Hughston, JC</author><author>Andrews, JR</author><author>Cross, MJ</author><author>Moschi, A</author></authors></contributors><titles><title>Classification of knee ligament instabilities. Part II. The lateral compartment</title><secondary-title>Journal of bone and joint surgery (American volume)</secondary-title></titles><periodical><full-title>Journal of bone and joint surgery (American volume)</full-title></periodical><pages>173</pages><volume>58</volume><number>2</number><dates><year>1976</year></dates><isbn>0021-9355</isbn><urls></urls></record></Cite></EndNote>1 were the first to popularize the term ‘anterolateral rotatory instability’ and associated it with a rupture of the midthird lateral capsular ligament and the ACL. However, they did not mention the capsulo-osseous layer of the ITT, which obviously runs directly above the anterolateral knee capsule. Terry et al. ADDIN EN.CITE <EndNote><Cite><Author>Terry</Author><Year>1993</Year><RecNum>12</RecNum><DisplayText><style face="superscript">16</style></DisplayText><record><rec-number>12</rec-number><foreign-keys><key app="EN" db-id="rapw0xaz5e22wqepzdavr2tf2f2sxftp5xzf" timestamp="1445164168">12</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Terry, G C</author><author>Norwood, L A</author><author>Hughston, J C</author><author>Caldwell, K M</author></authors></contributors><titles><title>How iliotibial tract injuries of the knee combine with acute anterior cruciate ligament tears to influence abnormal anterior tibial displacement</title><secondary-title>American journal of sports medicine</secondary-title></titles><periodical><full-title>American journal of sports medicine</full-title></periodical><pages>55-60</pages><volume>21</volume><keywords><keyword>Acute Disease</keyword><keyword>Anterior Cruciate Ligament</keyword><keyword>Dislocations</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Joint Instability</keyword><keyword>Knee Injuries</keyword><keyword>Ligaments</keyword><keyword>Male</keyword><keyword>Range of Motion, Articular</keyword></keywords><dates><year>1993</year><pub-dates><date>1993 Jan-Feb</date></pub-dates></dates><isbn>0363-5465</isbn><urls></urls><remote-database-name>NCBI PubMed</remote-database-name><language>eng</language></record></Cite></EndNote>15 and later Viera et al.13 described the capsulo osseous layer of the ITT forming a sling around the posterolateral femur and called it ‘anterolateral ligament’ (Figure 3). This was implied to resist anterolateral rotatory instability and was found to have been ruptured in 93% of the functionally unstable knees that they reconstructed. This fits with the observation of Terry and Laprade that not only capsular structures insert at the Segond fracture, but also the capsulo-osseous layer of the ITB and the anterior arm of the biceps femoris muscle. ADDIN EN.CITE <EndNote><Cite><Author>Terry</Author><Year>1996</Year><RecNum>43</RecNum><DisplayText><style face="superscript">48</style></DisplayText><record><rec-number>43</rec-number><foreign-keys><key app="EN" db-id="rapw0xaz5e22wqepzdavr2tf2f2sxftp5xzf" timestamp="1445164169">43</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Terry, Glenn C</author><author>LaPrade, Robert F</author></authors></contributors><titles><title>The biceps femoris muscle complex at the knee Its anatomy and injury patterns associated with acute anterolateral-anteromedial rotatory instability</title><secondary-title>American journal of sports medicine</secondary-title></titles><periodical><full-title>American journal of sports medicine</full-title></periodical><pages>2-8</pages><volume>24</volume><number>1</number><dates><year>1996</year></dates><isbn>0363-5465</isbn><urls></urls></record></Cite></EndNote>44Recently there has been much confusion regarding the anatomy of the anterolateral structures. A distinct structure running distally across the anterolateral joint line from the lateral femoral epicondyle was described by Vincent et al.10 in 2011 and later popularized by Claes et al. ADDIN EN.CITE <EndNote><Cite><Author>Claes</Author><Year>2013</Year><RecNum>26</RecNum><DisplayText><style face="superscript">5</style></DisplayText><record><rec-number>26</rec-number><foreign-keys><key app="EN" db-id="rapw0xaz5e22wqepzdavr2tf2f2sxftp5xzf" timestamp="1445164168">26</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Claes, Steven</author><author>Vereecke, Evie</author><author>Maes, Michael</author><author>Victor, Jan</author><author>Verdonk, Peter</author><author>Bellemans, Johan</author></authors></contributors><titles><title>Anatomy of the anterolateral ligament of the knee</title><secondary-title>Journal of Anatomy</secondary-title></titles><periodical><full-title>Journal of Anatomy</full-title></periodical><pages>321–328</pages><volume>223</volume><keywords><keyword>anatomy</keyword><keyword>Anterior Cruciate Ligament</keyword><keyword>anterolateral ligament</keyword><keyword>pivot-shift</keyword><keyword>Segond fracture</keyword></keywords><dates><year>2013</year><pub-dates><date>2013</date></pub-dates></dates><isbn>1469-7580</isbn><urls><related-urls><url> et al. - 2013 - Anatomy of the anterolateral ligament of the knee.pdf</url></pdf-urls></urls><electronic-resource-num>10.1111/joa.12087</electronic-resource-num><remote-database-name>Wiley Online Library</remote-database-name><language>en</language><access-date>2013-11-13 16:01:32</access-date></record></Cite></EndNote>5. Since then many papers described the ALL as a capsular or extra-capsular structure. Some of them claimed that the capsulo-osseous layer of the ITB and the ALL are the same structure and should be termed the anterolateral complex, similarly to the posterolateral corner. However, in our own observations we found a clear layer-by-layer anatomy existing of the superficial ITT layer, the deep and capsulo-osseous layer of the ITT, and the anterolateral capsule. In fact, in some knees, some fibres separated superficially from the capsular layer, such that they passed superficial to the lateral collateral ligament, and were so pronounced that they formed a capsular thickening imitating a distinct ligament. This observation is in line with several other studies, which did not find a distinct ligament on the anterolateral side in fresh frozen knees, formalin embedded knees ADDIN EN.CITE <EndNote><Cite><Author>Fardin</Author><Year>2017</Year><RecNum>124</RecNum><DisplayText><style face="superscript">49</style></DisplayText><record><rec-number>124</rec-number><foreign-keys><key app="EN" db-id="rapw0xaz5e22wqepzdavr2tf2f2sxftp5xzf" timestamp="1496181054">124</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Fardin, Paloma Batista Almeida</author><author>Lizardo, Juliana Hott de Fúcio</author><author>Baptista, Josemberg da Silva</author></authors></contributors><titles><title>Study of the anterolateral ligament of the knee in formalin-embedded cadavers</title><secondary-title>Acta Ortopédica Brasileira</secondary-title></titles><pages>89-92</pages><volume>25</volume><number>2</number><dates><year>2017</year></dates><isbn>1413-7852</isbn><urls></urls></record></Cite></EndNote>45, and foetal knees46.There have been several cutting studies of the anterolateral side of the knee using a six degree of freedom robotic setup, and almost all reported a significant increase in laxity after cutting the ALL. Parsons et al.47 found a 30-45% contribution in restraining a 5Nm internal rotation moment in 35-90° knee flexion, falling to 5% near extension. Unfortunately, the ITB had been removed prior to testing, therefore most likely overstating the contribution of the ALL, as the ITB has since been shown to be the primary restraint. Another in-vitro study found a pooled laxity increase of 2.8° internal rotation in response to a simulated pivot shift, when the ALL was cut.48 They cut the ALL on the tibia midway between Gerdy’s tubercle and the fibular head (Segond location), which has been found to be the attachment site for the capsulo-osseous ITB layer and the anterolateral capsular structures. Thus, most likely this increase in laxity did not only come from the ALL, but also from the combined transection of the whole anterolateral structures, including the capsulo-osseous layer of the ITT. Kittl et al. ADDIN EN.CITE <EndNote><Cite><Author>Kittl</Author><Year>2015</Year><RecNum>93</RecNum><DisplayText><style face="superscript">36</style></DisplayText><record><rec-number>93</rec-number><foreign-keys><key app="EN" db-id="rapw0xaz5e22wqepzdavr2tf2f2sxftp5xzf" timestamp="1458390645">93</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Kittl, Christoph</author><author>El-Daou, Hadi</author><author>Athwal, Kiron K.</author><author>Gupte, Chinmay M.</author><author>Weiler, Andreas</author><author>Williams, Andy</author><author>Amis, Andrew A.</author></authors></contributors><titles><title>The Role of the Anterolateral Structures and the ACL in Controlling Laxity of the Intact and ACL-Deficient Knee</title><secondary-title>The American Journal of Sports Medicine</secondary-title></titles><periodical><full-title>Am J Sports Med</full-title><abbr-1>The American journal of sports medicine</abbr-1></periodical><dates><year>2015</year><pub-dates><date>December 10, 2015</date></pub-dates></dates><urls><related-urls><url> were the first to distinguish between the different layers of anterolateral structures, dividing them into the superficial layer of the ITT, the deep and capsulo-osseous layer of the ITT and the capsular structures running superficial (ALL) and deep to the LCL (anterolateral capsule) in the ACL intact and ACL-deficient knee. They found that the ITT was the primary restraint (that is: it resisted more than 50% of the torque) to a 5 Nm internal rotation moment in 30-90° of flexion (Figure 4). The ACL had a significant contribution at full extension, which was taken by the capsulo-osseous layer of the ITT in the ACL-deficient state of the knee. Considering the ALL as the capsular structure which runs superficial to the LCL, it had only a minor role in resisting tibial internal rotation. Although these in vitro robotic studies present a scientific basis, that can only represent the ‘time zero’ situation immediately post-surgery, and the ultimate goal would be to measure rotational laxity in a weight-bearing situation or with a real-world injury.Hudson et al 49 reported that, in a normally-aligned leg, walking caused tibial internal rotations of 13o during the stance phase. The axis of tibial internal-external rotation is close to the centre of the tibial plateau when the soft tissues are intact50, so the peripheral capsular and overlying tissues will then be subjected to a shearing effect of approximately 10-12 mm, as the rim of the tibial plateau moves in relation to the outer surface of the femur. This movement will cause elongation of any soft tissue structure that crosses the joint line, if it had an orientation slanting in the correct direction (for example, on the lateral aspect, the tissue will be stretched by tibial internal rotation if the tibial attachment is anterior to the femoral attachment; and vice-versa on the medial aspect).Elongation of soft tissues leads to an elastic stretching response, and so they then resist the relative movement between the ends of the bones by increasing their tensile forces as the attachments move apart.When Kittl et al ADDIN EN.CITE <EndNote><Cite><Author>Kittl</Author><Year>2015</Year><RecNum>93</RecNum><DisplayText><style face="superscript">36</style></DisplayText><record><rec-number>93</rec-number><foreign-keys><key app="EN" db-id="rapw0xaz5e22wqepzdavr2tf2f2sxftp5xzf" timestamp="1458390645">93</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Kittl, Christoph</author><author>El-Daou, Hadi</author><author>Athwal, Kiron K.</author><author>Gupte, Chinmay M.</author><author>Weiler, Andreas</author><author>Williams, Andy</author><author>Amis, Andrew A.</author></authors></contributors><titles><title>The Role of the Anterolateral Structures and the ACL in Controlling Laxity of the Intact and ACL-Deficient Knee</title><secondary-title>The American Journal of Sports Medicine</secondary-title></titles><periodical><full-title>Am J Sports Med</full-title><abbr-1>The American journal of sports medicine</abbr-1></periodical><dates><year>2015</year><pub-dates><date>December 10, 2015</date></pub-dates></dates><urls><related-urls><url> used a robot to measure the contributions to resisting tibial internal rotation with the soft tissues intact, they reported that, at 30o knee flexion, the superficial ITB resisted 18% of the torque imposed on the tibia, the deep ITB 26 %, the ALL 11%, the AL capsule 3%, the ACL 9%, the MCL 15%, and the posteromedial capsule (PMC) 15%. Thus, the ITB resisted 44% and the ALL and AL capsule together resisted 14%, a total of 58%. Similarly, the MCL plus PMC resisted 30%. Thus, with the 9% of the ACL, we approach 100% of the resistance to tibial internal rotation arising solely from the soft tissues crossing the joint, and so almost none from the engagement of the articular surfaces and menisci – in this non load-bearing test set-up. The situation will differ under the loads encountered during gait, but there has been little work on rotation of the load-bearing knee.Conclusion:Tibial internal rotation is controlled mostly by the lateral extra-articular structures, which are the lateral capsule and the iliotibial band. Based on recent findings the ITT is the primary restraint to internal tibial rotation and the pivot shift phenomenon as the knee flexes. The ALL is a capsular thickening, which has, similarly to the deep MCL, only a secondary role in restraining the anterior subluxation of the lateral tibial plateau.Captions for illustrationsFigure 1: Lateral aspect of a left knee. The superficial layer (1) of the iliotibial band (ITB) has been flapped down, revealing the Kaplan fibres. The lateral superior genicular artery (5) passes through the lateral intermuscular septum (9) between the proximal (2) and supracondylar insertion (3). The retrograde insertion (4; capsulo-osseous layer) forms a sling around the posterolateral femur and inserts distally somewhat posterior to Gerdy’s tubercle (8). Lateral collateral ligament (6); fibular head (7). From Kittl C, El-Daou H, Athwal KK, et al. The Role of the Anterolateral Structures and the ACL in Controlling Laxity of the Intact and ACL-Deficient Knee. Am J Sports Med 2016;44:345-54; with permission.Figure 2: (A) 1: Patella, 2: Quadriceps tendon, 3:lateral femoral condyle, 4: anterior cruciate ligament (ACL), 5: lateral meniscus, 6: caspulo-osseous layer of the iliotibial band, 7: tibial insertion site of the capsulo-osseous layer 8: Gerdy?s tubercle. (B) The ACL and the capsulo-osseous layer of the ITB form a sling around the lateral femoral condyle. From Vieira EL, Vieira EA, da Silva RT, et al. An anatomic study of the iliotibial tract. Arthroscopy 2007;23:269-74; with permission.Figure 3: Segond fracture (anterior-posterior radiograph). Figure 4: Contribution of the anterolateral structures in controlling a 5 Nm internal rotation torque at 0°, 30°, 60°, and 90° knee flexion. Cross-hatched areas indicate results from the ACL-deficient knee (n=8). Together the superficial fibres (sITT) and the deep fibres (dcITT) of the iliotibial tract present the primary restraint to internal rotation at 30°- 90° flexion. Conversely, the anterolateral ligament (ALL) and the anterolateral capsule (Cap) show a non-significant contribution in restraining internal rotation. Medial collateral ligament (MCL; n=4); posteromedial capsule (PMC; n=4). From Kittl C, El-Daou H, Athwal KK, et al. The Role of the Anterolateral Structures and the ACL in Controlling Laxity of the Intact and ACL-Deficient Knee. Am J Sports Med 2016;44:345-54; with permission.References: ADDIN EN.REFLIST 1.Hughston J, Andrews J, Cross M, Moschi A. Classification of knee ligament instabilities. Part II. The lateral compartment. J Bone Jt Surg (Am) 1976;58:173-9.2.Lie DT, Bull AM, Amis AA. Persistence of the mini pivot shift after anatomically placed anterior cruciate ligament reconstruction. Clin Orthop Relat Res 2007;457:203-209.3.Harner CD, Honkamp NJ, Ranawat AS. Anteromedial portal technique for creating the anterior cruciate ligament femoral tunnel. 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