Synergistic effect of the anterolateral ligament and capsule injuries on the knee laxity in anterior cruciate ligament injured knees: A cadaveric study

Introduction: There is much controversy about the practical role of the anterolateral ligament (ALL) and its relation to other anterolateral knee structures including the anterolateral capsule (ALC) and iliotibial band (ITB). The purpose of this cadaveric study was to investigate the effect of the ALL and ALC injuries on knee laxity with the iliotibial band (ITB) preserved in the anterior cruciate ligament (ACL)-injured knee. Hypothesis: The ALL and ALC would contribute to knee joint stability during anterior translation and internal rotation of the tibia in an ACL-injured knee. Material and methods: For 10 fresh-frozen cadaveric knees, we measured knee laxity with the following state of knee injuries with ITB preserved: (1) intact knee, (2) ACL-sectioned knee (ACL-), (3) additional sectioning of the ALL (ACL-/ALL-), and (4) additional sectioning of the ALC (ACL-/ALL-/ALC-). We did biomechanical measurements in internal-external rotation, anterior-posterior translation, and varus-valgus angulation for each condition at knee flexion angles of 0°, 30°, 60°, and 90°. Results: After we sectioned the ALL (ACL-/ALL-), the mean IR at 0°, 30°, 60°, and 90° of knee flexion were significantly increased, compared to the intact knee (p = < 0.001, < 0.001, < 0.001, and 0.002) and ACL- (p = < 0.001, < 0.001, < 0.001, and 0.002). The additional transection of the ALC (ACL-/ALL-/ALC-) significantly increased IR laxity from the ACL-/ALL- at 30°, 60°, and 90° (p = 0.005, 0.003, and 0.047). For anterior laxity, ACL-/ALL- resulted in significantly increased anterior laxity from the ACL- at 30° and 60° (p = 0.003 and 0.019), and ACL-/ALL-/ALC- significantly increased anterior laxity even from the ACL-/ALL- at 30° and 60° (p = 0.007 and 0.011). For varus laxity, ACL-/ALL- resulted in significantly increased varus laxity from both the intact knee and ACL- at 60° (p = 0.004 and 0.007) and 90° (p = < 0.001 and < 0.001). ACL-/ALL-/ALC- resulted in significantly increased varus from ACL-/ALL- at 60° and 90° (p = < 0.001 and 0.003). Conclusion: The anterolateral ligament and anterolateral capsule injuries in ACL-injured knees even with ITB preserved had a synergistic effect on knee laxity in the aspects of internal rotation, anterior translation, and varus angulation. Level of evidence: II, Controlled laboratory study.