Rotational Knee Instability in ACL-Deficient Knees: Role of the Anterolateral Ligament and Iliotibial Band as Defined by Tibiofemoral Compartment Translations and Rotations

Background: The anterolateral ligament (ALL) has been proposed as a primary restraint for knee rotational stability. However, the data remain inconclusive. The purpose of this study was to determine the effect of the ALL and the iliotibial band (ITB) on knee rotational stability. Methods: A 6-degrees-of-freedom robotic simulator was used to test 14 fresh-frozen cadaveric knee specimens. There were 4 testing conditions: intact, anterior cruciate ligament (ACL)-sectioned, ACL and ALL or ITB-sectioned (determined at random), and ACL and both ALL and ITB-sectioned. Lateral, central, and medial tibiofemoral compartment translations and internal tibial rotations were measured under 100-N anterior drawer (Lachman), 5-Nm internal rotation torque, and 2 pivot-shift simulations (Pivot Shift 1 was 5 Nm of internal rotation torque, and Pivot Shift 2 was 1 Nm of internal rotation torque). Statistical equivalence within 2 mm and 2° was defined as p < 0.05. Results: Sectioning the ACL alone produced increased pivot shift and Lachman compartment translations (p > 0.05). Further sectioning of either the ALL or the ITB separately produced minor added increases in pivot-shift compartment translations and tibial internal rotations (<2 mm or <3°) in the ACL-deficient knee. Sectioning both the ALL and ITB produced increases not equivalent to the ACL-deficient knee in pivot-shift lateral compartment translations (4.4 mm; 95% confidence interval [CI], 2.7 to 6.1 mm [p = 0.99] for Pivot Shift 1 and 4.3 mm; 95% CI, 2.6 to 6.0 mm [p = 0.99] for Pivot Shift 2), with 10 of 14 knees being converted to a corresponding Grade-3 pivot-shift (>20 mm of lateral translation). Increases in internal rotation after ALL and ITB sectioning occurred at 25°, 60°, and 90° (p = 0.99 for all) and ranged from 1° to 12°, with 21% of the knees having 8° to 12° increases. Conclusions: With ACL sectioning, a positive pivot-shift anterior subluxation occurred even with intact ALL and ITB structures, which indicates that the latter are not primary restraints but function together as anterolateral secondary restraints. With ACL deficiency, concurrent loss of the ALL and ITB resulted in conversion in a majority of knees (71%) to a Grade-3 pivot-shift subluxation, along with major increases of internal rotation in select knees. Clinical Relevance: With ACL rupture, major increases in rotational instability are not adequately resisted by native ALL or ITB structures. Therefore, anatomic ALL or ITB surgical reconstruction would not block a positive pivot shift. The potential protective effects of ACL graft-unloading from these structures require further study.