Title: Biomechanical study of strength and stiffness of the knee anterolateral ligament

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1 Reviewer s report Title: Biomechanical study of strength and stiffness of the knee anterolateral ligament Version: 0 Date: 08 Nov 2015 Reviewer: JO Smith Reviewer's report: This is an interesting study that although in part replicates existing knowledge, does go towards corroborating the findings of prior studies (not all of which are mentioned in this manuscript). The field of interest is currently quite narrow, although this may increase in the future if the ALL and its reconstruction gains further recognition. Substantial modifications and improvements of the paper appear to have been undertaken in light of the previous reviewers' comments, however there are several areas that should undergo further revision before the paper should be accepted: Abstract: Line 4. Please clarify the line 'The importance of this ligament is related to its possible association with the anterior cruciate ligament (ACL) reconstruction cases that do not progress satisfactorily'. Do you mean 'The potential clinical importance of this ligament is exemplified by the minority of patients with combined ACL and ALL rupture who do not progress satisfactorily following isolated ACL reconstruction'? Line Please clarify the sentence 'Biomechanical parameters of the ALL, such as its resistance, regarding possible reconstruction have been evaluated with conflitant results'. Do you mean 'Previous biomechanical studies have assessed the resistance parameters of the ALL in order to inform potential reconstruction strategies, however these have reported conflicting results.'?

2 Line 10. Do you mean 'conflicting results'? Line 23. check spelling of 'aligned' Introduction: Line 4-5. 'more detail' compared to what? Suggest remove 'more' unless an appropriate comparator is included. Line 7. I would suggest the structures have actions in relation to knee stability, not instability, as described. Line 7-8. The relevance of combined ACL/ALL failure should be explained in a little more detail, as per my suggestion in the abstract. Line 11. Suggest amending 'Initially, anatomical and histological studies were performed, which confirmed...' to 'Initial anatomical and histological studies have confirmed...' or similar Line 16: Suggest amending '...tissue, followed by studies consisting of imaging examinations of the ALL' to '...tissue. These findings have been corroborated by imaging studies of the ALL...' or similar Line It would be interesting to note exactly where you found the landmarks to be in each cadaver you examined in the study, or perhaps note in the discussion which authors you agree with regarding the contentious issue of femoral origin. You have eluded to this in the results, but can you be more specific with exact dimensions, ranges, means? Line 18. Change 'bee' to 'been'

3 Line 22. Change 'fibullar' to 'fibular' Line 22. Change 'in details a meniscus attachment on' to 'in detail a meniscal attachment at' Line 29. Check spelling of 'length' Line 33. I would suggest the ALL is important for rotatory stability, as distinct from 'anterolateral stability' mentioned Line 34. Inconsistent use of '.' after 'et al' cf lines 26 and 31 for example. Line 36. Please clarify 'Despite this two biomechanical studies have used a similar methodology, the results found were completely different and these parameters are important for creating an adequate reconstruction technique regarding both the graft and the fixation method to be used'. Suggest 'Despite using similar methods, two biomechanical studies have reported substantially differing resistance characteristics of the ALL. This poses difficulty in creating appropriate reconstruction techniques that rely on such studies to define both the graft and fixation...' Line 42. Change 'aim' to 'aims' Methods: Line Please add into the discussion why male knees were used exclusively. Is this in common with other studies? How would you expect results to change in female knees? Line knees is a good number when compared to previous similar studies, but was a power study carried out to confirm statistical validity? Line 7. Change 'them reflected' to 'then reflected' Line 7. Change 'deatached' to 'detached'

4 Line 9. Change 'fibullar' to 'fibular' Line 14. Change 'specially' to 'especially' Line 53. Change 'alingned' to 'aligned' Line 51. Please clarify ' The test was performed with the knee in around 30 to 40 degrees of flexion, in a way that the ALL was alingned with the machine. (Figure 2)'. Do you mean that each knee was tested at a different amount of flexion which corresponded to the position at which the ALL was aligned? As the ALL has rather indistinct boundaries, how can you be certain that your method of dissection removed all tissue except the ALL, but removed none of the ALL itself? Results: Line 8. Change 'it's' to 'its' Line 8. Exactly how did the attachment relate to these landmarks for each cadaver? Was it a broad or narrow attachment. Was it easy to define the edge of the ligament? Line 14. Check spelling of epicondyle Line 16. Check spelling of 'fibular' Line 28. The absolute deformation length is noted, but what is this value as a proportion of the ALL total length in your cadavers, and how does this relate to other ligaments about the knee?

5 Discussion: Please consider including a discussion of the large range of results you got. Why was it so variable between patients? Was there any other characteristic to the specimen that may have predicted a particularly high or low result? Line 55. Suggest 'resist' of 'reduce' as an alternative to 'diminish' Line 57. Please amend 'are not anatomical based on the ALL anatomy' to either 'are not anatomical.' or 'are not based on the ALL anatomy.' Line 2-3. Please clarify 'other medial and lateral peripheral structures of the knee'. Do you mean just ligamentous and tendinous structures? Line 13. Suggest amend 'peripheral structures' to 'collateral structures' to clarify exclusion of the MPFL in this sentence. Line 13. Amend 'what suggests' to 'which suggests' Lines 14 and 16. Check spelling of structure and structures Line 24. Check typing of 'length' Line 27. Change 'presented failure' to 'failed' Line Please amend 'Even though the specimens ages differed among the three studies (Zens et al years, Kennedy et al years, this study ), the differences maximun load

6 at failure found can not be credited because of that, as suggeted by Zens et al, as this study found a higher age and a higher value for the ALL strenght than Kennedy et al.' to remove typos and make it easier to read. Line 55. Change 'compartiment' to 'compartment' and 'decriber' to 'described' You do not give evidence that thawed fresh-frozen cadaveric material behaves biomechanically in the same way as tissue in vivo. If there is no evidence, this should be stated as an assumption you have made for the study. Line 37. See my previous comment re. anterolateral knee stability cf rotational stability. Line 45. Why was it not possible to test rotational strength? Other limitations are that only males were used, and the ages were older than the patients we often see clinically with such instability. Conclusion: Line 65. Please clarify what you mean by 'resistance' in this line, presumably ultimate tensile strength? Line 1-4. Consider changing the sentence to 'This suggests that simple bands of all autologous or homologous grafts commonly used in clinical practice for ligament reconstruction around the knee possess the required biomechanical resistance characteristics for ALL reconstruction.' or similar. Figure Legends: Line 51. Check typing of 'fibular' Line 55. Check typing of 'Figure'

7 It is unfortunate that the original figure showing force-displacement has been completely removed. I have not seen the original figure, but such a graph would complement the study and consideration should be made to re-instating the reworked figure. Are the methods appropriate and well described? If not, please specify what is required in your comments to the authors. No Does the work include the necessary controls? If not, please specify which controls are required in your comments to the authors. Yes Are the conclusions drawn adequately supported by the data shown? If not, please explain in your comments to the authors. Yes Are you able to assess any statistics in the manuscript or would you recommend an additional statistical review? If an additional statistical review is recommended, please specify what aspects require further assessment in your comments to the editors. Not relevant to this manuscript Quality of written English Please indicate the quality of language in the manuscript: Needs some language corrections before being published Declaration of competing interests Please complete a declaration of competing interests, considering the following questions: 1. Have you in the past five years received reimbursements, fees, funding, or salary from an organisation that may in any way gain or lose financially from the publication of this manuscript, either now or in the future? 2. Do you hold any stocks or shares in an organisation that may in any way gain or lose financially from the publication of this manuscript, either now or in the future?

8 3. Do you hold or are you currently applying for any patents relating to the content of the manuscript? 4. Have you received reimbursements, fees, funding, or salary from an organization that holds or has applied for patents relating to the content of the manuscript? 5. Do you have any other financial competing interests? 6. Do you have any non-financial competing interests in relation to this paper? If you can answer no to all of the above, write 'I declare that I have no competing interests' below. If your reply is yes to any, please give details below. I declare that I have no competing interests I agree to the open peer review policy of the journal. I understand that my name will be included on my report to the authors and, if the manuscript is accepted for publication, my named report including any attachments I upload will be posted on the website along with the authors' responses. I agree for my report to be made available under an Open Access Creative Commons CC-BY license ( I understand that any comments which I do not wish to be included in my named report can be included as confidential comments to the editors, which will not be published. I agree to the open peer review policy of the journal

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