LIVRE JDG 2016

C. LUTZ, B. SONNERY-COTTET, M. DAGGETT, P. IMBERT

iliotibial tract layer (Kaplan’s fibers) attached

to the lateral intermuscular septum.

Once the ITB is reflected, an internal rotational

force is applied between 30 and 60° of flexion

of the knee to tighten the ALL as well as the

antero-lateral capsule (fig. 2a). This internal

rotation is absolutely essential to identify the

ALL: in neutral rotation, its relief can disappear

within the capsular thickness (fig. 2b). Once

this area is exposed, isolation of the lateral

collateral ligament (LCL) and the popliteus

tendon is carried out. The LCL is isolated by

applying varus stress and then dissected from

its distal insertion onto the head of the fibula to

its femoral insertion onto the lateral femoral

epicondyle (fig. 3). Care is taken to not incise

fibers overlapping the ALL.

Evaluation of the ALL physical characteristics

is then possible: the origin is determined by

placing tension on its proximal fibers; if

visualization of this origin is difficult because

of a confusion between proximal fibers from

the ALL and the LCL, these 2 structures can be

cut midbody and separated to see where the

main body of each structures is attached to the

lateral epicondyle, as recommended by

S. Caterine [1]. Identification of the tibial

insertion is done by placing tension on its distal

fibers. Measurement of length, width and

thickness complete this anatomical evaluation.

During the dissection, connections with

surrounding structures are also analyzed: ITB,

lateral meniscus, antero-lateral capsule.

ANATOMICAL

CHARACTERISTICS

(Table 1)

Femoral origin

One of the main conflicting points about the

anatomy of the ALL concerns its femoral

insertion. Most of the authors agreed on the

problems inherent to individualizing this

insertion because of the many connections with

the femoral insertion of the LCL and the fibers

coming from the fascia of the lateral vastus

muscle. The femoral attachment was initially

described by Vincent [12], Claes [2], and

Helito [5] to be anterior and distal to the

femoral LCL attachment, while Dodds [4],

Rezansoff [9] and our study [7] described

posterior and proximal attachments. Caterine

[1] explained these disparities by the existence

of anatomical variations and proposed a three-

stage classification according to the differences

in femoral and tibial insertions.

Fig. 2a:

ALL tight in internal rotation (blue pin =

Gerdy’s tubercle; yellow pin = femoral lateral

epicondyle, green pin = fibular head, dotted lines =

anterior and posterior ALL limits).

Fig. 2b:

Difficulties to located ALL in neutral rotation

(blue pin = Gerdy’s tubercle; yellow pin = femoral

lateral epicondyle, green pin = fibular head).

Fig. 3:

ALL (arrow) exposure after LCL (dotted

arrow) dissection and antero-lateral capsule

removing.