Dr. Mark Galland Discusses “New” Knee Ligament

Written by admin on January 7, 2014 – 1:54 pm -

There has been much consternation, if not outright titillation, recently regarding the “discovery” of a new knee ligament. Multiple news outlets breathlessly report that doctors in Belgium have “discovered” a new ligament. Reader’s comments in these online articles range from excitement to incredulity and borderline outrage “that doctors could miss such an obvious thing.”

Is this possible? Is it likely that there is an anatomical structure that has gone undiscovered despite centuries of patient, methodical, laborious anatomical research by thousands of surgeons, anatomists and students?

Certainly, anything is possible (that’s the premise behind lottery tickets, right)? Is it possible that this ligament can go unnoticed by the literally millions of MRI that have been performed over the past 30 years? Maybe a little less possible than the previous example, but for the sake of argument, let’s say “Yes, it’s possible.” Except that it’s not. You see, this ligament was first described in 1879–the same year the light bulb was invented! The ligament has never had one single name that we could all agree upon (previous monikers include: mid-third lateral capsular ligament, capsulo-osseous layer of the iliotibial band (What a mouthful!) and even the current ‘anterolateral ligament’ have been used in the past). Though, until recently, no clear anatomical description had been provided, surgeons have long been aware of it. Most Orthopaedic surgeons (particularly those specializing in sports injuries) have been aware of its significance, abeit indirectly,for decades. The Segond fracture caused when this ligament sometimes avulses a fragment of bone from the tibia when an ACL is torn, bears the name, not coincidentally, of the first physician to “discover” the ligament (he called it simply a “pearly fibrous band”). To emphasize this point, the authors of the paper that initiated this furor, do not claim “discovery” they merely proffer a standardized name for this ligament and
postulate its significance in knee stability.

Why the delay? If it was first noted in 1879, why are we only now: 1. giving it a name and 2. postulating its function? To answer, one must first understand the structure of a joint. Every joint is surrounded by a capsule. The capsule is like a balloon that surrounds and attaches to the bones that comprise a joint. Certain parts of the capsule are thin and others are thick and well defined. those parts that are well-defined and thick usually merit a name and are considered “ligaments” examples are the MCL (medial collateral ligament) and LCL (lateral collateral ligament). Some areas are slightly thicker than the rest of the capsule but not nearly as much as the named ligaments. Sometimes these get a name, sometimes not, and sometimes doctors argue over what name, if any, should be assigned to this “thickened area.” as you can imagine, doctor-scientist cocktail parties can get pretty rowdy! These in-between ligaments typically have arcane names like posterior oblique ligament and popliteo- fibular ligament–names like these can only result as the brain-chlild of the aforementioned post-party delirium–scientists! still it’s better than listening to them argue these points at a medical conference.

Additionally, with the advent and popularity of minimally invasive and arthroscopic surgery, these ligaments are no longer exposed in surgical procedures, unless the procedure is intended to specifically address an injury to one of these ligaments.

Arthroscopic surgery occurs within the joint, these “capsule ligaments” are by definition outside the confines of the joint and are not seen during routine arthroscopic surgery. anyone want to trade the 2 tiny incisions typical of any “scope” surgery for a 10’‘incision (and all the extra rehab and lost work-time attendant to such incisions) so that we can have the satisfaction of looking at all the knee ligaments? No? I didn’t think so.

What about MRI? “Why has no one mentioned this ligament before now, if we can, in fact evaluate it with MRI?” good question. the answer is simple. radiologists may see the ligament/capsular area on every scan, but until we name it and tell them that it is important, they view it not unlike like the skin and fat and gristle also well-visualized on every mri but are not worthy of mention.

Far from the discovery of a new ligament, these distinguished Belgian surgeons have provided us valuable insight into the importance of a known but previously disregarded structure, and have suggested its importance merits a standardized name upon which we can all agree. While not as earth shattering as a truly unique discovery, it is exciting to learn that we may have new insight into the inner-workings of the human knee. Now it is time for those of us who care for those with such injuries to begin developing and utilizing techniques to repair it when injured. Truly exciting news, indeed!

Dr. Mark Galland is a Board Certified Orthopaedic Surgeon and adjunct Clinical Professor, specializing in sports medicine, practicing in Wake Forest and Raleigh. He serves as team physician and Orthopaedic consultant to the Carolina Mudcats, High-A Affiliate of the Cleveland Indians of Major League Baseball, as well as several area high schools and colleges. Dr. Galland can be reached at (919) 562-9410 or by visiting www.orthonc.com or www.drmarkgalland.com, or on twitter @drmarkgalland.

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