High Prevalence of Anterolateral Ligament Abnormalities on MRI in Knees With Acute Anterior Cruciate Ligament Injuries. A Case-Control Series From the SANTI Study Group

Background: Broad variation in the reported rate of magnetic resonance imaging (MRI)–detected abnormalities of the anterolateral structures of the anterior cruciate ligament (ACL)–injured knee suggests a lack of reliability that has limited the use of MRI in clinical decision making. Purpose/Hypothesis: The aim of this study was to use MRI to determine the prevalence and spectrum of abnormalities of the anterolateral structures in acute ACL-injured knees, using the contralateral uninjured knee as a reference. We hypothesized that MRI evaluation of the acutely injured knee (using the uninjured knee as a reference) would allow reliable identification of abnormalities of the anterolateral structures. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: Patients with acute ACL injury underwent MRI scan of both knees. Images were evaluated by 3 observers. Inter- and intraobserver reliabilities were determined for MRI parameters of anterolateral ligament (ALL) injury by use of the kappa (κ) test. Univariate and multivariate analyses were conducted to test associations between ALL abnormality and associated injuries. Results: A total of 34 patients were evaluated. Of these, 30 patients (88.2%) had at least 1 ALL abnormality in the ACL-injured knee (increased signal: n = 27[79.4%]; increased thickness: n = 15[44.1%]; tapering: n = 7[20.6%]; irregularities in the path of the ALL fibers: n = 21[61.7%]). Asymmetries of the genicular vessels were observed in 21 patients (61.7%). ALL abnormality was significantly associated with lateral joint capsular tears (P <.001). No correlation was found between ALL lesions and iliotibial band lesions (P =.49). Inter- and intraobserver reliabilities were very good concerning ALL signal changes and femoral and tibial bone bruises (κ coefficient, 0.81-1). Conclusion: MRI evaluation of the ALL was associated with good and very good inter- and intraobserver reliabilities, and it demonstrated abnormalities of the ALL in the majority of acutely ACL-injured knees. The index of suspicion for ALL injury should be elevated by the presence of lesions of the lateral capsule. This suggests that the ALL is part of a wider area of the lateral capsule that is often injured simultaneously in an acute ACL tear

High prevalence of anterolateral ligament abnormalities on MRI in knees with acute anterior cruciate ligament injuries: a case-control series from the SANTI study group

Background: Broad variation in the reported rate of magnetic resonance imaging (MRI)–detected abnormalities of the anterolateral structures of the anterior cruciate ligament (ACL)–injured knee suggests a lack of reliability that has limited the use of MRI in clinical decision making. Purpose/Hypothesis: The aim of this study was to use MRI to determine the prevalence and spectrum of abnormalities of the anterolateral structures in acute ACL-injured knees, using the contralateral uninjured knee as a reference. We hypothesized that MRI evaluation of the acutely injured knee (using the uninjured knee as a reference) would allow reliable identification of abnormalities of the anterolateral structures. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: Patients with acute ACL injury underwent MRI scan of both knees. Images were evaluated by 3 observers. Inter- and intraobserver reliabilities were determined for MRI parameters of anterolateral ligament (ALL) injury by use of the kappa (κ) test. Univariate and multivariate analyses were conducted to test associations between ALL abnormality and associated injuries. Results: A total of 34 patients were evaluated. Of these, 30 patients (88.2%) had at least 1 ALL abnormality in the ACL-injured knee (increased signal: n = 27[79.4%]; increased thickness: n = 15[44.1%]; tapering: n = 7[20.6%]; irregularities in the path of the ALL fibers: n = 21[61.7%]). Asymmetries of the genicular vessels were observed in 21 patients (61.7%). ALL abnormality was significantly associated with lateral joint capsular tears (P < .001). No correlation was found between ALL lesions and iliotibial band lesions (P = .49). Inter- and intraobserver reliabilities were very good concerning ALL signal changes and femoral and tibial bone bruises (κ coefficient, 0.81-1). Conclusion: MRI evaluation of the ALL was associated with good and very good inter- and intraobserver reliabilities, and it demonstrated abnormalities of the ALL in the majority of acutely ACL-injured knees. The index of suspicion for ALL injury should be elevated by the presence of lesions of the lateral capsule. This suggests that the ALL is part of a wider area of the lateral capsule that is often injured simultaneously in an acute ACL tear

Correlation between magnetic resonance imaging and surgical exploration of the anterolateral structures of the acutely anterior cruciate ligament injured knee

Background: Combined Anterior Cruciate Ligament (ACL) and Anterolateral ligament (ALL) reconstruction is associated with improved clinical outcomes compared to isolated intra-articular reconstruction but the indications are not precisely defined. It may be the case that patients with proven anterolateral injury on pre-operative imaging are most likely to benefit but the accuracy of MRI is not known. Hypothesis/Purpose: To evaluate the correlation between MRI findings and intra-operative anterolateral compartment exploration in acute ACL injured knees. The study hypothesis was that a positive correlation would be identified between imaging and surgical findings for injuries to the ALL/capsule and the iliotibial band and that pre-operative MRI would be associated with high sensitivity, specificity and accuracy for these parameters. Study Design: Case Series. Methods: Between January 2016 to May 2016 patients presenting with an acute ACL injury were considered for study eligibility. A sample size calculation determined the numbers enrolled. Included patients underwent 1.5T MRI and this was evaluated by three investigators who attributed a Ferretti grade of injury to the anterolateral structures. At the time of ACL reconstruction, a lateral exploration was undertaken and macroscopic injuries were identified, classified and repaired. An evaluation of correlation between MRI and surgical exploration findings was performed. Results: 26 patients participated in the study. 96% had an ALL/capsule injury. The sensitivity, specificity and accuracy of MRI in the evaluation of ALL/capsule injury, when using surgical exploration as a gold standard were 88%, 100% and 88.5% respectively. For evaluation of iliotibial band injury these values were 62.5%, 40% and 50%. The percentage agreement between MRI and surgical findings for ALL/capsule injury was 88% but only 65% for the ITB. The sensitivity and specificity of MRI for complete or partial tear of ALL and capsule were 78.6 and 41.7 respectively. The k test for correlation between surgical and MRI findigs was 0.27 for ITB abnormalities, 0.47 for ALL/capsule abnormalities, 0.23 for ALL/capsule determination of partial or complete tear and 0.49 for ALL/capsule determination of anterior or posterior tear. The overall percentage agreement between MRI and the classification based on surgical findings was only 53% and the Altman classification of kappa was fair. This suggests that whilst the classification is useful for description of surgical findings the grade cannot be reliably established from MRI, at least with the parameters used in the current study. Conclusion: Surgical exploration demonstrates that injuries occur to the anterolateral structures in almost all acute ACL injured knees. Pre-operative MRI is highly sensitive, specific and accurate, for detection of abnormalities of the ALL/capsule and shows a high percentage of agreement with surgical findings. In contrast MRI has low sensitivity, specificity, and accuracy for the diagnosis of ITB injury. The agreement between MRI and surgical exploration with respect to ITB abnormality and determination of whether ALL/capsular tears were partial or complete was only fair

The anterolateral ligament of the knee: unwrapping the enigma. Anatomical study and comparison to previous reports.

It has been suggested that the anterolateral ligament (ALL) of the knee may have importance in limiting rotational instability, and reconstruction may prevent a continued pivot-shift following anterior cruciate ligament surgery. However, the anatomy of this ligament has not been consistently reported in recent publications. We describe our experience of cadaveric dissection with reference to other published work.This article is freely available via Open Access. Click on the 'Additional Link' above to access the full-text from the publisher's site.Published (Open Access

Anterolateral Ligament Expert Group consensus paper on the management of internal rotation and instability of the anterior cruciate ligament - deficient knee

Purpose of this paper is to provide an overview of the latest research on the anterolateral ligament (ALL) and present the consensus of the ALL Expert Group on the anatomy, radiographic landmarks, biomechanics, clinical and radiographic diagnosis, lesion classification, surgical technique and clinical outcomes. A consensus on controversial subjects surrounding the ALL and anterolateral knee instability has been established based on the opinion of experts, the latest publications on the subject and an exchange of experiences during the ALL Experts Meeting (November 2015, Lyon, France). The ALL is found deep to the iliotibial band. The femoral origin is just posterior and proximal to the lateral epicondyle; the tibial attachment is 21.6 mm posterior to Gerdy's tubercle and 4-10 mm below the tibial joint line. On a lateral radiographic view the femoral origin is located in the postero-inferior quadrant and the tibial attachment is close to the centre of the proximal tibial plateau. Favourable isometry of an ALL reconstruction is seen when the femoral position is proximal and posterior to the lateral epicondyle, with the ALL being tight upon extension and lax upon flexion. The ALL can be visualised on ultrasound, or on T2-weighted coronal MRI scans with proton density fat-suppressed evaluation. The ALL injury is associated with a Segond fracture, and often occurs in conjunction with acute anterior cruciate ligament (ACL) injury. Recognition and repair of the ALL lesions should be considered to improve the control of rotational stability provided by ACL reconstruction. For high-risk patients, a combined ACL and ALL reconstruction improves rotational control and reduces the rate of re-rupture, without increased postoperative complication rates compared to ACL-only reconstruction. In conclusion this paper provides a contemporary consensus on all studied features of the ALL. The findings warrant future research in order to further test these early observations, with the ultimate goal of improving the long-term outcomes of ACL-injured patients. Level of evidence Level V-Expert opinion

Poor Sleep quality and health-related quality of life impact in adolescents with and without chronic immunosuppressive conditions during COVID-19 quarantine

OBJECTIVE: To assess the possible factors that influence sleep quality in adolescents with and without chronic immunosuppressive conditions quarantined during the coronavirus disease 2019 (COVID-19) pandemic. METHODS: This cross-sectional study included 305 adolescents with chronic immunocompromised conditions and 82 healthy adolescents. Online surveys were completed, which included questions on socio-demographic data and self-rated healthcare routine during COVID-19 quarantine and the following validated questionnaires: the Pittsburgh Sleep Quality Index (PSQI), Pediatric Quality of Life Inventory 4.0 (PedsQL4.0), and Pediatric Outcome Data Collection Instrument (PODCI). RESULTS: The median current age [14 (10-18)&nbsp;vs. 15 (10-18) years,&nbsp;p=0.847] and frequency of female sex (62%&nbsp;vs. 58%,&nbsp;p=0.571) were similar in adolescents with chronic conditions compared with healthy adolescents. The frequency of poor sleep quality was similar in both groups (38%&nbsp;vs. 48%,&nbsp;p=0.118). Logistic regression analysis, including both healthy adolescents and adolescents with chronic conditions (n=387), demonstrated that self-reported increase in screen time (odds ratio [OR] 3.0; 95% confidence interval [CI] 1.3-6.8;&nbsp;p=0.008) and intrafamilial violence report (OR 2.1; 95% CI 1.2-3.5;&nbsp;p=0.008) were independently associated with poor sleep quality in these adolescents. However, the PODCI global function score was associated with a lower OR for poor sleep quality (OR 0.97; 95% CI 0.94-0.99;&nbsp;p=0.001). Further logistic regression, including only adolescents with chronic conditions (n=305), demonstrated that self-reported increase in screen time (OR 3.1; 95% CI 1.4-6.8;&nbsp;p=0.006) and intrafamilial violence report (OR 2.0; 95% CI 1.2-3.4;&nbsp;p=0.011) remained independently associated with poor quality of sleep, whereas a lower PODCI global function score was associated with a lower OR for sleep quality (OR 0.96; 95% CI 0.94-0.98;&nbsp;p&lt;0.001). CONCLUSION: Self-reported increases in screen time and intrafamilial violence report impacted sleep quality in both healthy adolescents and those with chronic conditions. Decreased health-related quality of life was observed in adolescents with poor sleep quality

Anatomic and histological study of the anterolateral aspect of the knee: a SANTI Group investigation

Background: The structure and function of the anterolateral aspect of the knee have been significantly debated, with renewed interest in this topic since the description of the anterolateral ligament (ALL). Purpose: To define and describe the distinct structures of the lateral knee and to correlate the macroscopic and histologic anatomic features. Study Design: Descriptive laboratory study. Methods: Twelve fresh-frozen human cadavers were used for anatomic analysis. In the left knee, a layer-by-layer dissection and macroscopic analysis were performed. In the right knee, an en bloc specimen was obtained encompassing an area from the Gerdy tubercle to the posterior fibular head and extending proximally from the anterior aspect to the posterior aspect of the lateral femoral epicondyle. The en bloc resection was then frozen, sliced at the level of the joint line, and reviewed by a musculoskeletal pathologist. Results: Macroscopically, the lateral knee has 4 main layers overlying the capsule of the knee: the aponeurotic layer, the superficial layer including the iliotibial band (ITB), the deep fascial layer, and the ALL. Histologically, 8 of 12 specimens demonstrated 4 consistent, distinct structures: the ITB, the ALL, the lateral collateral ligament, and the meniscus. Conclusion: The lateral knee has a complex orientation of layers and fibers. The ALL is a distinct structure from the ITB and is synonymous to the previously described capsulo-osseous layer of the ITB. Clinical Relevance: Increasingly, lateral extra-articular procedures are performed at the time of anterior cruciate ligament reconstruction. Understanding the anatomic features of the anterolateral aspect of the knee is necessary to understand the biomechanics and function of the structures present and allows surgeons to attempt to replicate those anatomic characteristics when performing extra-articular reconstruction

Emotional, hyperactivity and inattention problems in adolescents with immunocompromising chronic diseases during the COVID-19 pandemic

Objective: To assess factors associated with emotional changes and Hyperactivity/Inattention (HI) motivated by COVID-19 quarantine in adolescents with immunocompromising diseases. Methods: A cross-sectional study included&nbsp;343&nbsp;adolescents with immunocompromising diseases and 108&nbsp;healthy adolescents. Online questionnaires were answered including socio-demographic data and self-rated healthcare routine during COVID-19 quarantine and validated surveys: Strengths and Difficulties Questionnaire (SDQ), Pittsburgh Sleep Quality Index (PSQI), Pediatric Quality of Life Inventory 4.0 (PedsQL4.0). Results: The frequencies of abnormal emotional SDQ scores from adolescents with chronic diseases were similar to those of healthy subjects (110/343&nbsp;[32%] vs.&nbsp;38/108 [35%], p&nbsp;=&nbsp;0.548), as well as abnormal hyperactivity/inattention SDQ scores (79/343 [23%] vs.&nbsp;29/108 [27%], p&nbsp;=&nbsp;0.417). Logistic regression analysis of independent variables associated with abnormal emotional scores from adolescents with chronic diseases showed: female sex (Odds Ratio [OR&nbsp;=&nbsp;3.76]; 95%&nbsp;Confidence Interval (95%&nbsp;CI) 2.00‒7.05; p &lt; 0.001), poor sleep quality (OR&nbsp;=&nbsp;2.05; 95%&nbsp;CI&nbsp;1.08‒3.88; p&nbsp;=&nbsp;0.028) and intrafamilial violence during pandemic (OR&nbsp;=&nbsp;2.17; 95%&nbsp;CI&nbsp;1.12‒4.19; p&nbsp;=&nbsp;0.021) as independently associated with abnormal emotional scores, whereas total PedsQL score was inversely associated with abnormal emotional scores (OR&nbsp;=&nbsp;0.95; 95%&nbsp;CI&nbsp;0.93‒0.96; p &lt; 0.0001). Logistic regression analysis associated with abnormal HI scores from patients evidenced that total PedsQL score (OR&nbsp;=&nbsp;0.97; 95%&nbsp;CI&nbsp;0.95‒0.99; p&nbsp;=&nbsp;0.010], changes in medical appointments during the pandemic (OR&nbsp;=&nbsp;0.39; 95%&nbsp;CI&nbsp;0.19-0.79; p&nbsp;=&nbsp;0.021), and reliable COVID-19 information (OR&nbsp;=&nbsp;0.35; 95%&nbsp;CI&nbsp;0.16‒0.77; p&nbsp;=&nbsp;0.026) remained inversely associated with abnormal HI scores. Conclusion: The present study showed emotional and HI disturbances in adolescents with chronic immunosuppressive diseases during the COVID-19 pandemic. It reinforces the need to promptly implement a longitudinal program to protect the mental health of adolescents with and without chronic illnesses during future pandemics