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      Inter-rater reliability of an ultrasound protocol to evaluate the anterolateral ligament of the knee

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          Objectives: The aim of this study was to validate an ultrasound protocol for evaluating the anterolateral ligament of the knee. Methods: A Thiel technique cadaveric specimen was used to validate an optimal scanning position and develop an ultrasound protocol to evaluate the anterolateral ligament. Three musculoskeletal sonographers acquired short- and long-axis images of the anterolateral ligament in 36 knees from 18 healthy volunteers. Anterolateral ligament length, thickness, width, and distance between anterolateral ligament insertion and lateral tibia plateau were measured. Intraclass Correlation Coefficient (ICC) was calculated. Results: The inter-rater reliability for anterolateral ligament thickness was poor, ICC = 0.35 (95% CI: –0.06–0.63). The inter-rater reliability for anterolateral ligament length and width was good, ICC = 0.80 (95% CI 0.64–0.89), ICC = 0.88 (95% CI 0.79–0.94), respectively; and the inter-rater reliability for the distance between insertion and lateral tibia plateau was excellent, ICC = 0.96 (95% CI 0.93–0.98). Conclusions: Ultrasonography is a reliable method for evaluating the anterolateral ligament. There is an excellent reliability for the distal part of the anterolateral ligament. As injuries usually occur in this part of the ligament, this protocol may be used to evaluate the anterolateral ligament in patients with suspected anterior cruciate ligament tears in clinical practice.

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          Most cited references 28

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          A Guideline of Selecting and Reporting Intraclass Correlation Coefficients for Reliability Research.

           Mae Li,  Terry Koo (2016)
          Intraclass correlation coefficient (ICC) is a widely used reliability index in test-retest, intrarater, and interrater reliability analyses. This article introduces the basic concept of ICC in the content of reliability analysis.
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            Sample size and optimal designs for reliability studies.

            A method is developed to calculate the required number of subjects k in a reliability study, where reliability is measured using the intraclass correlation rho. The method is based on a functional approximation to earlier exact results. The approximation is shown to have excellent agreement with the exact results and one can use it easily without intensive numerical computation. Optimal design configurations are also discussed; for reliability values of about 40 per cent or higher, use of two or three observations per subject will minimize the total number of observations required.
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              Anatomy of the anterolateral ligament of the knee.

              In 1879, the French surgeon Segond described the existence of a 'pearly, resistant, fibrous band' at the anterolateral aspect of the human knee, attached to the eponymous Segond fracture. To date, the enigma surrounding this anatomical structure is reflected in confusing names such as '(mid-third) lateral capsular ligament', 'capsulo-osseous layer of the iliotibial band' or 'anterolateral ligament', and no clear anatomical description has yet been provided. In this study, the presence and characteristics of Segond's 'pearly band', hereafter termed anterolateral ligament (ALL), was investigated in 41 unpaired, human cadaveric knees. The femoral and tibial attachment of the ALL, its course and its relationship with nearby anatomical structures were studied both qualitatively and quantitatively. In all but one of 41 cadaveric knees (97%), the ALL was found as a well-defined ligamentous structure, clearly distinguishable from the anterolateral joint capsule. The origin of the ALL was situated at the prominence of the lateral femoral epicondyle, slightly anterior to the origin of the lateral collateral ligament, although connecting fibers between the two structures were observed. The ALL showed an oblique course to the anterolateral aspect of the proximal tibia, with firm attachments to the lateral meniscus, thus enveloping the inferior lateral geniculate artery and vein. Its insertion on the anterolateral tibia was grossly located midway between Gerdy's tubercle and the tip of the fibular head, definitely separate from the iliotibial band (ITB). The ALL was found to be a distinct ligamentous structure at the anterolateral aspect of the human knee with consistent origin and insertion site features. By providing a detailed anatomical characterization of the ALL, this study clarifies the long-standing enigma surrounding the existence of a ligamentous structure connecting the femur with the anterolateral tibia. Given its structure and anatomic location, the ALL is hypothesized to control internal tibial rotation and thus to affect the pivot shift phenomenon, although further studies are needed to investigate its biomechanical function.

                Author and article information

                J Ultrason
                J Ultrason
                Journal of Ultrasonography
                Exeley Inc.
                November 2019
                30 September 2019
                : 19
                : 78
                : 181-186
                [1 ]Physical Therapy Practice , Oberriet, Switzerland
                [2 ]Department of Experimental Anatomy , Vrije Universiteit Brussel , Brussels, Belgium
                [3 ]Department of Radiology , Universitair Ziekenhuis Brussel , Brussels, Belgium
                [4 ]Department of Radiology , Wake Forest School of Medicine , Winston-Salem, NC, USA
                [5 ]Ministry of Defence , the Netherlands
                Author notes
                Correspondence: Michel Kandel, Physical Therapy Practice, Staatsstrasse 46, 9463 Oberriet, Switzerland; e-mail:
                © Polish Ultrasound Society

                This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial NoDerivatives License (CC BY-NC-ND). Reproduction is permitted for personal, educational, non-commercial use, provided that the original article is in whole, unmodified, and properly cited.



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