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INTRODUCTION
Nearly all cases of ACL rupture are associated
with a “subluxation” of the lateral compartment
of the knee. This explains the characteristic
bone bruising associated with ACL rupture on
the middle of the lateral femoral condyle and
the posterior portion of the lateral tibia. To
achieve this “subluxation”, lateral soft tissues
must yield. Not surprisingly on an MRI scan
following an acute ACL rupture there is usually
significant oedema in the lateral soft tissues.
Furthermore, acute exploration of the lateral
side of the knee after ACL rupture will show
haemorrhage in the tissues [1]. It is likely that
most of these injured tissues heal spontaneously.
Nevertheless, the fact that they are ruptured at
the time of ACL injury implies there may be
some role of these tissues in controlling
anterolateral rotatory instability (ALRI). Since
not all ACL reconstructions, even if undertaken
technically perfectly, result in abolition of the
pivot shift, nor total patient confidence, lateral
surgical procedures to augment intra-articular
ACL reconstruction may have benefit.
Of course, in the past many different lateral
procedures were used in this context. With the
success of intra-articular ACL reconstruction
however, in large parts of the world, these
procedures were abandoned as they were thought
to be the cause of complications and both
biomechanically and clinically unnecessary.
This was certainly the approach in the English-
speaking world. Particularly in France, and
especially Lyon, the use of such procedures
persisted with good affect. When abandoned the
various tenodeses were criticized for being
associated with failure due to stretching, and
stiffness, and lateral osteoarthritis. The
suggestion was that the morbidity of the surgery
caused stiffness and that over constraint of the
lateral compartment caused osteoarthritis.
However, if one looks back to the era during
which lateral surgical procedures such as the
Macintosh and Lemaire were undertaken, it is
worth noting that the postoperative rehabilitation
often involved prolonged periods immobilised in
a cast with the knee flexed and the leg in external
rotation. Also many cases had previously had
total meniscectomies. Of course in many cases
no intra-articular ACL reconstruction was under
taken and so biomechanical success was unlikely
in this situation. Because of these mitigating
factors and the potential for lateral soft tissue
procedures being beneficial, it is time to re-
evaluate not only the procedures, but the lateral
soft tissue anatomy itself.
THE ILIOTIBIAL BAND WITH ITS
FEMORAL ATTACHMENTS AT THE
KNEE IS THE MOST IMPORTANT
LATERAL SOFT TISSUE RESTRAINT
TO “ALRI”
A. WILLIAMS