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Regarding “Anterolateral Ligament of the Knee, Fact or Fiction?”

      We are in total agreement with Lubowitz et al.
      • Lubowitz J.H.
      • Provencher M.T.
      • Rossi M.J.
      • Brand J.C.
      News you can use: The knee anterolateral ligament and the ISAKOS journal.
      and read with interest that the anterolateral ligament (ALL) is considered fictional by some authors. Musahl et al.
      • Musahl V.
      • Rahnemai-Azar A.A.
      • van Eck C.F.
      • Guenther D.
      • Fu F.H.
      Anterolateral ligament of the knee, fact or fiction?.
      state that in anatomic and radiologic evaluation, a “thickening” of the anterolateral capsule was identified in only 30% of patients. They also consider that ALL reconstruction is unable to restore rotational stability
      • Spencer L.
      • Burkhart T.A.
      • Tran M.N.
      • et al.
      Biomechanical analysis of simulated clinical testing and reconstruction of the anterolateral ligament of the knee.
      and may result in overconstraint.
      • LaPrade R.F.
      Editorial commentary: Defining the anatomy of the anterolateral aspect of the knee among experts is clearly needed.
      Much of this dissent arises from ongoing confusion regarding the anatomy of the ALL, and it is clear that a consensus should be sought.
      • LaPrade R.F.
      Editorial commentary: Defining the anatomy of the anterolateral aspect of the knee among experts is clearly needed.
      To do so, it is important to share our experience of dissection. We consider that this can be difficult and almost impossible when one starts from the femoral insertion. However, when following the “Daggett protocol,” the ALL can be identified in all cases.
      • Daggett M.
      • Busch K.
      • Sonnery-Cottet B.
      Surgical dissection of the anterolateral ligament.
      This also seems to be the case from a radiologic perspective with several recent publications showing that the ALL can be clearly identified on magnetic resonance imaging in the majority of patients.

      Coquart B, Corroller TL, Laurent PE, et al. Anterolateral ligament of the knee: Myth or reality? [published online March 2, 2016]. Surg Radiol Anat. doi:10.1007/s00276-016-1657-2.

      • Taneja A.K.
      • Miranda F.C.
      • Braga C.A.
      • et al.
      MRI features of the anterolateral ligament of the knee.
      • Helito C.P.
      • Helito P.V.
      • Costa H.P.
      • et al.
      MRI evaluation of the anterolateral ligament of the knee: Assessment in routine 1.5-T scans.
      It is an error to state that ALL reconstruction is unable to restore rotational stability on the basis of the cited study because the authors evaluated a single-strand tape reconstruction fixed distal to the lateral epicondyle.
      • Taneja A.K.
      • Miranda F.C.
      • Braga C.A.
      • et al.
      MRI features of the anterolateral ligament of the knee.
      Recent literature has shown that the femoral origin is in fact proximal and posterior to the epicondyle
      • Daggett M.
      • Ockuly A.C.
      • Cullen M.
      • et al.
      Femoral origin of the anterolateral ligament: An anatomic analysis.
      • Kennedy M.I.
      • Claes S.
      • Fuso F.A.
      • et al.
      The anterolateral ligament: An anatomic, radiographic, and biomechanical analysis.
      (Fig 1) and that this is the optimal location for a reconstruction in order to reproduce the biomechanical function of the native ALL, which is tight in extension and lax in flexion.

      Imbert P, Lutz C, Daggett M, et al. Isometric characteristics of the anterolateral ligament of the knee: A cadaveric navigation study [published online May 4, 2016]. Arthroscopy. doi:10.1016/j.arthro.2016.02.007.

      Figure thumbnail gr1
      Fig 1(A) An anteroposterior radiograph of the right knee shows a large Segond fracture (circle) in a patient undergoing open reduction and internal fixation with concomitant anterior cruciate ligament reconstruction. (B, C) The photographs show that the structure that overlaps the lateral collateral ligament (LCL) and has a broad attachment to the bony avulsion is the anterolateral ligament (ALL) identified during previous dissections.
      • Daggett M.
      • Busch K.
      • Sonnery-Cottet B.
      Surgical dissection of the anterolateral ligament.
      (ITB, iliotibial band.)
      Figure 1 is also important in addressing the point raised by Musahl et al.
      • Musahl V.
      • Rahnemai-Azar A.A.
      • van Eck C.F.
      • Guenther D.
      • Fu F.H.
      Anterolateral ligament of the knee, fact or fiction?.
      that the Segond fracture, which has been suggested as the bony equivalent of an ALL rupture, has not been linked to increased rotational laxity. We believe that the clinical photograph of a large Segond fracture in a patient undergoing anterior cruciate ligament (ACL) reconstruction clearly shows that this rotational injury is a bony avulsion of the ALL (as it corresponds exactly with our surgical dissection of the ALL).
      The final point to make is that we do not believe the concerns raised about overconstraint of the knee are valid if anatomic reconstruction is performed and the graft is fixed in full extension and neutral rotation.

      Imbert P, Lutz C, Daggett M, et al. Isometric characteristics of the anterolateral ligament of the knee: A cadaveric navigation study [published online May 4, 2016]. Arthroscopy. doi:10.1016/j.arthro.2016.02.007.

      In our published experience of 92 combined ACL and ALL reconstructions, with 2 years' follow-up, there has been no clinical evidence of overconstraint (no stiffness and no reoperations to cut a tight ALL). In addition, we report a very low ACL graft failure rate of only 1.1%.
      • Sonnery-Cottet B.
      • Thaunat M.
      • Freychet B.
      • et al.
      Outcome of a combined anterior cruciate ligament and anterolateral ligament reconstruction technique with a minimum 2-year follow-up.
      The best answer to this ongoing controversy is our clinical results, which are very promising on retrospective study. Such results strongly suggest that the ALL is not fiction and that there is an urgent need to start a prospective randomized study to confirm this.

      References

        • Lubowitz J.H.
        • Provencher M.T.
        • Rossi M.J.
        • Brand J.C.
        News you can use: The knee anterolateral ligament and the ISAKOS journal.
        Arthroscopy. 2016; 32: 727-728
        • Musahl V.
        • Rahnemai-Azar A.A.
        • van Eck C.F.
        • Guenther D.
        • Fu F.H.
        Anterolateral ligament of the knee, fact or fiction?.
        Knee Surg Sports Traumatol Arthrosc. 2016; 24: 2-3
        • Spencer L.
        • Burkhart T.A.
        • Tran M.N.
        • et al.
        Biomechanical analysis of simulated clinical testing and reconstruction of the anterolateral ligament of the knee.
        Am J Sports Med. 2015; 43: 2189-2197
        • LaPrade R.F.
        Editorial commentary: Defining the anatomy of the anterolateral aspect of the knee among experts is clearly needed.
        Arthroscopy. 2016; 32: 842-843
        • Daggett M.
        • Busch K.
        • Sonnery-Cottet B.
        Surgical dissection of the anterolateral ligament.
        Arthrosc Tech. 2016; 5: e185-e188
      1. Coquart B, Corroller TL, Laurent PE, et al. Anterolateral ligament of the knee: Myth or reality? [published online March 2, 2016]. Surg Radiol Anat. doi:10.1007/s00276-016-1657-2.

        • Taneja A.K.
        • Miranda F.C.
        • Braga C.A.
        • et al.
        MRI features of the anterolateral ligament of the knee.
        Skeletal Radiol. 2015; 44: 403-410
        • Helito C.P.
        • Helito P.V.
        • Costa H.P.
        • et al.
        MRI evaluation of the anterolateral ligament of the knee: Assessment in routine 1.5-T scans.
        Skeletal Radiol. 2014; 43: 1421-1427
        • Daggett M.
        • Ockuly A.C.
        • Cullen M.
        • et al.
        Femoral origin of the anterolateral ligament: An anatomic analysis.
        Arthroscopy. 2016; 32: 835-841
        • Kennedy M.I.
        • Claes S.
        • Fuso F.A.
        • et al.
        The anterolateral ligament: An anatomic, radiographic, and biomechanical analysis.
        Am J Sports Med. 2015; 43: 1606-1615
      2. Imbert P, Lutz C, Daggett M, et al. Isometric characteristics of the anterolateral ligament of the knee: A cadaveric navigation study [published online May 4, 2016]. Arthroscopy. doi:10.1016/j.arthro.2016.02.007.

        • Sonnery-Cottet B.
        • Thaunat M.
        • Freychet B.
        • et al.
        Outcome of a combined anterior cruciate ligament and anterolateral ligament reconstruction technique with a minimum 2-year follow-up.
        Am J Sports Med. 2015; 43: 1598-1605

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      • Authors' Reply
        ArthroscopyVol. 32Issue 9
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          We thank Sonnery-Cottet et al. for raising points in their letter to the editor, giving us the opportunity for much needed clarification of confusing statements for the reader of both journals—Arthroscopy and Knee Surgery, Sports Traumatology, Arthroscopy—regarding the anterolateral complex of the knee. The main points raised are consistent identification of the anterolateral ligament (ALL), the role of the anterolateral complex in restoring rotational knee stability, and overconstraint. We would also like to congratulate Sonnery-Cottet et al.
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