Anterolateral ligament of the bilateral knees: assessment of morphological profiles on multi-planar reformatted magnetic resonance imaging

Anterolateral ligament of the bilateral knees: assessment of morphological profiles on multi-planar reformatted magnetic resonance imaging | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Anterolateral ligament of the bilateral knees: assessment of morphological profiles on multi-planar reformatted magnetic resonance imaging Yu Liu, Lixue Wang, Jie Li, Jianchao Liang, Zhihong Lan, Xiangrong Yu, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4528915/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose The anterior lateral ligament (ALL) plays a pivotal role in providing rotational stability to the knee. We aimed to evaluate the visualization and symmetry of the bilateral ALL by utilizing multi-planar reformatted (MPR) MRI, which was clinical significance for surgical reconstruction procedures. Methods Between January 2021 and October 2022, 162 patients who underwent bilateral knee MRI scans were included. Two professional osteoarticular-oriented radiologists assessed the visibility, length, and thickness of the ALL on MPR images. The visibility of the ALL can be classified as "visible", "partially visible", and "invisible". Inter-observer consistency of the ALL profiles was assessed using Fleiss’ kappa or intraclass correlation coefficient (ICC). The McNemar-Bowker test and t-test were used to analyze ordered categorical and continuous variables, respectively. Results The interobserver reliability in the visualization, length, and thickness of the bilateral ALL was good to excellent. The ALL was visible in 116 (71.6%) left and 99 (61.1%) right knees, partially visible in 14 (8.6%) left, and 20 (12.3%) right knees, and invisible in 32 (19.8%) left and 43 (26.5%) right knees. The bilateral ALL was judged as visible in 90 (55.6%), partially visible in 5 (3.1%), and invisible in 29 (17.9%) cases. In the measurable cases, the length and thickness of the bilateral ALLs were non-significant (all P > 0.05). Subgroup analysis showed that the visibility of bilateral ALL was significantly different in the minors and males. Conclusion The integrity of the ALL differs between bilateral knees, and the ALLs were asymmetric in the minors and males. Anterior lateral ligament Morphological symmetry Visibility MRI Surgical reconstruction Figures Figure 1 Figure 2 Figure 3 Introduction Knee ligament injuries, specifically those that involve the anterior cruciate ligament (ACL), are prevalent and can cause considerable pain, swelling, and restricted joint motion. Furthermore, these injuries can lead to chronic joint instability and an increased risk of osteoarthritis. In 2013, the anterolateral ligament (ALL) was identified as a distinct ligament that extends anteriorly from the lateral femoral condyle to the midpoint between the head of the fibula and the Gerdy's tubercle of the tibia ( 1 – 4 ). The ALL serves to restrict anterior movement and internal rotation of the knee, especially following an ACL injury or reconstruction. It counteracts the tension exerted by the anteromedial bundle of the ACL, thus alleviating stress on the knee after ACL reconstruction ( 5 – 10 ). Additionally, the ALL may contribute to the dynamic control of the knee joint during physical activity by working in conjunction with other ligaments and muscles to regulate knee motion, maintain joint stability, and uphold standard movement patterns ( 11 , 12 ). Several studies have shown that injury to the ALL can impair the rotational stability of the knee, impacting athletic performance and increasing the risk of further injury ( 5 , 13 , 14 ). Thus, a comprehensive understanding of ALL's anatomy and its relationship with other knee structures is imperative for enhancing patient prognosis and optimizing joint function. Knee symmetry, or balance between the right and left knee joints, is a significant consideration for knee health and function ( 15 ). Asymmetries in ligamentous structures, including the ALL, can potentially affect joint stability and increase the risk of injury. For instance, if one knee possesses a stronger or more intact ALL compared to the other knee, it can lead to imbalanced forces on the joint during movement, placing excessive stress on certain structures and potentially escalating the likelihood of subsequent injury. In addition, knee symmetry plays a pivotal role in the rehabilitation process following an injury. Rehabilitation protocols typically aim to restore normal mechanics and function in the joint, including achieving symmetry between the injured and uninjured knee joints (16). Failing to attain symmetrical joint function during rehabilitation may result in deficiencies in knee stability, strength, and movement patterns, thereby impacting long-term outcomes and increasing the risk of re-injury ( 17 , 18 ). Complete visualization of ALL is crucial for its accurate identification and evaluation. Recently, the application of multi-planar reconstruction (MPR) has demonstrated significant advancements in showcasing the entire length of the ALL, surpassing the limitations of the traditional coronal position utilized in conventional MRI scans ( 19 , 20 ). To enhance clinical decision-making and facilitate surgical planning, we employed a noninvasive MPR technique on MRI to assess the visibility and symmetry of bilateral ALL. This study will provide valuable insights for preoperative ALL reconstruction, enabling surgeons to better understand of the anatomical characteristics of the ALL, leading to more tailored surgical approaches. Materials and Methods Patients The institutional review board of our hospital approved this study and waived the need for written consent. A total of 208 patients who underwent a knee MRI due to atraumatic knee pain between January 2021 and October 2022 were identified from the picture archiving and communication system. The exclusion criteria were as follows: ( 1 ) repeat MRI of the knees (n = 16); ( 2 ) previous surgery around the knee (n = 7); ( 3 ) acute or chronic knee injury (n = 5); ( 4 ) tears of the lateral knee joint structures (anterior cruciate ligament, lateral meniscus, lateral collateral ligament, and iliotibial tract) (n = 6); ( 5 ) severe osteoarthritis (n = 10); ( 6 ) abnormal knee joint mechanics (genu varus or valgus) (n = 2). Finally, a total of 162 patients who met the inclusion criteria were included. The detailed inclusion and exclusion criteria and enrolment process are illustrated in Fig. 1 . MRI examinations All imaging studies were performed on a 3.0-T MR system (Philips Ingenia CX) with an 8-channel phased-array knee coil to acquire standard sagittal scans of both knees of each patient using the three-dimensional T2-weighted volume isotropic turbo spin-echo acquisition (3D T2W-VISTA) sequence. The following imaging parameters were used: Repetition time = 1100 ms, Echo time = 85 ms, field of view = 160 mm × 160 mm × 120 mm, slice thickness = 0.7 mm, interslice gap = -0.3 mm, flip angle = 90°, voxel size = 0.7 mm × 0.7 mm × 0.7 mm, reconstructed voxel size = 0.4 mm × 0.4 mm × 0.4 mm, and echo train length = 16. Fat suppression was achieved using the spectral attenuated inversion recovery (SPAIR) technique. Identification of the ALL visualization on MPR images The MPR technique enables the analysis of three-dimensional acquisitions and allows for the free orientation of axial, coronal, and sagittal image planes. The ALL runs from the lateral femoral condyle, extends anteriorly and downward, and attaches at the midpoint between Gerdy's tubercle on the tibia and the anterior edge of the fibular head. MPR was performed to obtain oblique coronal views parallel to the ALL, aiming to display the ligament as completely as possible ( 19 ). The ALL was divided into three sub-portions: femoral, meniscal, and tibial. The visibility of ALL was classified into three categories: visible, partially visible, and invisible. Visibility was defined as the identification of the entire ALL, including its tibial and femoral insertions on a single MRI layer, partial visibility was defined as only one or two parts of the ALL were visible, and invisibility refers to the absence of any visible portion of the ALL ( 21 ). Two musculoskeletal radiologists (5 and 10 years of experience, respectively) independently assessed the visibility of bilateral ALLs after reconstructing the oblique coronal images at Philips workstation (Fig. 2 ). ALL length measurements were done in cases where the ALL was visible. The thickness of the ALL was measured at the tibial plateau level. Statistical Analysis Statistical analysis was conducted using IBM SPSS Statistics for Windows, Version 26.0. Armonk, NY: IBM Corp. Categorical variables were presented as n (%), while continuous variables were presented as mean (standard deviation). Inter-observer consistency was assessed using the intraclass correlation coefficient (ICC) for continuous variables and Fleiss’ kappa for categorical variables. The level of agreement was classified into four categories: poor (0.00-0.20), fair (0.21–0.40), moderate (0.41–0.60), good (0.61–0.80), and excellent (0.81-1.00). The McNemar-Bowker test was utilized to compare the visibility of the ALL, whereas the Wilcoxon Signed-Rank Test was employed to assess the length and thickness of the ALL between two knees. A two-tailed P < 0.05 indicated statistical significance. Results Patient characteristics The median age of the 162 patients was 38.5 years (interquartile range, 18.0–58.0; range, 6.0–80.0). Among them, 82 (50.6%) patients were females, and 82 (49.4%) were males. There were 36 (22.2%) patients ≤ 18 years, with a mean age of 13.5 years ± 2.8, and the remaining 126 were adults, with a mean age of 46.3 years ± 17.8. Visualization and symmetry of the bilateral ALL The interobserver agreement for the visualization of the ALL in entire (left knee, kappa = 0.944; right knee, kappa = 0.943), femoral portion (left knee, kappa = 0.954; right knee, kappa = 0.974), meniscal portion (left knee, kappa = 0.981; right knee, kappa = 0.985), and tibial portion (left knee, kappa = 0.960; right knee, kappa = 0.953). The mean full-length of the ALL was 35.6 ± 4.1 mm and 35.5 ± 4.2 mm in the left knees (n = 116) and right knees (n = 99) with visible ALLs, respectively. The mean thickness of the ALL was 1.1 ± 0.3 mm and 1.1 ± 0.3 mm, respectively. The bilateral ALL was judged as visible in 90 (55.6%), partially visible in 5 (3.1%), and invisible in 29 (17.9%) cases. The results of the McNemar-Bowker test showed a significant difference in the visibility of ALL in the entire knee as well as femoral, meniscal, and tibial portions ( P < 0.010, P = 0.014, P = 0.007, P = 0.004, respectively) (Fig. 3 and Table 1 ). Table 1 Visualization, consistency, and symmetry analysis of bilateral ALLs Visibility in left knee Visibility in right knee Kappa P-value Visible Partially visible Invisible Visible Partially visible Invisible ALL 116 14 32 99 20 43 0.530 0.010 Femoral portion 116 / 46 101 / 61 0.544 0.014 Meniscus portion 129 / 33 116 / 46 0.652 0.007 Tibia portion 130 / 32 117 / 45 0.679 0.004 The results of ICC showed good consistency among the length and thickness of ALL in the left and right knees. For the length of ALL, ICC = 0.861 (95%CI: 0.797–0.907, P < 0.001); for the thickness of ALL, ICC = 0.797 (95%CI, 0.706–0.862, P < 0.001). The Wilcoxon Signed-Rank Test indicated no significant difference in the length (P = 0.912) and thickness (P = 0.077) of ALL between the left and right knees. Stratification analysis by age and sex Among patients aged ≤ 18 (n = 41), the bilateral ALLs were judged as visible in 23 (56.1%), partially visible in 1 (2.4%), and invisible in 8 (19.5%) cases. Significant differences were observed in the visibility of ALL in the whole knee and its three sub-portions between the two knees ( P = 0.029, P = 0.016, P = 0.031, and P = 0.031, respectively). The full-length of the visible ALL did not show a significant difference between the left (n = 31) and right knees (n = 23) (36.0 ± 3.1 vs 36.2 ± 3.9 mm, P = 0.912). A marginal difference was found in the thickness of the left and right ALLs (1.1 ± 0.2 vs 1.0 ± 0.3 mm, P = 0.045). In patients aged over 18 years (n = 121), the bilateral ALLs were judged as visible in 67 (55.4%), partially visible in 4 (3.3%), and invisible in 21 (17.4%) cases. No significant difference was observed in the visibility of ALL in the whole knee and its three sub-portions ( P > 0.167, P = 0.169, P = 0.118, P = 0.092, respectively). The full-length of the left (n = 85) and right (n = 76) ALLs was very similar (35.3 ± 4.2 vs 35.5 ± 4.5 mm, P = 0.936), as well as the thickness (1.1 ± 0.3 vs 1.1 ± 0.3 mm, P = 0.492). In the male patients (n = 80), the bilateral ALLs were judged as visible in 44 (55.0%), partially visible in 2 (2.5%), and invisible in 15 (18.8%) cases. There were significant differences in the visibility of ALL in the entire knee as well as femoral and tibial portions ( P = 0.028, P = 0.035, and P = 0.039, respectively). In contrast no significant difference was shown in the meniscal portion ( P = 0.065). Among the visible cases, there was no significant difference observed in the full-length of the left (n = 58) or the right (n = 47) ALLs (37.1 ± 3.9 vs 36.8 ± 4.3 mm, P = 0.812). However, there was a significant difference in the thickness of the bilateral ALLs (1.2 ± 0.3 vs 1.1 ± 0.3 mm, P = 0.020). In the female patients (n = 82), the bilateral ALL was judged as visible in 46 (56.1%), partially visible in 3 (3.7%), and invisible in 14 (17.1%) cases. There were no significant differences in the visibility of ALL in the entire and three sub-portions ( P = 0.109–0.274). The full-length of the left (n = 58) and right (n = 52) visible ALLs was 34.2 ± 3.9 mm and 34.3 ± 3.6 mm, respectively. The thickness of the left and right ALLs measured 1.1 ± 0.2 mm and 1.1 ± 0.3 mm, respectively. Both the length and thickness of the bilateral ALLs showed no significant differences ( P = 0.706 and P = 874, respectively). Discussion Despite extensive studies into the anatomy, biomechanics, and surgical reconstruction techniques of the ALL, there lacks of evaluation of the visualization and symmetry, which is the motivation behind our study. According to our study findings, there was a notable disparity in the visualization of the ALL between the two knees, which may be consistent with Eckhoff et al.'s results on bilateral femoral and tibial anatomical asymmetry ( 22 ). The left knee exhibited a higher proportion of visible ALL, whereas the right knee showed a higher proportion of partially visible and invisible ALL. In addition, non-traumatic asymmetry was observed in the bilateral ALLs in the majority of cases, except for the minors and males. Previous studies ( 12 , 22 – 24 ) have reported varying incidence rates of visible ALL in different regions, ranging from 51–100%. In our study, the rate of visible ALL was well within this range. Most autopsy results indicated nearly 100% visibility of ALL, whereas the range of ALL visibility in MRI images varied significantly. This suggests that despite using MPR techniques, there was still a discernible disparity between MRI images and the actual display of ALL. Specifically, the tibia portion of ALL demonstrated the highest level of visibility, whereas the femur portion exhibited relatively lower visibility. It is worth noting that although ALL is a distinct ligament, there may be partial overlap between its femoral portion and the adjacent lateral collateral ligament, lateral iliotibial tract, and anterior lateral capsule. These findings are consistent with the findings from Andrade et al. ( 12 ), emphasizing the substantial influence of femoral visibility on the overall visibility of ALL. Our study also revealed that the length and thickness of bilateral ALLs were remarkably similar, which aligns with conventional anatomical studies ( 23 , 24 ). Stratification analysis reveals the presence of asymmetry in the bilateral ALLs of minors, emphasizing the need for clinicians to be aware of potential ALL asymmetry when evaluating young patients. As an injury or instability in one knee joint can affect the ALL, clinicians should consider the impact of asymmetry in the contralateral knee when creating a treatment plan. During the developmental period from 6 to 14 years of age, it is observed that limb mass experiences twice the growth rate compared to limb length. This discrepancy in growth rates can potentially lead to ligament imbalances as muscles are required to generate increased force to accommodate the movement of growing limbs ( 25 , 26 ). However, as individuals age, the ligaments may become more symmetrical. Thus, conducting thorough assessments and closely monitoring both knees are crucial when evaluating knee joint injuries or instability in young patients. In this way, accurate diagnosis, effective treatment, and successful rehabilitation can be achieved, ultimately improving patient outcomes. Thus, the identification of asymmetry in the bilateral ALLs in patients under 18 years of age emphasizes the significance of careful evaluation and monitoring of both knees in young patients with knee joint injuries or instability. Additionally, a significant difference in MPR visibility was observed in the bilateral ALLs of males. The asymmetry in bilateral ALLs of males may be attributed to biomechanical disparities between their left and right legs, such as variations in muscle activation modes and joint load. It is noteworthy that differences in sports activity levels and participation between genders may also contribute to varying degrees of ligament wear ( 27 , 28 ). Compared with females, males are more susceptible to knee injuries, such as ACL tears, which can induce compensatory ligament changes, and consequently, asymmetry in the appearance of the ALL on MRI. Moreover, natural anatomical variations, including differences in size, shape, and orientation of knee joint bones and soft tissues, can also influence the appearance of ligaments on MRI. This study had some limitations. First, the sample size of this study might not be large enough to establish definitive conclusions regarding ALL symmetry across age and gender subgroups. Second, this study examined the ALLs at a single time point. Longitudinal follow-up can provide comprehensive insights into the changes of the ALL symmetry with age, as well as the injury and rehabilitation processes. Third, we were unable to evaluate ALL injuries simultaneously on MRI because it was difficult to determine if the ALLs were congenitally absent or lost after injury. The purpose of this study was to assess the visibility of ALL in a healthy state. ALL injury can interfere with the assessment of normal visibility and symmetry of ALL under normal conditions. We will utilize MRI to evaluate ALL injuries in future research. In conclusion, bilateral knee ALLs were symmetrical in over 70% of the patients except for minors and males. There were no significant differences in the length and thickness of bilateral ALL. These findings provide crucial evidence from non-invasive MRI for the preoperative reconstruction of ALL in clinical practice. Declarations Conflict of interest The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Funding This work was financed by the Capital's Funds for Health Improvement and Research (2022-2Z-2241), Tsinghua University Initiative Scientific Research Program of Precision Medicine (2022PY002), Beijing Natural Science Foundation (7202240), National Natural Science Foundation of China (82071915), GuangDong Basic and Applied Basic Research Foundation (2022A1515220015), Project of Zhuhai City Department of science and technology (2220004000131). Author Contribution Y.L. and L.W. wrote the main manuscript text. J.L. and Z.L. organized the data and analysis. J.L. prepared figures 1-3. All authors reviewed the manuscript Data availability statement The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4528915","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":316169945,"identity":"c57b2ea6-dcdd-4ca8-8f5d-c8f0a20fe2b8","order_by":0,"name":"Yu Liu","email":"","orcid":"","institution":"Zhuhai People's Hospital (Zhuhai hospital affiliated with Jinan University)","correspondingAuthor":false,"prefix":"","firstName":"Yu","middleName":"","lastName":"Liu","suffix":""},{"id":316169946,"identity":"2bd1cd7b-4870-448c-9990-0f6f919b21e2","order_by":1,"name":"Lixue Wang","email":"","orcid":"","institution":"Beijing Tsinghua Chang Gung Hospital","correspondingAuthor":false,"prefix":"","firstName":"Lixue","middleName":"","lastName":"Wang","suffix":""},{"id":316169947,"identity":"424433d0-6c7c-459c-8ffc-2fdd54f05d8c","order_by":2,"name":"Jie Li","email":"","orcid":"","institution":"Beijing Tsinghua Chang Gung Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jie","middleName":"","lastName":"Li","suffix":""},{"id":316169948,"identity":"663f04a9-3d07-45e6-8596-c28e8bb789f4","order_by":3,"name":"Jianchao Liang","email":"","orcid":"","institution":"Zhuhai People's Hospital (Zhuhai hospital affiliated with Jinan University)","correspondingAuthor":false,"prefix":"","firstName":"Jianchao","middleName":"","lastName":"Liang","suffix":""},{"id":316169949,"identity":"4fa116ee-69f5-4291-b861-949075ae7e8a","order_by":4,"name":"Zhihong Lan","email":"","orcid":"","institution":"Zhuhai People's Hospital (Zhuhai hospital affiliated with Jinan University)","correspondingAuthor":false,"prefix":"","firstName":"Zhihong","middleName":"","lastName":"Lan","suffix":""},{"id":316169950,"identity":"5ef1b617-41e0-4537-82e5-e95bd51a9ce6","order_by":5,"name":"Xiangrong Yu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4klEQVRIie3RsQrCMBCA4RQhU7BriqA+wonQqQ9zLtmUgoubitAO4q5v0UeoBtol7h0E69LJQUdB1HR1aDsK5h/DfcPlCDGZfrQYwZtTsl/mOPMaCSu/+QJtS0rIlWhEWoPtTaKzSoRzCQ7185CNiw6D1gQS5c6QxsQO11hNVOpqQqeglJshOxGujlE1SQOqCbOirCS8IMDHNUTSknArOl9dH0E2IGmg1wcY7RaJIIgNiKMS/cmAQ5tIyTEWrHaXdib0KZ/vbnnK++Plde1wU0368dcDqxwv6y1qR0wmk+nv+wB801JpFRZEbgAAAABJRU5ErkJggg==","orcid":"","institution":"Zhuhai People's Hospital (Zhuhai hospital affiliated with Jinan University)","correspondingAuthor":true,"prefix":"","firstName":"Xiangrong","middleName":"","lastName":"Yu","suffix":""},{"id":316169951,"identity":"b620788d-69d7-47e5-98ba-e12977722048","order_by":6,"name":"Zhuozhao Zheng","email":"","orcid":"","institution":"Beijing Tsinghua Chang Gung Hospital","correspondingAuthor":false,"prefix":"","firstName":"Zhuozhao","middleName":"","lastName":"Zheng","suffix":""}],"badges":[],"createdAt":"2024-06-04 14:51:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4528915/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4528915/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":59122743,"identity":"246b22a3-451a-440a-8354-348a8c21c60a","added_by":"auto","created_at":"2024-06-26 15:07:17","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":75997,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart illustrating the inclusion and exclusion criteria.\u003c/p\u003e","description":"","filename":"OnlineFigure1.png","url":"https://assets-eu.researchsquare.com/files/rs-4528915/v1/bc2a2d6959600f412afdc21d.png"},{"id":59122745,"identity":"cd08500f-5d00-45ce-9404-fc0ac54afcd1","added_by":"auto","created_at":"2024-06-26 15:07:17","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":600516,"visible":true,"origin":"","legend":"\u003cp\u003eIllustration of ALL visibility on standard coronal reformations. (A) a completely visible ALL (white arrow), showing the femoral and tibial insertion as well as the meniscal portion; (B) a partially visible ALL (white arrow); C) no presence of ALL.\u003c/p\u003e","description":"","filename":"OnlineFigure2.png","url":"https://assets-eu.researchsquare.com/files/rs-4528915/v1/ec8f9ba447e2d48ae2061cd7.png"},{"id":59122744,"identity":"50ed2a8d-fab5-48c8-a571-2d7c2e1f7465","added_by":"auto","created_at":"2024-06-26 15:07:17","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":74020,"visible":true,"origin":"","legend":"\u003cp\u003ePercent stacked bar charts showing the visualization of bilateral ALLs. (A) whole ALL; (B) femoral portion; (C) meniscus portion; (D) tibial portion.\u003c/p\u003e","description":"","filename":"OnlineFigure3.png","url":"https://assets-eu.researchsquare.com/files/rs-4528915/v1/d3bfb2266e23df982abc7331.png"},{"id":59858264,"identity":"bad1cca6-bb6d-4c91-9e33-a2eeee59c7b3","added_by":"auto","created_at":"2024-07-08 13:59:13","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1455248,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4528915/v1/2fd9d7d6-13f2-4b51-84f1-f2f02693f8d4.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Anterolateral ligament of the bilateral knees: assessment of morphological profiles on multi-planar reformatted magnetic resonance imaging","fulltext":[{"header":"Introduction","content":"\u003cp\u003eKnee ligament injuries, specifically those that involve the anterior cruciate ligament (ACL), are prevalent and can cause considerable pain, swelling, and restricted joint motion. Furthermore, these injuries can lead to chronic joint instability and an increased risk of osteoarthritis. In 2013, the anterolateral ligament (ALL) was identified as a distinct ligament that extends anteriorly from the lateral femoral condyle to the midpoint between the head of the fibula and the Gerdy's tubercle of the tibia (\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). The ALL serves to restrict anterior movement and internal rotation of the knee, especially following an ACL injury or reconstruction. It counteracts the tension exerted by the anteromedial bundle of the ACL, thus alleviating stress on the knee after ACL reconstruction (\u003cspan additionalcitationids=\"CR6 CR7 CR8 CR9\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Additionally, the ALL may contribute to the dynamic control of the knee joint during physical activity by working in conjunction with other ligaments and muscles to regulate knee motion, maintain joint stability, and uphold standard movement patterns (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Several studies have shown that injury to the ALL can impair the rotational stability of the knee, impacting athletic performance and increasing the risk of further injury (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Thus, a comprehensive understanding of ALL's anatomy and its relationship with other knee structures is imperative for enhancing patient prognosis and optimizing joint function.\u003c/p\u003e \u003cp\u003eKnee symmetry, or balance between the right and left knee joints, is a significant consideration for knee health and function (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Asymmetries in ligamentous structures, including the ALL, can potentially affect joint stability and increase the risk of injury. For instance, if one knee possesses a stronger or more intact ALL compared to the other knee, it can lead to imbalanced forces on the joint during movement, placing excessive stress on certain structures and potentially escalating the likelihood of subsequent injury. In addition, knee symmetry plays a pivotal role in the rehabilitation process following an injury. Rehabilitation protocols typically aim to restore normal mechanics and function in the joint, including achieving symmetry between the injured and uninjured knee joints (16). Failing to attain symmetrical joint function during rehabilitation may result in deficiencies in knee stability, strength, and movement patterns, thereby impacting long-term outcomes and increasing the risk of re-injury (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eComplete visualization of ALL is crucial for its accurate identification and evaluation. Recently, the application of multi-planar reconstruction (MPR) has demonstrated significant advancements in showcasing the entire length of the ALL, surpassing the limitations of the traditional coronal position utilized in conventional MRI scans (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e20\u003c/span\u003e). To enhance clinical decision-making and facilitate surgical planning, we employed a noninvasive MPR technique on MRI to assess the visibility and symmetry of bilateral ALL. This study will provide valuable insights for preoperative ALL reconstruction, enabling surgeons to better understand of the anatomical characteristics of the ALL, leading to more tailored surgical approaches.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003e The institutional review board of our hospital approved this study and waived the need for written consent. A total of 208 patients who underwent a knee MRI due to atraumatic knee pain between January 2021 and October 2022 were identified from the picture archiving and communication system. The exclusion criteria were as follows: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) repeat MRI of the knees (n\u0026thinsp;=\u0026thinsp;16); (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) previous surgery around the knee (n\u0026thinsp;=\u0026thinsp;7); (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) acute or chronic knee injury (n\u0026thinsp;=\u0026thinsp;5); (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) tears of the lateral knee joint structures (anterior cruciate ligament, lateral meniscus, lateral collateral ligament, and iliotibial tract) (n\u0026thinsp;=\u0026thinsp;6); (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) severe osteoarthritis (n\u0026thinsp;=\u0026thinsp;10); (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) abnormal knee joint mechanics (genu varus or valgus) (n\u0026thinsp;=\u0026thinsp;2). Finally, a total of 162 patients who met the inclusion criteria were included. The detailed inclusion and exclusion criteria and enrolment process are illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eMRI examinations\u003c/h2\u003e \u003cp\u003eAll imaging studies were performed on a 3.0-T MR system (Philips Ingenia CX) with an 8-channel phased-array knee coil to acquire standard sagittal scans of both knees of each patient using the three-dimensional T2-weighted volume isotropic turbo spin-echo acquisition (3D T2W-VISTA) sequence. The following imaging parameters were used: Repetition time\u0026thinsp;=\u0026thinsp;1100 ms, Echo time\u0026thinsp;=\u0026thinsp;85 ms, field of view\u0026thinsp;=\u0026thinsp;160 mm \u0026times; 160 mm \u0026times; 120 mm, slice thickness\u0026thinsp;=\u0026thinsp;0.7 mm, interslice gap = -0.3 mm, flip angle\u0026thinsp;=\u0026thinsp;90\u0026deg;, voxel size\u0026thinsp;=\u0026thinsp;0.7 mm \u0026times; 0.7 mm \u0026times; 0.7 mm, reconstructed voxel size\u0026thinsp;=\u0026thinsp;0.4 mm \u0026times; 0.4 mm \u0026times; 0.4 mm, and echo train length\u0026thinsp;=\u0026thinsp;16. Fat suppression was achieved using the spectral attenuated inversion recovery (SPAIR) technique.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eIdentification of the ALL visualization on MPR images\u003c/h2\u003e \u003cp\u003eThe MPR technique enables the analysis of three-dimensional acquisitions and allows for the free orientation of axial, coronal, and sagittal image planes. The ALL runs from the lateral femoral condyle, extends anteriorly and downward, and attaches at the midpoint between Gerdy's tubercle on the tibia and the anterior edge of the fibular head. MPR was performed to obtain oblique coronal views parallel to the ALL, aiming to display the ligament as completely as possible (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e19\u003c/span\u003e). The ALL was divided into three sub-portions: femoral, meniscal, and tibial. The visibility of ALL was classified into three categories: visible, partially visible, and invisible. Visibility was defined as the identification of the entire ALL, including its tibial and femoral insertions on a single MRI layer, partial visibility was defined as only one or two parts of the ALL were visible, and invisibility refers to the absence of any visible portion of the ALL (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Two musculoskeletal radiologists (5 and 10 years of experience, respectively) independently assessed the visibility of bilateral ALLs after reconstructing the oblique coronal images at Philips workstation (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). ALL length measurements were done in cases where the ALL was visible. The thickness of the ALL was measured at the tibial plateau level.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eStatistical analysis was conducted using IBM SPSS Statistics for Windows, Version 26.0. Armonk, NY: IBM Corp. Categorical variables were presented as n (%), while continuous variables were presented as mean (standard deviation). Inter-observer consistency was assessed using the intraclass correlation coefficient (ICC) for continuous variables and Fleiss\u0026rsquo; kappa for categorical variables. The level of agreement was classified into four categories: poor (0.00-0.20), fair (0.21\u0026ndash;0.40), moderate (0.41\u0026ndash;0.60), good (0.61\u0026ndash;0.80), and excellent (0.81-1.00). The McNemar-Bowker test was utilized to compare the visibility of the ALL, whereas the Wilcoxon Signed-Rank Test was employed to assess the length and thickness of the ALL between two knees. A two-tailed \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 indicated statistical significance.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003ePatient characteristics\u003c/h2\u003e \u003cp\u003eThe median age of the 162 patients was 38.5 years (interquartile range, 18.0\u0026ndash;58.0; range, 6.0\u0026ndash;80.0). Among them, 82 (50.6%) patients were females, and 82 (49.4%) were males. There were 36 (22.2%) patients\u0026thinsp;\u0026le;\u0026thinsp;18 years, with a mean age of 13.5 years\u0026thinsp;\u0026plusmn;\u0026thinsp;2.8, and the remaining 126 were adults, with a mean age of 46.3 years\u0026thinsp;\u0026plusmn;\u0026thinsp;17.8.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eVisualization and symmetry of the bilateral ALL\u003c/h2\u003e \u003cp\u003eThe interobserver agreement for the visualization of the ALL in entire (left knee, kappa\u0026thinsp;=\u0026thinsp;0.944; right knee, kappa\u0026thinsp;=\u0026thinsp;0.943), femoral portion (left knee, kappa\u0026thinsp;=\u0026thinsp;0.954; right knee, kappa\u0026thinsp;=\u0026thinsp;0.974), meniscal portion (left knee, kappa\u0026thinsp;=\u0026thinsp;0.981; right knee, kappa\u0026thinsp;=\u0026thinsp;0.985), and tibial portion (left knee, kappa\u0026thinsp;=\u0026thinsp;0.960; right knee, kappa\u0026thinsp;=\u0026thinsp;0.953).\u003c/p\u003e \u003cp\u003eThe mean full-length of the ALL was 35.6\u0026thinsp;\u0026plusmn;\u0026thinsp;4.1 mm and 35.5\u0026thinsp;\u0026plusmn;\u0026thinsp;4.2 mm in the left knees (n\u0026thinsp;=\u0026thinsp;116) and right knees (n\u0026thinsp;=\u0026thinsp;99) with visible ALLs, respectively. The mean thickness of the ALL was 1.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.3 mm and 1.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.3 mm, respectively.\u003c/p\u003e \u003cp\u003eThe bilateral ALL was judged as visible in 90 (55.6%), partially visible in 5 (3.1%), and invisible in 29 (17.9%) cases. The results of the McNemar-Bowker test showed a significant difference in the visibility of ALL in the entire knee as well as femoral, meniscal, and tibial portions (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.010, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.014, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.007, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.004, respectively) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e \u003cb\u003eand\u003c/b\u003e Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eVisualization, consistency, and symmetry analysis of bilateral ALLs\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eVisibility in left knee\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003eVisibility in right knee\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eKappa\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVisible\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePartially visible\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eInvisible\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eVisible\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePartially visible\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eInvisible\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eALL\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e116\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.530\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.010\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFemoral portion\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e116\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e101\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.544\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.014\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMeniscus portion\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e129\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e116\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.652\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.007\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTibia portion\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e130\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e117\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.679\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe results of ICC showed good consistency among the length and thickness of ALL in the left and right knees. For the length of ALL, ICC\u0026thinsp;=\u0026thinsp;0.861 (95%CI: 0.797\u0026ndash;0.907, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001); for the thickness of ALL, ICC\u0026thinsp;=\u0026thinsp;0.797 (95%CI, 0.706\u0026ndash;0.862, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The Wilcoxon Signed-Rank Test indicated no significant difference in the length (P\u0026thinsp;=\u0026thinsp;0.912) and thickness (P\u0026thinsp;=\u0026thinsp;0.077) of ALL between the left and right knees.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eStratification analysis by age and sex\u003c/h2\u003e \u003cp\u003eAmong patients aged\u0026thinsp;\u0026le;\u0026thinsp;18 (n\u0026thinsp;=\u0026thinsp;41), the bilateral ALLs were judged as visible in 23 (56.1%), partially visible in 1 (2.4%), and invisible in 8 (19.5%) cases. Significant differences were observed in the visibility of ALL in the whole knee and its three sub-portions between the two knees (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.029, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.016, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.031, and \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.031, respectively). The full-length of the visible ALL did not show a significant difference between the left (n\u0026thinsp;=\u0026thinsp;31) and right knees (n\u0026thinsp;=\u0026thinsp;23) (36.0\u0026thinsp;\u0026plusmn;\u0026thinsp;3.1 vs 36.2\u0026thinsp;\u0026plusmn;\u0026thinsp;3.9 mm, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.912). A marginal difference was found in the thickness of the left and right ALLs (1.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.2 vs 1.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.3 mm, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.045). In patients aged over 18 years (n\u0026thinsp;=\u0026thinsp;121), the bilateral ALLs were judged as visible in 67 (55.4%), partially visible in 4 (3.3%), and invisible in 21 (17.4%) cases. No significant difference was observed in the visibility of ALL in the whole knee and its three sub-portions (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.167, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.169, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.118, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.092, respectively). The full-length of the left (n\u0026thinsp;=\u0026thinsp;85) and right (n\u0026thinsp;=\u0026thinsp;76) ALLs was very similar (35.3\u0026thinsp;\u0026plusmn;\u0026thinsp;4.2 vs 35.5\u0026thinsp;\u0026plusmn;\u0026thinsp;4.5 mm, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.936), as well as the thickness (1.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.3 vs 1.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.3 mm, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.492).\u003c/p\u003e \u003cp\u003eIn the male patients (n\u0026thinsp;=\u0026thinsp;80), the bilateral ALLs were judged as visible in 44 (55.0%), partially visible in 2 (2.5%), and invisible in 15 (18.8%) cases. There were significant differences in the visibility of ALL in the entire knee as well as femoral and tibial portions (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.028, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.035, and \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.039, respectively). In contrast no significant difference was shown in the meniscal portion (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.065). Among the visible cases, there was no significant difference observed in the full-length of the left (n\u0026thinsp;=\u0026thinsp;58) or the right (n\u0026thinsp;=\u0026thinsp;47) ALLs (37.1\u0026thinsp;\u0026plusmn;\u0026thinsp;3.9 vs 36.8\u0026thinsp;\u0026plusmn;\u0026thinsp;4.3 mm, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.812). However, there was a significant difference in the thickness of the bilateral ALLs (1.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.3 vs 1.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.3 mm, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.020). In the female patients (n\u0026thinsp;=\u0026thinsp;82), the bilateral ALL was judged as visible in 46 (56.1%), partially visible in 3 (3.7%), and invisible in 14 (17.1%) cases. There were no significant differences in the visibility of ALL in the entire and three sub-portions (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.109\u0026ndash;0.274). The full-length of the left (n\u0026thinsp;=\u0026thinsp;58) and right (n\u0026thinsp;=\u0026thinsp;52) visible ALLs was 34.2\u0026thinsp;\u0026plusmn;\u0026thinsp;3.9 mm and 34.3\u0026thinsp;\u0026plusmn;\u0026thinsp;3.6 mm, respectively. The thickness of the left and right ALLs measured 1.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.2 mm and 1.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.3 mm, respectively. Both the length and thickness of the bilateral ALLs showed no significant differences (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.706 and \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;874, respectively).\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eDespite extensive studies into the anatomy, biomechanics, and surgical reconstruction techniques of the ALL, there lacks of evaluation of the visualization and symmetry, which is the motivation behind our study. According to our study findings, there was a notable disparity in the visualization of the ALL between the two knees, which may be consistent with Eckhoff et al.'s results on bilateral femoral and tibial anatomical asymmetry (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e22\u003c/span\u003e). The left knee exhibited a higher proportion of visible ALL, whereas the right knee showed a higher proportion of partially visible and invisible ALL. In addition, non-traumatic asymmetry was observed in the bilateral ALLs in the majority of cases, except for the minors and males.\u003c/p\u003e \u003cp\u003ePrevious studies (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan additionalcitationids=\"CR23\" citationid=\"CR23\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e24\u003c/span\u003e) have reported varying incidence rates of visible ALL in different regions, ranging from 51\u0026ndash;100%. In our study, the rate of visible ALL was well within this range. Most autopsy results indicated nearly 100% visibility of ALL, whereas the range of ALL visibility in MRI images varied significantly. This suggests that despite using MPR techniques, there was still a discernible disparity between MRI images and the actual display of ALL. Specifically, the tibia portion of ALL demonstrated the highest level of visibility, whereas the femur portion exhibited relatively lower visibility. It is worth noting that although ALL is a distinct ligament, there may be partial overlap between its femoral portion and the adjacent lateral collateral ligament, lateral iliotibial tract, and anterior lateral capsule. These findings are consistent with the findings from Andrade et al. (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e), emphasizing the substantial influence of femoral visibility on the overall visibility of ALL. Our study also revealed that the length and thickness of bilateral ALLs were remarkably similar, which aligns with conventional anatomical studies (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eStratification analysis reveals the presence of asymmetry in the bilateral ALLs of minors, emphasizing the need for clinicians to be aware of potential ALL asymmetry when evaluating young patients. As an injury or instability in one knee joint can affect the ALL, clinicians should consider the impact of asymmetry in the contralateral knee when creating a treatment plan. During the developmental period from 6 to 14 years of age, it is observed that limb mass experiences twice the growth rate compared to limb length. This discrepancy in growth rates can potentially lead to ligament imbalances as muscles are required to generate increased force to accommodate the movement of growing limbs (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e26\u003c/span\u003e). However, as individuals age, the ligaments may become more symmetrical. Thus, conducting thorough assessments and closely monitoring both knees are crucial when evaluating knee joint injuries or instability in young patients. In this way, accurate diagnosis, effective treatment, and successful rehabilitation can be achieved, ultimately improving patient outcomes. Thus, the identification of asymmetry in the bilateral ALLs in patients under 18 years of age emphasizes the significance of careful evaluation and monitoring of both knees in young patients with knee joint injuries or instability. Additionally, a significant difference in MPR visibility was observed in the bilateral ALLs of males. The asymmetry in bilateral ALLs of males may be attributed to biomechanical disparities between their left and right legs, such as variations in muscle activation modes and joint load. It is noteworthy that differences in sports activity levels and participation between genders may also contribute to varying degrees of ligament wear (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Compared with females, males are more susceptible to knee injuries, such as ACL tears, which can induce compensatory ligament changes, and consequently, asymmetry in the appearance of the ALL on MRI. Moreover, natural anatomical variations, including differences in size, shape, and orientation of knee joint bones and soft tissues, can also influence the appearance of ligaments on MRI.\u003c/p\u003e \u003cp\u003eThis study had some limitations. First, the sample size of this study might not be large enough to establish definitive conclusions regarding ALL symmetry across age and gender subgroups. Second, this study examined the ALLs at a single time point. Longitudinal follow-up can provide comprehensive insights into the changes of the ALL symmetry with age, as well as the injury and rehabilitation processes. Third, we were unable to evaluate ALL injuries simultaneously on MRI because it was difficult to determine if the ALLs were congenitally absent or lost after injury. The purpose of this study was to assess the visibility of ALL in a healthy state. ALL injury can interfere with the assessment of normal visibility and symmetry of ALL under normal conditions. We will utilize MRI to evaluate ALL injuries in future research.\u003c/p\u003e \u003cp\u003eIn conclusion, bilateral knee ALLs were symmetrical in over 70% of the patients except for minors and males. There were no significant differences in the length and thickness of bilateral ALL. These findings provide crucial evidence from non-invasive MRI for the preoperative reconstruction of ALL in clinical practice.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eConflict of interest\u003c/h2\u003e \u003cp\u003eThe authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis work was financed by the Capital's Funds for Health Improvement and Research (2022-2Z-2241), Tsinghua University Initiative Scientific Research Program of Precision Medicine (2022PY002), Beijing Natural Science Foundation (7202240), National Natural Science Foundation of China (82071915), GuangDong Basic and Applied Basic Research Foundation (2022A1515220015), Project of Zhuhai City Department of science and technology (2220004000131).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eY.L. and L.W. wrote the main manuscript text. J.L. and Z.L. organized the data and analysis. J.L. prepared figures 1-3. All authors reviewed the manuscript\u003c/p\u003e\u003ch2\u003eData availability statement\u003c/h2\u003e \u003cp\u003eThe raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eClaes S, Vereecke E, Maes M, Victor J, Verdonk P, Bellemans J (2013) Anatomy of the anterolateral ligament of the knee. J Anat 223(4):321\u0026ndash;328\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFeucht MJ, Zens M, Frosch K-H, Akoto R, S\u0026uuml;dkamp NP, Niemeyer P (2016) The anterolateral ligament of the knee: anatomy, biomechanics, and clinical implications. Curr Orthop Pract ;27(3)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePatel RM, Brophy RH Anterolateral Ligament of the Knee: Anatomy, Function, Imaging, and Treatment. Am J Sports Med 2017:363546517695802\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDiego ADL, Helito CP, Lana LDL, Daniel DCS, Costa Cavalcante ML, Dias Leite JA (2019) Anatomy of the Anterolateral Ligament of the Knee: A Systematic Review. Arthroscopy The Journal of Arthroscopic and Related Surgery\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWillinger L, Athwal K, Holthof S, Imhoff A, Williams A, Amis A (2023) Role of the Anterior Cruciate Ligament, Anterolateral Complex, and Lateral Meniscus Posterior Root in Anterolateral Rotatory Knee Instability: A Biomechanical Study. Am J Sports Med 51(5):1136\u0026ndash;1145\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePark J, Han S, Lee C, Jeon O, Jang K (2022) Anatomy, Biomechanics, and Reconstruction of the Anterolateral Ligament of the Knee Joint. Med (Kaunas Lithuania) ;58(6)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSaithna A, Thaunat M, Delaloye J, Ouanezar H, Fayard J, Sonnery-Cottet B (2018) Combined ACL and Anterolateral Ligament Reconstruction. JBJS Essent Surg techniques 8(1):e2\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKraeutler MJ, Welton KL, Chahla J, Laprade RF, Mccarty EC (2017) Current Concepts of the Anterolateral Ligament of the Knee Anatomy, Biomechanics, and Reconstruction. Am J Sports Med ;46(4)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBertrand S-C (2017) Nuno, et al. Clinical outcomes of extra-articular tenodesis/anterolateral reconstruction in the ACL injured knee. 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Arthroscopy the Journal of Arthroscopic \u0026amp; Related Surgery\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMusahl V, Herbst E, Burnham J, Fu F (2018) The Anterolateral Complex and Anterolateral Ligament of the Knee. J Am Acad Orthop Surg 26(8):261\u0026ndash;267\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmis A (2017) Anterolateral knee biomechanics. Knee surgery, sports traumatology, arthroscopy. official J ESSKA 25(4):1015\u0026ndash;1023\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHill C, Romero M, Rogers M, Queen R, Brolinson P (2021) Effect of osteopathic manipulation on gait asymmetry. J Osteopath Med 122(2):85\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRocchi J. Editorial Commentary: Gait Symmetry After Anterior Cruciate Ligament Reconstruction Is Improved Using Functional Rehabilitation Braces That Resist Knee Motion. Arthroscopy: the journal of arthroscopic \u0026amp; related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association 2022;38(11):3056\u0026ndash;3057.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArhos E, Capin J, Buchanan T, Snyder-Mackler L. Quadriceps Strength Symmetry Does Not Modify Gait Mechanics After Anterior Cruciate Ligament Reconstruction, Rehabilitation, and Return-to-Sport Training. The American journal of sports medicine 2021;49(2):417\u0026ndash;425.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWhite K, Di Stasi S, Smith A, Snyder-Mackler L. Anterior cruciate ligament- specialized post-operative return-to-sports (ACL-SPORTS) training: a randomized control trial. BMC musculoskeletal disorders 2013;14:108.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHecker A, Egli R, Liechti E, Leibold C, Klenke F. 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Sports medicine (Auckland, NZ)\u003c/span\u003e \u003cspan\u003e;18(3):173\u0026ndash;201.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Anterior lateral ligament, Morphological symmetry, Visibility, MRI, Surgical reconstruction","lastPublishedDoi":"10.21203/rs.3.rs-4528915/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4528915/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eThe anterior lateral ligament (ALL) plays a pivotal role in providing rotational stability to the knee. We aimed to evaluate the visualization and symmetry of the bilateral ALL by utilizing multi-planar reformatted (MPR) MRI, which was clinical significance for surgical reconstruction procedures.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eBetween January 2021 and October 2022, 162 patients who underwent bilateral knee MRI scans were included. Two professional osteoarticular-oriented radiologists assessed the visibility, length, and thickness of the ALL on MPR images. The visibility of the ALL can be classified as \"visible\", \"partially visible\", and \"invisible\". Inter-observer consistency of the ALL profiles was assessed using Fleiss\u0026rsquo; kappa or intraclass correlation coefficient (ICC). The McNemar-Bowker test and t-test were used to analyze ordered categorical and continuous variables, respectively.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe interobserver reliability in the visualization, length, and thickness of the bilateral ALL was good to excellent. The ALL was visible in 116 (71.6%) left and 99 (61.1%) right knees, partially visible in 14 (8.6%) left, and 20 (12.3%) right knees, and invisible in 32 (19.8%) left and 43 (26.5%) right knees. The bilateral ALL was judged as visible in 90 (55.6%), partially visible in 5 (3.1%), and invisible in 29 (17.9%) cases. In the measurable cases, the length and thickness of the bilateral ALLs were non-significant (all \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Subgroup analysis showed that the visibility of bilateral ALL was significantly different in the minors and males.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe integrity of the ALL differs between bilateral knees, and the ALLs were asymmetric in the minors and males.\u003c/p\u003e","manuscriptTitle":"Anterolateral ligament of the bilateral knees: assessment of morphological profiles on multi-planar reformatted magnetic resonance imaging","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-26 15:07:12","doi":"10.21203/rs.3.rs-4528915/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c95b8ea1-e15e-4c20-8e04-b6baec5ae9a5","owner":[],"postedDate":"June 26th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-07-08T13:51:06+00:00","versionOfRecord":[],"versionCreatedAt":"2024-06-26 15:07:12","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4528915","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4528915","identity":"rs-4528915","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}