The anterolateral complex of the knee: results from the International ALC Consensus Group Meeting
- 973 Downloads
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.
KeywordsAnterolateral complex Kaplan fibres Iliotibial band Anterolateral ligament Anterior cruciate ligament
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.
Compliance with ethical standards
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.
- 10.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 5:2325967117731767PubMedPubMedCentralGoogle Scholar
- 11.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 25:1149–1160CrossRefPubMedGoogle Scholar
- 14.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 CrossRefPubMedGoogle Scholar
- 22.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 45:1558–1566CrossRefPubMedGoogle Scholar
- 34.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 34:1009–1014CrossRefPubMedGoogle Scholar
- 38.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 45:1018–1027CrossRefPubMedGoogle Scholar
- 41.Pearl AJ, Bergfeld JA (1992) Extra-articular reconstruction in the anterior cruciate ligament deficient knee. Am Orthop Soc Sports MedGoogle Scholar
- 43.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 44:585–592CrossRefPubMedGoogle Scholar
- 47.Segond P (1879) Recherches cliniques et experimentales sur les epanchements sanguins du genou par entorse. Progres Medical. http://www.patrimoine.edilivre.com/
- 52.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 45:1547–1557CrossRefPubMedGoogle Scholar
- 56.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 45:2569–2577CrossRefPubMedGoogle Scholar
- 61.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 45:3233–3242CrossRefPubMedGoogle Scholar