title: The Anterolateral Capsule of the Knee Behaves Like a Sheet of Fibrous Tissue.
abstract: BACKGROUND
  The function of the anterolateral capsule of the knee has not been clearly defined. However, the contribution of this region of the capsule to knee stability in comparison with other anterolateral structures can be determined by the relative force that each structure carries during loading of the knee. Purpose/Hypothesis: The purpose of this study was to determine the forces in the anterolateral structures of the intact and anterior cruciate ligament (ACL)-deficient knee in response to an anterior tibial load and internal tibial torque. It was hypothesized that the anterolateral capsule would not function like a traditional ligament (ie, transmitting forces only along its longitudinal axis).
  
  
  METHODS
  Controlled laboratory study.
  
  
  METHODS
  Loads (134-N anterior tibial load and 7-N·m internal tibial torque) were applied continuously during flexion to 7 fresh-frozen cadaveric knees in the intact and ACL-deficient state using a robotic testing system. The lateral collateral ligament (LCL) and the anterolateral capsule were separated from the surrounding tissue and from each other. This was done by performing 3 vertical incisions: lateral to the LCL, medial to the LCL, and lateral to the Gerdy tubercle. Attachments of the LCL and anterolateral capsule were detached from the underlying tissue (ie, meniscus), leaving the insertions and origins intact. The force distribution in the anterolateral capsule, ACL, and LCL was then determined at 30°, 60°, and 90° of knee flexion using the principle of superposition.
  
  
  RESULTS
  In the intact knee, the force in the ACL in response to an anterior tibial load was greater than that in the other structures ( P < .001). However, in response to an internal tibial torque, no significant differences were found between the ACL, LCL, and forces transmitted between each region of the anterolateral capsule after capsule separation. The anterolateral capsule experienced smaller forces (~50% less) compared with the other structures ( P = .048). For the ACL-deficient knee in response to an anterior tibial load, the force transmitted between each region of the anterolateral capsule was 434% greater than was the force in the anterolateral capsule ( P < .001) and 54% greater than the force in the LCL ( P = .036) at 30° of flexion. In response to an internal tibial torque at 30°, 60°, or 90° of knee flexion, no significant differences were found between the force transmitted between each region of the anterolateral capsule and the LCL. The force in the anterolateral capsule was significantly smaller than that in the other structures at all knee flexion angles for both loading conditions ( P = .004 for anterior tibial load and P = .04 for internal tibial torque).
  
  
  CONCLUSIONS
  The anterolateral capsule carries negligible forces in the longitudinal direction, and the forces transmitted between regions of the capsule were similar to the forces carried by the other structures at the knee, suggesting that it does not function as a traditional ligament. Thus, the anterolateral capsule should be considered a sheet of tissue.
  
  
  CONCLUSIONS
  Surgical repair techniques for the anterolateral capsule should restore the ability of the tissue to transmit forces between adjacent regions of the capsule rather than along its longitudinal axis.
authors.affiliation: Orthopaedic Robotics Laboratory, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.|Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.|Trauma Department, Hannover Medical School (MHH), Hannover, Germany.
authors.forename: Daniel
authors.initials: D
authors.lastname: Guenther
authors.affiliation: Orthopaedic Robotics Laboratory, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.|Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
authors.forename: Amir A
authors.initials: AA
authors.lastname: Rahnemai-Azar
authors.affiliation: Orthopaedic Robotics Laboratory, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.|Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
authors.forename: Kevin M
authors.initials: KM
authors.lastname: Bell
authors.affiliation: Orthopaedic Robotics Laboratory, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.|Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
authors.forename: Sebastián
authors.initials: S
authors.lastname: Irarrázaval
authors.affiliation: Orthopaedic Robotics Laboratory, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.|Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
authors.forename: Freddie H
authors.initials: FH
authors.lastname: Fu
authors.affiliation: Orthopaedic Robotics Laboratory, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.|Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.|Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
authors.forename: Volker
authors.initials: V
authors.lastname: Musahl
authors.affiliation: Orthopaedic Robotics Laboratory, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.|Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
authors.forename: Richard E
authors.initials: RE
authors.lastname: Debski
mesh_terms: D000070598:Anterior Cruciate Ligament Injuries / Q000503:physiopathology*; D001696:Biomechanical Phenomena; D002102:Cadaver; D006801:Humans; D007593:Joint Instability / Q000503:physiopathology; D007719:Knee Joint / Q000502:physiology* / Q000503:physiopathology*; D017844:Lateral Ligament, Ankle / Q000502:physiology / Q000503:physiopathology; D008875:Middle Aged; D016059:Range of Motion, Articular / Q000502:physiology; D012371:Robotics; D019415:Torque
keywords: anterior cruciate ligament; anterolateral capsule; biomechanics; in situ forces