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J Bone Joint Surg Am. 2017 Jul 5;99(13):1111-1118. doi: 10.2106/JBJS.16.01139.

An in Vivo Simulation of Isometry of the Anterolateral Aspect of the Healthy Knee.

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1Bioengineering Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 2Focus Clinic Orthopedic Surgery, Medical Center Haaglanden and Bronovo-Nebo, The Hague, the Netherlands 3Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, the Netherlands 4Steadman Philippon Research Institute, Vail, Colorado.



To assess the isometry of theoretical lateral extra-articular reconstruction (LER), we evaluated theoretical grafts attached to various points on the lateral femoral condylar area and to either Gerdy's tubercle or the anatomic attachment site of the anterolateral ligament to the tibia.


In 18 subjects, healthy knees with no history of either injury or surgery involving the lower extremity were studied. The subjects performed a sit-to-stand motion (from approximately 90° of flexion to full extension), and each knee was studied using magnetic resonance and dual fluoroscopic imaging techniques. The 3-dimensional wrapping paths of each theoretical LER graft were measured. Grafts showing the least change in length during the sit-to-stand motion were considered to be the most isometric.


The most isometric attachment site on the lateral femoral epicondyle to either of the studied tibial attachment sites was posterior-distal to the femoral attachment site of the fibular collateral ligament. The LER graft had a mean change in length of approximately 3%. Moving the femoral attachment site anteriorly resulted in increased length of the graft with increasing flexion; more posterior attachment sites resulted in decreased length with increasing flexion. Moving the attachment site in the proximal-distal direction had a less profound effect. Moving the tibial attachment site from Gerdy's tubercle to the tibial attachment site of the anterolateral ligament affected the overall isometric distribution on the lateral femoral epicondyle.


The most isometric attachment site on the femur for an LER would be posterior-distal to the femoral attachment site of the fibular collateral ligament. Different length changes for LER grafts were identified with respect to different femoral attachment sites. Desirable graft fixation locations for treating anterolateral rotatory instability were found posterior-proximal to the femoral fibular collateral ligament attachment.


The present data could be used both in biomechanical studies and in clinical studies as guidelines for planning LER surgical procedures.

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