The structure and function of the anterolateral complex (ALC) of the knee has created much controversy since the ‘re-discovery’ of the anterolateral ligament (ALL) and its proposed role in aiding control of anterolateral rotatory laxity in the anterior cruciate ligament (ACL) injured knee. A group of surgeons and researchers prominent in the field gathered to produce consensus as to the anatomy and biomechanical properties of the ALC. The evidence for and against utilisation of ALC reconstruction was also discussed, generating a number of consensus statements by following a modified Delphi process. Key points include that the ALC consists of the superficial and deep aspects of the iliotibial tract with its Kaplan fibre attachments on the distal femur, along with the ALL, a capsular structure within the anterolateral capsule. A number of structures attach to the area of the Segond fracture including the capsule-osseous layer of the iliotibial band, the ALL and the anterior arm of the short head of biceps, and hence it is not clear which is responsible for this lesion. The ALC functions to provide anterolateral rotatory stability as a secondary stabiliser to the ACL. Whilst biomechanical studies have shown that these structures play an important role in controlling stability at the time of ACL reconstruction, the optimal surgical procedure has not yet been defined clinically. Concern remains that these procedures may cause constraint of motion, yet no clinical studies have demonstrated an increased risk of osteoarthritis development. Furthermore, clinical evidence is currently lacking to support clear indications for lateral extra-articular procedures as an augmentation to ACL reconstruction. The resulting statements and scientific rationale aim to inform readers on the most current thinking and identify areas of needed basic science and clinical research to help improve patient outcomes following ACL injury and subsequent reconstruction.
Level of evidence V.
This is a preview of subscription content, log in to check access.
Buy single article
Instant unlimited access to the full article PDF.
Price includes VAT for USA
Subscribe to journal
Immediate online access to all issues from 2019. Subscription will auto renew annually.
This is the net price. Taxes to be calculated in checkout.
Albers M, Shaikh H, Herbst E, Onishi K, Nagai K, Musahl V et al (2018) The iliotibial band and anterolateral capsule have a combined attachment to the Segond fracture. Knee Surg Sports Traumatol Arthrosc 26:1305–1310
Anderson AF, Snyder RB, Lipscomb AB Jr (2001) Anterior cruciate ligament reconstruction. A prospective randomized study of three surgical methods. Am J Sports Med 29:272–279
Bell KM, Rahnemai-Azar AA, Irarrazaval S, Guenther D, Fu FH, Musahl V et al (2018) In situ force in the anterior cruciate ligament, the lateral collateral ligament, and the anterolateral capsule complex during a simulated pivot shift test. J Orthop Res 36:847–853
Caterine S, Litchfield R, Johnson M, Chronik B, Getgood A (2015) A cadaveric study of the anterolateral ligament: re-introducing the lateral capsular ligament. Knee Surg Sports Traumatol Arthrosc 23:3186–3195
Cavaignac E, Faruch M, Wytrykowski K, Constant O, Murgier J, Berard E et al (2017) Ultrasonographic evaluation of anterolateral ligament injuries: correlation with magnetic resonance imaging and pivot-shift testing. Arthroscopy 33:1384–1390
Claes S, Luyckx T, Vereecke E, Bellemans J (2014) The Segond fracture: a bony injury of the anterolateral ligament of the knee. Arthroscopy 30:1475–1482
Claes S, Vereecke E, Maes M, Victor J, Verdonk P, Bellemans J (2013) Anatomy of the anterolateral ligament of the knee. J Anat 223:321–328
Corbo G, Norris M, Getgood A, Burkhart TA (2017) The infra-meniscal fibers of the anterolateral ligament are stronger and stiffer than the supra-meniscal fibers despite similar histological characteristics. Knee Surg Sports Traumatol Arthrosc 25:1078–1085
Daggett M, Busch K, Sonnery-Cottet B (2016) Surgical dissection of the anterolateral ligament. Arthrosc Tech 5:e185–e188
Devitt BM, Bell SW, Ardern CL, Hartwig T, Porter TJ, Feller JA et al (2017) The role of lateral extra-articular tenodesis in primary anterior cruciate ligament reconstruction: a systematic review with meta-analysis and best-evidence synthesis. Orthop J Sports Med 5:2325967117731767
Devitt BM, Bouguennec N, Barfod KW, Porter T, Webster KE, Feller JA (2017) Combined anterior cruciate ligament reconstruction and lateral extra-articular tenodesis does not result in an increased rate of osteoarthritis: a systematic review and best evidence synthesis. Knee Surg Sports Traumatol Arthrosc 25:1149–1160
Dodds AL, Halewood C, Gupte CM, Williams A, Amis AA (2014) The anterolateral ligament: anatomy, length changes and association with the Segond fracture. Bone Jt J 96-B:325–331
Ferretti A, Monaco E, Fabbri M, Maestri B, De Carli A (2017) Prevalence and classification of injuries of anterolateral complex in acute anterior cruciate ligament tears. Arthroscopy 33:147–154
Geeslin AG, Moatshe G, Chahla J, Kruckeberg BM, Muckenhirn KJ, Dornan GJ et al (2017) Anterolateral knee extra-articular stabilizers: a robotic study comparing anterolateral ligament reconstruction and modified Lemaire lateral extra-articular tenodesis. Am J Sports Med.https://doi.org/10.1177/0363546517745268363546517745268
Guenther D, Rahnemai-Azar AA, Bell KM, Irarrazaval S, Fu FH, Musahl V et al (2017) The anterolateral capsule of the knee behaves like a sheet of fibrous tissue. Am J Sports Med 45:849–855
Helito CP, Demange MK, Bonadio MB, Tirico LE, Gobbi RG, Pecora JR et al (2013) Anatomy and histology of the knee anterolateral ligament. Orthop J Sports Med 1:2325967113513546
Helito CP, Helito PV, Costa HP, Demange MK, Bordalo-Rodrigues M (2017) Assessment of the anterolateral ligament of the knee by magnetic resonance imaging in acute injuries of the anterior cruciate ligament. Arthroscopy 33:140–146
Herbst E, Albers M, Burnham JM, Shaikh HS, Naendrup JH, Fu FH et al (2017) The anterolateral complex of the knee: a pictorial essay. Knee Surg Sports Traumatol Arthrosc 25:1009–1014
Herbst E, Arilla FV, Guenther D, Yacuzzi C, Rahnemai-Azar AA, Fu FH et al (2018) Lateral extra-articular tenodesis has no effect in knees with isolated anterior cruciate ligament injury. Arthroscopy 34:251–260
Hewison CE, Tran MN, Kaniki N, Remtulla A, Bryant D, Getgood AM (2015) Lateral extra-articular tenodesis reduces rotational laxity when combined with anterior cruciate ligament reconstruction: a systematic review of the literature. Arthroscopy 31:2022–2034
Huser LE, Noyes FR, Jurgensmeier D, Levy MS (2017) Anterolateral ligament and iliotibial band control of rotational stability in the anterior cruciate ligament-intact knee: defined by tibiofemoral compartment translations and rotations. Arthroscopy 33:595–604
Ibrahim SA, Shohdy EM, Marwan Y, Ramadan SA, Almisfer AK, Mohammad MW et al (2017) Anatomic reconstruction of the anterior cruciate ligament of the knee with or without reconstruction of the anterolateral ligament: a randomized clinical trial. Am J Sports Med 45:1558–1566
Inderhaug E, Stephen JM, El-Daou H, Williams A, Amis AA (2017) The effects of anterolateral tenodesis on tibiofemoral contact pressures and kinematics. Am J Sports Med 45:3081–3088
Inderhaug E, Stephen JM, Williams A, Amis AA (2017) Anterolateral tenodesis or anterolateral ligament complex reconstruction: effect of flexion angle at graft fixation when combined with ACL reconstruction. Am J Sports Med 45:3089–3097
Inderhaug E, Stephen JM, Williams A, Amis AA (2017) Biomechanical comparison of anterolateral procedures combined with anterior cruciate ligament reconstruction. Am J Sports Med 45:347–354
Kaplan EB (1958) The iliotibial tract; clinical and morphological significance. J Bone Jt Surg Am 40-A:817–832
Kennedy MI, Claes S, Fuso FA, Williams BT, Goldsmith MT, Turnbull TL et al (2015) The anterolateral ligament: an anatomic, radiographic, and biomechanical analysis. Am J Sports Med 43:1606–1615
Kittl C, El-Daou H, Athwal KK, Gupte CM, Weiler A, Williams A et al (2016) The role of the anterolateral structures and the ACL in controlling laxity of the intact and ACL-deficient knee. Am J Sports Med 44:345–354
Kittl C, Halewood C, Stephen JM, Gupte CM, Weiler A, Williams A et al (2015) Length change patterns in the lateral extra-articular structures of the knee and related reconstructions. Am J Sports Med 43:354–362
Klos B, Scholtes M, Konijnenberg S (2017) High prevalence of all complex Segond avulsion using ultrasound imaging. Knee Surg Sports Traumatol Arthrosc 25:1331–1338
Lobenhoffer P, Posel P, Witt S, Piehler J, Wirth CJ (1987) Distal femoral fixation of the iliotibial tract. Arch Orthop Trauma Surg 106:285–290
Lording T, Corbo G, Bryant D, Burkhart TA, Getgood A (2017) Rotational laxity control by the anterolateral ligament and the lateral meniscus is dependent on knee flexion angle: a cadaveric biomechanical study. Clin Orthop Relat Res 475:2401–2408
Lubowitz JH, Provencher MT, Brand JC, Rossi MJ (2014) The knee anterolateral ligament. Arthroscopy 30:1385–1388
Monaco E, Fabbri M, Mazza D, Daggett M, Redler A, Lanzetti RM et al (2018) The effect of sequential tearing of the anterior cruciate and anterolateral ligament on anterior translation and the pivot-shift phenomenon: a cadaveric study using navigation. Arthroscopy 34:1009–1014
Muller W (1984) Functional anatomy and clinical findings of the knee joint. Helv Chir Acta 51:505–514
Musahl V, Rahnemai-Azar AA, Costello J, Arner JW, Fu FH, Hoshino Y et al (2016) The influence of meniscal and anterolateral capsular injury on knee laxity in patients with anterior cruciate ligament injuries. Am J Sports Med 44:3126–3131
Musahl V, Rahnemai-Azar AA, van Eck CF, Guenther D, Fu FH (2016) Anterolateral ligament of the knee, fact or fiction? Knee Surg Sports Traumatol Arthrosc 24:2–3
Noyes FR, Huser LE, Jurgensmeier D, Walsh J, Levy MS (2017) Is an anterolateral ligament reconstruction required in ACL-reconstructed knees with associated injury to the anterolateral structures? A robotic analysis of rotational knee stability. Am J Sports Med 45:1018–1027
Noyes FR, Huser LE, Levy MS (2017) Rotational knee instability in ACL-deficient knees: role of the anterolateral ligament and iliotibial band as defined by tibiofemoral compartment translations and rotations. J Bone Jt Surg Am 99:305–314
O’Brien SJ, Warren RF, Wickiewicz TL, Rawlins BA, Allen AA, Panariello R et al (1991) The iliotibial band lateral sling procedure and its effect on the results of anterior cruciate ligament reconstruction. Am J Sports Med 19:21–24 (discussion 24–25)
Pearl AJ, Bergfeld JA (1992) Extra-articular reconstruction in the anterior cruciate ligament deficient knee. Am Orthop Soc Sports Med
Pernin J, Verdonk P, Si Selmi TA, Massin P, Neyret P (2010) Long-term follow-up of 24.5 years after intra-articular anterior cruciate ligament reconstruction with lateral extra-articular augmentation. Am J Sports Med 38:1094–1102
Rasmussen MT, Nitri M, Williams BT, Moulton SG, Cruz RS, Dornan GJ et al (2016) An in vitro robotic assessment of the anterolateral ligament, Part 1: secondary role of the anterolateral ligament in the setting of an anterior cruciate ligament injury. Am J Sports Med 44:585–592
Saiegh YA, Suero EM, Guenther D, Hawi N, Decker S, Krettek C et al (2017) Sectioning the anterolateral ligament did not increase tibiofemoral translation or rotation in an ACL-deficient cadaveric model. Knee Surg Sports Traumatol Arthrosc 25:1086–1092
Schon JM, Moatshe G, Brady AW, Serra Cruz R, Chahla J, Dornan GJ et al (2016) Anatomic anterolateral ligament reconstruction of the knee leads to overconstraint at any fixation angle. Am J Sports Med 44:2546–2556
Seebacher JR, Inglis AE, Marshall JL, Warren RF (1982) The structure of the posterolateral aspect of the knee. J Bone Jt Surg Am 64:536–541
Segond P (1879) Recherches cliniques et experimentales sur les epanchements sanguins du genou par entorse. Progres Medical. http://www.patrimoine.edilivre.com/
Shybut TB, Vega CE, Haddad J, Alexander JW, Gold JE, Noble PC et al (2015) Effect of lateral meniscal root tear on the stability of the anterior cruciate ligament-deficient knee. Am J Sports Med 43:905–911
Smeets K, Slane J, Scheys L, Forsyth R, Claes S, Bellemans J (2017) The anterolateral ligament has similar biomechanical and histologic properties to the inferior glenohumeral ligament. Arthroscopy 33:1028–1035 (e1021)
Song GY, Hong L, Zhang H, Zhang J, Li Y, Feng H (2016) Clinical outcomes of combined lateral extra-articular tenodesis and intra-articular anterior cruciate ligament reconstruction in addressing high-grade pivot-shift phenomenon. Arthroscopy 32:898–905
Sonnery-Cottet B, Lutz C, Daggett M, Dalmay F, Freychet B, Niglis L et al (2016) The involvement of the anterolateral ligament in rotational control of the knee. Am J Sports Med 44:1209–1214
Sonnery-Cottet B, Saithna A, Cavalier M, Kajetanek C, Temponi EF, Daggett M et al (2017) Anterolateral ligament reconstruction is associated with significantly reduced ACL graft rupture rates at a minimum follow-up of 2 years: a prospective comparative study of 502 patients from the SANTI study group. Am J Sports Med 45:1547–1557
Sonnery-Cottet B, Thaunat M, Freychet B, Pupim BH, Murphy CG, Claes S (2015) Outcome of a combined anterior cruciate ligament and anterolateral ligament reconstruction technique with a minimum 2-year follow-up. Am J Sports Med 43:1598–1605
Spencer L, Burkhart TA, Tran MN, Rezansoff AJ, Deo S, Caterine S et al (2015) Biomechanical analysis of simulated clinical testing and reconstruction of the anterolateral ligament of the knee. Am J Sports Med 43:2189–2197
Terry GC, Hughston JC, Norwood LA (1986) The anatomy of the iliopatellar band and iliotibial tract. Am J Sports Med 14:39–45
Thaunat M, Clowez G, Saithna A, Cavalier M, Choudja E, Vieira TD et al (2017) Reoperation rates after combined anterior cruciate ligament and anterolateral ligament reconstruction: a series of 548 patients from the SANTI study group with a minimum follow-up of 2 years. Am J Sports Med 45:2569–2577
Thein R, Boorman-Padgett J, Stone K, Wickiewicz TL, Imhauser CW, Pearle AD (2016) Biomechanical assessment of the anterolateral ligament of the knee: a secondary restraint in simulated tests of the pivot shift and of anterior stability. J Bone Jt Surg Am 98:937–943
Vieira EL, Vieira EA, da Silva RT, Berlfein PA, Abdalla RJ, Cohen M (2007) An anatomic study of the iliotibial tract. Arthroscopy 23:269–274
Vincent JP, Magnussen RA, Gezmez F, Uguen A, Jacobi M, Weppe F et al (2012) The anterolateral ligament of the human knee: an anatomic and histologic study. Knee Surg Sports Traumatol Arthrosc 20:147–152
Webster KE, Feller JA (2016) Exploring the high reinjury rate in younger patients undergoing anterior cruciate ligament reconstruction. Am J Sports Med 44:2827–2832
Zaffagnini S, Marcheggiani Muccioli GM, Grassi A, Roberti di Sarsina T, Raggi F, Signorelli C et al (2017) Over-the-top ACL reconstruction plus extra-articular lateral tenodesis with hamstring tendon grafts: prospective evaluation with 20-year minimum follow-up. Am J Sports Med 45:3233–3242
Zens M, Niemeyer P, Ruhhammer J, Bernstein A, Woias P, Mayr HO et al (2015) Length changes of the anterolateral ligament during passive knee motion. Am J Sports Med 43:2545–2552
The ALC Consensus Group would like to acknowledge the generous support from Smith and Nephew PLC to enable this meeting. ALC Consensus Group: Andrew Amis, UK; Charles Brown, UAE; Etienne Cavaignac, France; Steven Claes, Belgium; Matt Daggett, USA; David Dejour, France; Lars Engebretsen, Norway; Hua Feng, China; Braden Fleming, USA; Freddie Fu, USA; Andrew Geeslin, USA; Alan Getgood, Canada; Daniel Guenther, Germany; Camilo Partezani Helito, Brazil; Elmar Herbst, Germany; Eivind Inderhaug, Norway; Jon Karlsson, Sweden; Christoph Kittl, Germany; Ryosuke Kuroda, Japan; Robert LaPrade, USA; Philippe Landreau, Qatar; Tim Lording, Australia; Werner Mueller, Switzerland; Volker Musahl, USA; Phillippe Neyret, France; Frank Noyes, USA; Andrew Pearle, USA; Adnan Saithna, UK; Robert Smigielski, Poland; Bertrand Sonnery-Cottet, France; Tim Spalding, UK; Pieter Van Dyck, Belgium; Peter Verdonk, Belgium; Andy Williams, UK; Adrian Wilson, UK; and Stefano Zaffagnini, Italy.
The ALC Concensus meeting was supported via an educational grant from Smith and Nephew PLC.
Conflict of interest
The authors declare that there is no Conflict of interest.
This article does not contain any studies with human participants or animals performed by any of the authors.
For this type of study informed consent is not required.
The members of the ALC Consensus Group are listed in Acknowledgements.
About this article
Cite this article
Getgood, A., Brown, C., Lording, T. et al. The anterolateral complex of the knee: results from the International ALC Consensus Group Meeting. Knee Surg Sports Traumatol Arthrosc 27, 166–176 (2019). https://doi.org/10.1007/s00167-018-5072-6
- Anterolateral complex
- Kaplan fibres
- Iliotibial band
- Anterolateral ligament
- Anterior cruciate ligament