Diagnostic findings caused by cutting of the iliotibial tract and anterolateral ligament in an ACL intact knee using a standardized and automated clinical knee examination

PURPOSE: The purpose of this study was to evaluate the separate contribution of the two definitions of the anterolateral ligament (ALL), the mid-third lateral capsular ligament (MTLCL) and deep capsule-osseous layer of the iliotibial tract (dcITT) in addition to the superficial iliotibial tract (sITT) to the control of tibial motion with respect to the femur during the application of force/torque seen during the three tests of the standard clinical knee examination (AP Lachman test, tibial axial rotation test and varus–valgus stress test). METHODS: Six pelvis-to-toe cadaveric specimens were examined using an automated testing device that carried out the three components of the clinical knee examination. Internal/external rotation torque, anteroposterior load and adduction/abduction torque were applied, while torque/force and positional measurements were recorded. Sequential sectioning of the structures followed the same order for each knee, sITT, dcITT and MTLCL. Testing was repeated after release of each structure. RESULTS: During the tibial axial rotation test, releasing the sITT caused an increase in internal rotation of 2.6° (1.4–4.1°, p < 0.0005), while release of the dcITT increased internal rotation an additional 0.8° (0.4–1.1°, p < 0.0015). Changes in secondary motions of the tibia after sITT release demonstrated an increase in anterior translation of 1.2 mm (0.6–2.0 mm, p < 0.0005) during internal rotation, while release of the dcITT increased the same motion an additional 0.4 mm (0.2–0.5 mm, p < 0.0005). During the AP Lachman test, release of the sITT caused the tibia to move more anteriorly by 0.7 mm (0.4–1.1 mm, p < 0.0005) and increased internal rotation by 2.7° (0.9–5.2°, p < 0.004). The additional release of the dcITT resulted in more anterior translation by 0.3 mm (0.1–0.4 mm, p < 0.002) and internal rotation by 0.9° (0.2–1.7°, p < 0.005). During the varus–valgus stress test, release of the sITT permitted 0.9° (0.4–1.4°, p < 0.0005) more adduction of the tibia, while the additional release of the dcITT significantly increased adduction by 0.4° (0.2°–0.5°, p < 0.001). Release of the MTLCL had a nominal but significant increase in internal rotation, 0.6° (0.1–1.1°, p < 0.0068) and external rotation, −0.1° (−0.1° to −0.2°, p < 0.0025) during the tibial axial rotation test, anterior translation of 0.2 mm (0.0–0.4 mm, p < 0.021) only during the AP Lachman test, and adduction rotation, 0.2° (0.0–0.3°, p < 0.034) only during the varus–valgus stress test. CONCLUSION: The presence of increased adduction during an automated knee examination provides unique information identifying the release of the sITT, dcITT and the MTLCL in this cadaveric study. While their sequential release caused similar pattern changes in the three components of the automated knee examination, the extent of change due to release of the MTLCL was markedly less than after release of the dcITT which was markedly less than after release of the sITT.