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Identification of Normal and Injured Anterolateral Ligaments of the Knee: A Systematic Review of Magnetic Resonance Imaging Studies

  • Renato Andrade
    Affiliations
    Clínica do Dragão, Espregueira-Mendes Sports Centre–FIFA Medical Centre of Excellence, Porto, Portugal

    Dom Henrique Research Centre, Porto, Portugal

    Faculty of Sports, University of Porto, Porto, Portugal
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  • Alexandre Rebelo-Marques
    Affiliations
    Clínica do Dragão, Espregueira-Mendes Sports Centre–FIFA Medical Centre of Excellence, Porto, Portugal

    Dom Henrique Research Centre, Porto, Portugal

    Faculty of Medicine, University of Coimbra, Coimbra, Portugal

    Instituto de Investigação Clínica e Biomédica de Coimbra (iCBR), Coimbra, Portugal
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  • Ricardo Bastos
    Affiliations
    Clínica do Dragão, Espregueira-Mendes Sports Centre–FIFA Medical Centre of Excellence, Porto, Portugal

    Dom Henrique Research Centre, Porto, Portugal

    Fluminense Federal University, Niteroi, Brazil
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  • Stefano Zaffagnini
    Affiliations
    Rizzoli Orthopaedic Institute, University of Bologna, Bologna, Italy

    Second Orthopaedic and Traumatology Clinic, Rizzoli Orthopaedic Institute, Bologna, Italy
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  • Romain Seil
    Affiliations
    Département de l’Appareil Locomoteur, Centre Hospitalier de Luxemburg, Luxembourg, Luxembourg

    Sports Medicine Research Laboratory, Luxembourg Institute of Health, Luxembourg, Luxembourg
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  • Olufemi R. Ayeni
    Affiliations
    Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
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  • João Espregueira-Mendes
    Correspondence
    Address correspondence to João Espregueira-Mendes, M.D., Ph.D., Clínica do Dragão, Espregueira-Mendes Sports Centre–FIFA Medical Centre of Excellence, Via Futebol Clube do Porto, F. C. Porto Stadium, Porto, Portugal.
    Affiliations
    Clínica do Dragão, Espregueira-Mendes Sports Centre–FIFA Medical Centre of Excellence, Porto, Portugal

    Dom Henrique Research Centre, Porto, Portugal

    Orthopaedics Department of Minho University, Minho, Portugal

    3B's Research Group–Biomaterials, Biodegradables and Biomimetics, University of Minho, Headquarters of the European Institute of Excellence on Tissue Engineering and Regenerative Medicine, AvePark, Parque de Ciência e Tecnologia, Zona Industrial da Gandra, Barco, Portugal

    ICVS/3B's–PT Government Associate Laboratory, Braga, Portugal
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      Purpose

      To identify the normal and injured magnetic resonance imaging appearance of the anterolateral ligament (ALL).

      Methods

      A systematic review was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The PubMed and Cochrane Library electronic databases were used to search for studies that reported the imaging outcomes of the appearance of the ALL. Two authors performed the searches in duplicate up to April 30, 2018, and interobserver agreement was calculated. The methodologic quality of included articles was assessed using an adaptation of the Arrivé methodologic quality scale for clinical studies of radiologic examinations.

      Results

      From the original 270 records, a total of 24 studies (κ = 0.94) comprising 2,427 knees in 2,388 patients (mean age, 33.3 years; 66% male patients; 63% with anterior cruciate ligament [ACL] injury) were included. The ALL appeared in 51% to 100% of all assessed knees (71%-100% in ACL-injured knees and 64%-97% in uninjured knees) and was injured in 11% to 79% of ACL-injured knees. Reliability rates varied considerably (0.04-1.0 for intraobserver and 0.143-1.0 for interobserver agreement), and the entire portion of the ligament was often not seen. The tibial insertion was seen in 21% to 96% of cases, followed by the meniscal (range, 0%-100%) and femoral (range, 0%-90%) insertions. The mean methodologic quality score was 5.1 ± 1.8 out of a possible score of 9.

      Conclusions

      High variability was found in the identification of normal and injured ALL definition methods and the respective magnetic resonance imaging findings. Reliability rates varied considerably, and the entire portion of the ligament was often not seen.

      Level of Evidence

      Level IV, systematic review of Level II to IV studies.
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      Linked Article

      • Regarding “Identification of Normal and Injured Anterolateral Ligaments of the Knee: A Systematic Review of Magnetic Resonance Imaging Studies”
        ArthroscopyVol. 35Issue 8
        • Preview
          We would like to commend the authors of the article “Identification of Normal and Injured Anterolateral Ligaments of the Knee: A Systematic Review of Magnetic Resonance Imaging Studies.”1 We completely agree with the main findings, which were that the literature up until April 2018 (the end date of the literature search) reported high variability in the rates of identification of the anterolateral ligament (ALL), and also the rates of injury in anterior cruciate ligament (ACL)-deficient knees. Andrade et al.
        • Full-Text
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      • Editorial Commentary: Magnetic Resonance Imaging of the Knee Anterolateral Ligament: Does It Really Matter?
        ArthroscopyVol. 35Issue 5
        • Preview
          Great interest remains in the structures of the knee anterolateral complex and how they work synergistically with the anterior cruciate ligament to control anterolateral rotatory laxity. Many studies have now used magnetic resonance imaging to assess the degree of damage to the anterolateral ligament. The systematic review described in this commentary rigorously highlights the many deficiencies that exist within our current understanding of the imaging analysis of these structures. Marked variability in the definition of anterolateral ligament injury, significant methodological differences, and the lack of a gold standard reference make it very challenging to translate the findings of these imaging studies into clinical practice.
        • Full-Text
        • PDF