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Participação do Dr Cesar Martins como formador de opinião, no site de pesquisa www.researchgate.net, o qual reúne os expoentes da cirurgia do joelho no mundo. O questionamento foi sobre o método de reconstrução do ligamento anterolateral do joelho associado à reconstrução do ligamento cruzado anterior do joelho. Para ler as opiniões dos outros pesquisadores, o leitor deverá se cadastrar no referido site.

Question: What is your opinion on the relevance of the "Anterolateral Ligament - ALL" and its relevance for rotational stability of the knee?
By Philipp Niemeyer
Prof. Dr. med.
Orthopedic Surgeon
University of Freiburg · Department of Orthopedics and Traumatology. Germany.

Answer by: Cesar A Q Martins, M.D.
University of Passo Fundo, Brazil.
Human Movement Institute, Passo Fundo, Brazil.

“Nothing New on the front”
We have to congratulate Dr. Claes for bringing into focus different aspects of the anterior cruciate ligament (ACL) reconstruction associated to anterior lateral capsule reconstruction of the knee as well, despite all the stir created around the findings of anterior lateral ligament (ALL).
The first known author to publish about that structure was Dr Paul Segond in 1879, who described based on cadaveric dissections (Segond. Progres Med, 1879) entitled Recherches cliniques et expérimentales sur les épanchements sanguins du genou par entorse. After Dr Segond’s findings, many others have presented anterior lateral capsule bone avulsion to nearly 100% of the cases associated to ACL tears, which is said to be pathognomonic of ACL ruptures.

Many authors have presented in the literature techniques for anterior lateral reconstruction of the knee capsule with clinical results (Lemaire, Rev. Chir., 1967; MacIntosh et al. JBJS, 1972; Kostuik, JBJS, 1977; Kennedy, Stewart and Walker, JBJS, 1978; Losee, Johnson and Soutwick, JBJS, 1978; Ellison, JBJS, 1979; Arnold et al., AJSM, 1979; Fox et al., CORR, 1980; Ireland and Trickey, JBJS, 1980; Teitge et al., AJSM, 1980; Lemaire and Combelle, Rev. Chir. Orthop., 1980; Clancy et al. JBJS, 1982; Fleming, Blatz and McCarroll, AJSM, 1983; Lemaire, Rev. Chir. Orthop., 1983).
More recently, Claes and colleagues (Journal of Anatomy, 2013) presented their version of the facts. We still have to accept the statements of our colleagues from Belgium because things like that make us grow in understanding and developing new and improved techniques in Medicine.
Perhaps one can say in the future that ALL reconstruction is not reliable and reproducible or does not bring any improvement to ACLR. Just the time will answer that question. Basic and clinical studies have to be conducted before one say that the technique presented is not feasible.
In my opinion, Dr Claes is talking about a mid-third anterior lateral capsule thickening as proposed by Hughstone et al. in1976, just as we talk about medial patelofemoral ligament which is a wide spread technique in the world and not a real “new” ligament or posterior oblique ligament as one of the semimembranosus expansions on the medial posterior corner of the knee. Nevertheless, techniques for these “ligaments” do exist and they play an important role on the surgical armamentarium.

A ligament is called to be a fibrous tissue connecting structures not depending on human body part.  It is important to mention “the articular system (arthrology ) consists of joints and their associated ligaments, connecting the bony parts of the skeletal system and providing the sites at which movements occur”(Clinically Oriented Anatomy 6th ed. pg 3, 2010). It is well known that we have a fibrous tissue bands linking subcutaneous tissue to deep layer of the dermis, the so-called ligament retinacula cutis (Clinically Oriented Anatomy 6th ed. pg 13, 2010) and so on.

I am not stating that we have to or we do not have to reconstruct anterior lateral capsule. Literature will clarify that to all of us. Regarding anterior lateral capsule tears it is important to recognize the mechanism of trauma as far as it is known that Segond’s fracture occurs during a varus stress of the knee, however just a few patients present that mechanism after sprains. Therefore, is the anterior tibial stress strong enough for a knee to end in tear like that? Should we do extra articular procedures for pivot 2+ or 3+? Can association of both structures (extra articular plus ACR) decrease the frequency of ACL revision cases?

 I am not stating that we have to or we do not have to reconstruct anterior lateral capsule. Literature will clarify that to all of us.

Figure and legend retrieved from “Claes et al., Anatomy of the anterolateral ligament of the knee, Journal of Anatomy. 2013.”

Fig. 1 Lateral view of a typical right knee during dissection. With the ITB reflected, the ALL fibers are clearly distinguishable from the thin anterolateral joint capsule anterior to it. ALL, anterolateral ligament; LCL, lateral collateral ligament; LFE, lateral femoral epicondyle; BFT, biceps femoris tendon; FH, fibular head; JC, joint capsule.