Correlation between ACL injury and involvement of the anterolateral ligament A retrospective study by Prof. Dr. Hesham N. Mustafa

S P E C I A L F O C U S

Sports Medicine Correlation between ACL injury and involvement of the anterolateral ligament: A retrospective study Downloaded from https://journals.lww.com/c-orthopaedicpractice by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3iopPs8eUYyrcmCnINBANu4vhZE/A2mRJUWriZTa6KCY= on 12/29/2019

Adel Hegaze, MDa, Khalid Khashoggi, MDb, Mohammed Alsayyad, MDa, Rawan Haﬁz, MDb, Abdulraof Alqrache, MDc and Hesham N. Mustafa, MDd a

Orthopedic Department, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia Radiology Department, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia c Clinical Biochemistry Department, Faculty of Medicine – Rabigh, King Abdulaziz University, Jeddah, Saudi Arabia d Anatomy Department, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia b

ABSTRACT Background: Clinical testing has demonstrated the role of the anterolateral ligament (ALL) in controlling anterolateral laxity and knee instability at high angles of flexion. Few studies have discussed the association between an anterior cruciate ligament (ACL) injury and ALL injury, specifically after residual internal rotation and a post-ACL reconstruction positive pivot-shift that could be attributed to ALL injury. The goal of this study was to assess the correlation between ALL injury and ALL injury with concomitant ACL injury using MRI. Material and Methods: This was a retrospective study of 246 patients with unilateral ACL knee injuries from a database that was reexamined to identify whether ALL injuries occurred in association with ACL injuries. We excluded the postoperative reconstructed cases. The charts were reviewed on the basis of the presence or absence of diagnosed ACL injury with no regard for age or sex. Results: Of the 246 patients with ACL injury, there were 165 (67.1%) patients with complete tears, 55 (22.4%) with partial tears, and 26 (10.6%) with sprains. There were 176 (71.5%) patients with ALL and associated ACL injuries, whereas 70 (28.5%) did not have associated ACL injuries. There was a significant statistical relationship between ACL and ALL injuries (P < 0.0001). Conclusions: There is high incidence of ALL tears associated with ACL injuries. Clinicians should be aware of this injury and consider the possibility of simultaneous ALL and ACL repair to prevent further knee instability. Level of Evidence: Level IV. Financial Disclosure: The authors report no conﬂicts of interest. Correspondence to Hesham N. Mustafa, MD, Anatomy Department, Faculty of Medicine, King Abdulaziz University, Jeddah 21589, Saudi Arabia Tel: +966566764762; fax: +0096612 640 0000-20123; e-mail: hesham977@gmail.com. 1941-7551 Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

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Key Words knee, anterolateral ligament ALL, anterior cruciate ligament ACL, MRI, injury, reconstruction

INTRODUCTION

ecently, many studies have been conducted after the publication by Claes et al.1 who described the anterolateral ligament (ALL). The ALL has been anatomically and biomechanically described as a lateral knee structure that provides effective rotatory stability of the knee, specifically controlling pivot shift.1–3 Proximally, the ALL attaches at a location that is adjacent to the lateral collateral ligament (LCL), and distally it attaches to the proximal portion of the tibia approximately halfway between Gerdy’s tubercle and the fibular head.1,2,4,5 Although the tensile properties of the ALL have been quantified,5 the in situ biomechanical function is not well understood.6 It is known that the iliotibial band and the soft tissues comprising the mediolateral capsule together resist rotational moments and anterior loads. It has been theorized that the ALL may be an important stabilizer to prevent the pivot-shift phenomenon.1 Radiographic studies of the ALL have become important for the identification of radiographic femoral and tibial landmarks, which are essential for biomechanical studies and ligamentous reconstruction.4,7–9 MRI has been used to visualize the ALL in many studies. Coquart et al.10 concluded that the ALL can be identified using routine 1.5 T MRI. Other studies also have confirmed that MRI can be used to identify the ALL.11,12 Studies using MRI for detection of ALL injuries occurring concomitantly with other knee injuries were conducted in cases of Segond fractures 13 and ACL injuries.14,15 The findings of these studies showed that ALL injuries can be identified with these other injuries.16 One study recommended performing MRI examinations of the knee within 6 wk after surgery to increase the rate of detection of ALL injuries in ACL-injured knees.16 There were two studies demonstrating that MRI alone was not reliable for detecting simultaneous ALL and ACL injuries.3,6 Arthroscopic and cadaver identifications of the ALL also have been made.17,18 Arthroscopy showed the existence of the Current Orthopaedic Practice

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ligament and that this method of assessment could be beneficial in extraarticular knee reconstructions. There are very few ultrasound studies that have detected ALL with promising results.19,20 Most portions of the ALL, including the femoral, meniscal, and tibial portions, as well as their relationship with other ALL complexes, can be identified using ultrasonography (US). As most ALL injuries occur at the femoral or tibial portion of the ligament, US may be useful as a diagnostic tool in ALL injuries.21 A recent study showed that US was superior to MRI for viewing ALL injuries.22 Many biomechanical studies have been conducted to try to identify the role of the ALL in promoting knee stability and preventing internal rotation. Other biomechanical studies have shown that the anatomical position of the ALL, which lies in an oblique direction with an anterior insertion, tends to resist internal rotation. Most studies showed that the function of the ALL affects internal rotational stability during flexion. Some concluded that the angle of flexion was greater than 35 degrees.5 Studies detecting the true role of the ALL in preventing internal rotation showed that 15% to 30% of ACL reconstructions had residual deficiencies of internal rotation stability and that pivot shifts were persistent.23–25 Many studies have focused on the relationship between the ACL and the ALL with respect to internal rotation control. Double-bundle ACL biomechanical studies showed that the anteromedial (AM) bundle provided resistance to anterior tibial translation but the posterolateral (PL) ligament had no role in resisting internal rotation.26 Meanwhile, other studies concluded that the PL functions primarily to resist internal rotation when the knee is extended.27 These findings led to a debate whether the double-bundle or the single-bundle ACL reconstruction would be the superior procedure for ACL repair.28 The residual internal rotation laxity and pivot shift after ACL reconstruction showed that lateral repairs must be combined with ACL repairs in the presence of high pivot shifts. Studies in cadaver human knees in which internal rotation torque and simulated pivot-shift tests were conducted provided evidence of the role of the ALL in maintaining rotational stability after sectioning of the ACL alone or in combination with the ALL. Combined sectioning of the ACL and ALL resulted in a significant increase in internal rotation when compared to the intact and ACL-deficient states. Additional sectioning of the ALL increased the level of internal rotation in comparison to the ACLdeficient state.29 Meanwhile, other studies showed that the ALL is not the main functional element needed for maintaining rotational stability because after sectioning the ACL, the rotational stability and pivot shift are elicited in the presence of an intact ALL and iliotibial band. Therefore, the authors concluded that each ligament alone is not a primary restraint, but that they all function together as anterolateral secondary restraints and that the components of the anterolateral complex of the knee act synergistically to provide rotatory knee stability.30,31 However, the recommendation to perform ALL reconstructions to correct pivotshift abnormalities has been questioned.25,32,33 Some studies have advocated for combined reconstruction of both the ACL and ALL as an effective procedure with minimal complications,25,34,35 whereas others have shown that lateral extraarticular tendinosis is effective for governing anterior and rotational laxity.36 It has also been reported that the reoperation rate after a combined ACL and ALL reconstruction is comparable

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to the reoperation rate after an isolated ACL repair.35 In addition, some studies have advised lateral tendinosis during revision after ACL failure to supplement intraarticular graft revision, thus minimizing the potential for internal rotational instability.36 Although ALL is related to Segond fractures, a recent study concluded that it is not necessary to reconstruct or repair Segond fractures at the time of a primary repair of the ACL with no early ACL graft failure.37 Based on these reports of the ALL and its role in knee stability, our study goal was to determine whether there is an association between ACL and ALL injuries by retrospectively reviewing the MRI studies of patients with ACL and ALL injuries. Examination of the ALL with the injured ACL will increase the successful repair of both ligaments and reduce the possibility of postoperative knee instability.

MATERIALS AND METHODS Ethical Review and Study Design This retrospective study was approved by the Unit of Biomedical Ethics at King Abdulaziz University (approval no. 587-17) and informed consent requirements were waived due to the retrospective nature of the study.

Data Collection This retrospective study focused on patients who were diagnosed with ACL injuries before any surgical intervention. The data were collected from the hospital’s image retrieval system in the radiology department. The evaluation was performed by one consulting musculoskeletal radiologist (MD FRCP[C] ABR). The variables of interest included: age, sex, presence of ACL tear, presence of ALL injury, and Segond fracture. Other associated injuries were not included because our study was focused on detecting ALL injury, which is not routinely reported. ACL tears were categorized as complete, partial, or sprain, depending on whether there was a complete or partial interruption of the ligament ﬁbers or an abnormal signal intensity, respectively. Patients who had knee MRIs from 2012 to 2015 with ACL injuries were included in the study. We excluded patients who had an injured ACL after reconstruction.

Imaging MRI was obtained in 178 patients (72.4%) 4 wk after injury, while 45 patients (18.3%) had an MRI at 6 wk, and the remaining 23 (9.3%) between 7 and 8 wk. All patients were imaged on a 1.5-T Symphony system (Siemens Medical Solutions, Erlangen, Germany), or 3-T Verio system (Siemens Medical Solutions, Erlangen, Germany), or 3-T Skyra system (Siemens Medical Solutions, Erlangen, Germany). All examinations included at least the following sequences: axial fast or turbo spin-echo proton density-weighted sequence; coronal fast or turbo spin-echo proton density and T2-weighted sequences; and either sagittal conventional spin-echo proton density- and T2-weighted and fast or turbo spin-echo T2-weighted sequences or sagittal fast or turbo spin-echo proton density- and T2-weighted sequences. Additional sequences included T1-weighted and T1- or T2-weighted gradientrecalled echo sequences. All fast and turbo spin-echo sequences were fat suppressed.

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TABLE 1. Patient sex Valid

TABLE 3. Anterolateral ligament

Frequency

Percent

Valid percent

Cumulative percent

221 25 246

89.8 10.2 100.0

89.8 100.0

Male Female Total

Statistical Analysis The study data were analyzed using IBM SPSS version 24 (IBM Corp, Armonk, NY, USA). Simple descriptive statistics were used to deﬁne the characteristics of the study variables using counts and percentages for the categorical and nominal variables, and mean and standard deviations for the continuous variables. The chi-square test was used to identify relationships between normally distributed categorical variables. A conventional P-value <0.05 was considered statistically signiﬁcant.

RESULTS We included a total of 246 patients with unilateral ACL tears. Our population ranged in age from 15 to 77 yr, with a mean ± SD of 31 ± 12.5 yr. There were 221 (89.8%) men and 25 (10.2%) women with ACL tears in our patient population. The tears were divided into complete, partial, and strain/ sprain, with frequencies (percentages) of 165 (67.1%), 55 (22.4%), and 26 (10.6%), respectively. The ALL was visualized in all patients. Of those with a torn ACL, 176 (71.5%) had an injured ALL, whereas 70 (28.5%) were found to have an intact ALL. We found a significant relationship between ACL and ALL injuries with a P value of <0.0001 (Tables 1–3). With respect to the demographics, there was a significant statistical correlation between age and sex, with the ACL tears being more common in men younger than 50 yr of age (P = 0.001, age; P = 0.002, sex). However, we did not find a significant relationship between ALL tears and the age or sex of the study patients. An association between ACL tears (Figure 1B) and ALL tears was identified at different sites along the course of the ALL. The proximal tear is shown in Figure 1A, and the complete tear is also identified alone and in association with the ACL tear in Figure 2A and B, respectively. The anatomy of the ALL and its relationship with the lateral knee structures were clearly identified. The femoral origin, direction, and meniscofemoral component; its relationship with lateral meniscus; and the tibial insertion were clearly identified with respect to the ALL (Figure 3A through F).

TABLE 2. Anterior cruciate ligament Valid Complete tear Partial tear Strain/sprain Total

Frequency

Percent

Valid percent

Cumulative percent

165 55 26 246

67.1 22.4 10.6 100.0

67.1 89.4 100.0

Valid Injured Intact Total

Frequency

Percent

Valid percent

Cumulative percent

176 70 246

71.5 28.5 100.0

71.5 100.0

Segond fractures were present in only 2 (0.01%) of the patients (Figure 4A through D), and there was no concomitant ALL tear in these patients. There were other associated injuries in the 176 cases of combined ACL and ALL. Injuries of menisci, bone, and collateral ligaments were assessed (Table 4). Twenty-nine (16.4%) patients had lateral meniscal injury, and 87 patients (49.4%) had medial meniscal injury. Bone injuries were found in the form of bone edema in nine patients (5.1%) and subluxation of the patella in eight patients. Meanwhile, collateral injuries were seen in ﬁve patients (2.8%), the lateral collateral ligament in 12 patients (6.8%) with injuries to the medial side.

DISCUSSION In our study, we retrospectively evaluated patients with ACL tears before any surgical intervention. Our results showed that the ALL could be identified in all 246 patients. Among the patients with a torn ACL, 176 (71.5%) had coexisting ALL injuries, whereas 70 (28.5%) had intact ALL, which nearly agrees with the findings of Claes et al.1,38 who reported that 78.8% of patients had coexisting ALL injuries. Meanwhile, Segond fracture was not frequently associated with ACL injury, regardless of the presence or absence of ALL injury. In a study of the ALL, Claes et al.1,38,39 used MRI to identify the ligament as well as to identify an association between ACL and ALL injuries. That study found that 78.8% of MRIs showed ALL injuries, whereas 21.2% were normal.38,39 Rossi20 found that of the simultaneous ALL and ACL injuries identified on MRI, ALL was identified in all patients. They also showed that there was no correlation between instability and the degree of ALL injury, which indicated that the ALL plays a minor role in knee stability.38,39 Other studies showed that the ALL can be identified on MRI and it is attached to the Segond fracture fragment.13 Meanwhile, a study of the ALL using routine 1.5-T MRI scans to detect all parts of the ligament revealed that it could be at least partially visualized in 97.8% of patients and entirely observed in 71.7% of patients.7,14 A similar study using 1.5-T MRI reported visualization of all parts of the ALL ligament as a distinct structure.15 In an MRI study that retrospectively reviewed patients’ preoperative data prior to torn ACL repair using standard 1.5 T MRI to evaluate for concomitant ALL tears revealed that ALL was identified in 100% of patients. However, they were unable to identify whether the ALLs were intact or torn.40 A similar study showed that MRI alone was not reliable for the diagnosis of ALL tears with concomitant ACL injuries;41 however, another study con-

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FIGURE 1. A, Coronal proton density with fat saturation image in a 35-year-old male patient with a tear in the proximal portion of the anterolateral ligament (arrow) and a partial thickness tear of the medial collateral ligament (arrowhead). B, Sagittal proton density with fat saturation image showing a complete fullthickness tear of the anterior cruciate ligament (arrow).

cluded that ALL injuries were more often identified if MRI was performed at 6 wk or more after the injury.11 Recently, there was a study that revealed that the ALL is visible on MRI using 1.5-T and that ALL tears are related to ACL tears.12 In recent years, combined ACL and ALL reconstruction has begun to increase. Sonnery-Cottet et al.17,42,43 underwent 92 combined reconstruction operations with better results in terms of knee stability without specific complications at 2-year follow-up. Mogos et al.44 in a prospective study of 32 patients concluded that combined ACL and ALL reconstruction is an effective surgical procedure, with improved postoperative clinical results and no significant short-term complications. Schon, et al.45 concluded that ALL repair in conjunction ACL repair reduce rotatory laxity. Sonnery-Cottet et al.42,43 in their prospective study of 502

patients advised that combined reconstruction of the ACL by hamstring tendon and ALL decreases the graft failure. They also provided an overview of the latest research of the ALL expert group on the ALL reconstruction, concluding that recognition and repair of ALL lesions should be considered to improve the control of rotational stability provided by ACL reconstruction. All these studies were short-term studies and advised for long-term follow-up to better evaluate the results of this procedure.

CONCLUSIONS ALL injuries are strongly correlated with ACL tears and are visible on MRI in adult patients. This high association between ACL and ALL injuries should alert clinicians to

FIGURE 2. A, A coronal proton density (TR = 3180, TE = 33) image with fat saturation in a 24-year-old man showing a complete tear of the anterolateral ligament (arrows). B, A sagittal proton density (TR = 3180, TE = 33) image with fat saturation in the same patient showing a complete tear of the anterior cruciate ligament (arrow).

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FIGURE 3. Proton density-weighted, fat-suppressed MRI of the knee (sequentially through the knee, from proximal to distal). The corresponding localizers represent slice levels between the axial and coronal images. Axial (A) and coronal (B) images, above the level of the ALL, showing the femoral origin of the fibular collateral ligament (grey arrow) and the iliotibial band (white arrow). Axial (C) and coronal (D) images show the anterolateral ligament (blue arrows) arising anteriorly from the fibular collateral ligament (grey arrow) continue anterior oblique, deep to the iliotibial band (white arrow), and proximal to the lateral meniscus. The coronal image shows the meniscofemoral component merging with the body of the lateral meniscus. Axial (E) and coronal (F) images showing the anterolateral ligament (blue arrow) at the tibial insertion site, near the insertion of the iliotibial band (white arrow) and Gerdy’s tubercle.

FIGURE 4. A 26-year-old man with an ACL tear. A, Coronal proton density fat-saturated weighted image shows complete tear of the anterior cruciate ligament (green arrow). B, Axial proton density fat-saturated weighted image shows the iliotibial band (white arrow), fibular collateral ligament (grey), and intermediate bright signal intensity of the anterolateral ligament (blue arrow). C, Segond fracture on radiograph (arrow). D, Corresponding T1-weighted images (arrow) of Segon fracture.

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TABLE 4. Injuries associated with anterior cruciate ligament (ACL) and anterolateral ligament (ALL) injuries Associated injuries Menisci Bone injuries Collaterals

Affection Lateral Medial Both Bone edema Subluxation of the Patella Lateral Medial Both

Number/176 (%) 29 87 0 9 8

(16.4) (49.4) (0) (5.1) (4.5)

5 (2.8) 12 (6.8) 0 (0)

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knees with standard 1.5-Tesla magnetic resonance imaging. Arthroscopy. 2016; 32:2061–2065. Devitt BM, O’Sullivan R, Feller JA, et al. MRI is not reliable in diagnosing of concomitant anterolateral ligament and anterior cruciate ligament injuries of the knee. Knee Surg Sports Traumatol Arthrosc. 2017; 25:1345–1351. Sonnery-Cottet B, Saithna A, Cavalier M, et al. Anterolateral ligament reconstruction is associated with significantly reduced ACL graft rupture rates at a minimum follow-up of 2 years: a prospective comparative study of 502 patients from the SANTI study group. Am J Sports Med. 2017; 45:1547–1557. Sonnery-Cottet B, Daggett M, Fayard JM, et al. Anterolateral ligament expert group consensus paper on the management of internal rotation and instability of the anterior cruciate ligament deficient knee. J Orthop Traumatol. 2017; 18:91–106. Mogos S, Sendrea B, Stoica IC. Combined anatomic anterior cruciate ligament and anterolateral ligament reconstruction. Maedica. 2017; 12:30–35. Schon JM, Moatshe G, Brady AW, et al. Anatomic anterolateral ligament reconstruction leads to overconstraint at any fixation angle: response. Am J Sports Med. 2016; 44:NP58–NP59.