Contribution of the anterolateral complex to rotational stability of the knee: a biomechanical analysis

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1 THOMAS NERI 1,4* Dane Dabirrahmani 2 Aaron Beach 1 Samuel Grasso 1 Sven Putnis 1 Takeshi Oshima 1 Joseph Cadman 2 Brian Devitt 3 Myles Coolican 1 Brett Fritsch 1 Richard Appleyard 2 David Parker 1 1 Sydney Orthopaedic Research Institute, Sydney, Australia 2 Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia 3 OrthoSport Victoria, Melbourne, Australia 4 Inter-university Laboratory of Human Movement Science, EA 7424, Univ Lyon, France Contribution of the anterolateral complex to rotational stability of the knee: a biomechanical analysis Page 1

2 Declaration of Interest I declare that in the past three years I have: held shares in: no received royalties from: no done consulting work for: no given paid presentations for: no received institutional support from: no Signed: Thomas Neri

3 Introduction & aims The individual functions of the extra-articular structures of the anterolateral complex (ALC) 1 including the anterolateral ligament (ALL) 2, the anterolateral capsule, and the iliotibial band Kaplan fibres 3, in the setting of the anterior cruciate ligament (ACL) deficient knee, are still controversial and unclear 4,5. Their potential individual contribution to the residual anterolateral rotational laxity after an isolated ACLR requires furthers investigation, Objective: evaluate the contribution of ALC injury, and specific injuries to its individual anatomical components, to rotational instability in ACL-deficient knees. Page 3

4 Method Specimen preparation A total of 10 cadaveric knees (5 half body) dissection protocol previously published 6 without damaging the lateral structures Page 4

5 Method Experimental set-up Protocol prevously validated 7 3D optoelectronic system: Motion Analysis, 5 HD cameras complete knee kinematic analyses Page 5

6 Method Experimental set-up Bone markers (tibia and femur) 8,9 Every knee had a CT scan before the assessment to do a 3D modelling -> bone and joint landmarks 10 Page 6

7 Method Experimental set-up Kinematics: Extension to 90 of flexion By controlling the rotation (IR, NR, ER) with a Dynamometric torque rig -> 5 Nm Page 7

8 Method Data Acquisition For each parameters: 3 series of 3 repetitions Data analysed: 11,12 Kinematic from 0 to 90 of flexion in forced internal rotation (IR) AP translation at 30 and 90 of flexion (anterior tibial load = 90 Nm) Page 8

9 Method Conditions of testing 1 Intact knee 2 - ACL section Proximal KF section 3A - ALC section (ALL+Anterolateral capsule) Testing was first performed in ACL-intact. After ACL sectioning, sectioning was randomly performed for the ALC anatomical components, either ALL plus anterolateral capsule or Kaplan fibres (distal and proximal) The kinematics motion relating to each procedure was compared to the intact knee. 3B - Proximal + Distal Kaplan Fibres section Page 9

10 Results Internal Rotation (IR) conditions ACL section ALC (ALL+ AL capsule) section Kaplan fibres section Effect (compare to intact) tibial IR (P<0.05) tibial IR (P<0.05) tibial IR (P<0.05) At 30 of flexion ALL-capsule sectioning led to significantly greater internal rotation when compared with Kaplan fibres sectioning. At higher flexion angles (50 to 90 ), the effect of Kaplan fibres sectioning on increased internal rotation was greater than ALL-capsule sectioning. Page 10

11 Results AP translation P>0.05 =No additional effect Of ALC or KF section P<0.001 ACLprimary stabilizer Page 11

12 Conclusion ALC: Additional IR control in the ACL deficient knee -> At 30 of flexion +++ No control of anterior tibial translation Kaplan Fibres - Additional IR control in the ACL deficient knee -> after 50 of flexion No control of anterior tibial translation By highlighting the increased rotational knee laxity with combined ACL and anterolateral complex knee injuries, these findings suggest that these extra articular injuries should be taken into account when managing patient with ACL deficient knee, with consideration given to addressing the injuries to these structures as well as the intra-articular reconstruction 13,14,15,16. Page 12

13 References 1. Getgood A, Brown C, Lording T, Amis A, Claes S, Geeslin A, Musahl V, ALC Consensus Group (2018) The anterolateral complex of the knee: results from the International ALC Consensus Group Meeting. Knee Surg Sports Traumatol Arthrosc. doi: /s Claes S, Vereecke E, Maes M, Victor J, Verdonk P, Bellemans J (2013) Anatomy of the anterolateral ligament of the knee. J Anat 223: doi: /joa Amis AA (2017) Anterolateral knee biomechanics. Knee Surg Sports Traumatol Arthrosc 25: doi: /s x 4. Guenther D, Griffith C, Lesniak B, Lopomo N, Grassi A, Zaffagnini S, Fu FH, Musahl V (2015) Anterolateral rotatory instability of the knee. Knee Surg Sports Traumatol Arthrosc 23: doi: /s Rezende FC, de Moraes VY, Martimbianco ALC, Luzo MV, da Silveira Franciozi CE, Belloti JC (2015) Does Combined Intra- and Extraarticular ACL Reconstruction Improve Function and Stability? A Meta-analysis. Clin Orthop Relat Res 473: doi: /s y 6. Neri T, Palpacuer F, Testa R, Bergandi F, Boyer B, Farizon F, Philippot R (2017) The anterolateral ligament: Anatomic implications for its reconstruction. Knee. doi: /j.knee Neri T, Testa R, Laurendon L, Dehon M, Putnis S, Grasso S, Parker DA, Farizon F, Philippot R (2019) Determining the change in length of the anterolateral ligament during knee motion: A three-dimensional optoelectronic analysis. Clin Biomech (Bristol, Avon) 62: doi: /j.clinbiomech Grood ES, Suntay WJ (1983) A joint coordinate system for the clinical description of three-dimensional motions: application to the knee. J Biomech Eng 105: Wu G, Siegler S, Allard P, Kirtley C, Leardini A, Rosenbaum D, Whittle M, D Lima DD, Cristofolini L, Witte H, Schmid O, Stokes I, Standardization and Terminology Committee of the International Society of Biomechanics (2002) ISB recommendation on definitions of joint coordinate system of various joints for the reporting of human joint motion--part I: ankle, hip, and spine. International Society of Biomechanics. J Biomech 35: Grasso S, Linklater J, Li Q, Parker DA (2018) Validation of an MRI Protocol for Routine Quantitative Assessment of Tunnel Position in Anterior Cruciate Ligament Reconstruction. Am J Sports Med 46: doi: / Pezzack JC, Norman RW, Winter DA (1977) An assessment of derivative determining techniques used for motion analysis. J Biomech 10: Winter DA, Sidwall HG, Hobson DA (1974) Measurement and reduction of noise in kinematics of locomotion. J Biomech 7: Sonnery-Cottet B, Thaunat M, Freychet B, Pupim BHB, Murphy CG, Claes S (2015) Outcome of a Combined Anterior Cruciate Ligament and Anterolateral Ligament Reconstruction Technique With a Minimum 2-Year Follow-up. Am J Sports Med 43: doi: / Thaunat M, Clowez G, Saithna A, Cavalier M, Choudja E, Vieira TD, Fayard J-M, Sonnery-Cottet B (2017) Reoperation Rates After Combined Anterior Cruciate Ligament and Anterolateral Ligament Reconstruction: A Series of 548 Patients From the SANTI Study Group With a Minimum Follow-up of 2 Years. Am J Sports Med doi: / Geeslin AG, Moatshe G, Chahla J, Kruckeberg BM, Muckenhirn KJ, Dornan GJ, Coggins A, Brady AW, Getgood AM, Godin JA, LaPrade RF (2018) Anterolateral Knee Extra-articular Stabilizers: A Robotic Study Comparing Anterolateral Ligament Reconstruction and Modified Lemaire Lateral Extra-articular Tenodesis. Am J Sports Med 46: doi: / Samuelson M, Draganich LF, Zhou X, Krumins P, Reider B (1996) The effects of knee reconstruction on combined anterior cruciate ligament and anterolateral capsular deficiencies. Am J Sports Med 24: doi: / Page 13