Advertisement

Knee Surgery, Sports Traumatology, Arthroscopy

, Volume 27, Issue 1, pp 166–176 | Cite as

The anterolateral complex of the knee: results from the International ALC Consensus Group Meeting

  • Alan GetgoodEmail author
  • Charles Brown
  • Timothy Lording
  • Andrew Amis
  • Steven Claes
  • Andrew Geeslin
  • Volker Musahl
  • ALC Consensus Group
Knee

Abstract

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.

Keywords

Anterolateral complex Kaplan fibres Iliotibial band Anterolateral ligament Anterior cruciate ligament 

Notes

Acknowledgements

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.

Funding

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.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.

Informed consent

For this type of study informed consent is not required.

Supplementary material

167_2018_5072_MOESM1_ESM.pdf (127 kb)
Supplementary material 1 (PDF 127 KB)
167_2018_5072_MOESM2_ESM.docx (334 kb)
Supplementary material 2 (DOCX 334 KB)

References

  1. 1.
    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 26:1305–1310CrossRefPubMedGoogle Scholar
  2. 2.
    Anderson AF, Snyder RB, Lipscomb AB Jr (2001) Anterior cruciate ligament reconstruction. A prospective randomized study of three surgical methods. Am J Sports Med 29:272–279CrossRefPubMedGoogle Scholar
  3. 3.
    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 36:847–853PubMedGoogle Scholar
  4. 4.
    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 23:3186–3195CrossRefPubMedGoogle Scholar
  5. 5.
    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 33:1384–1390CrossRefPubMedGoogle Scholar
  6. 6.
    Claes S, Luyckx T, Vereecke E, Bellemans J (2014) The Segond fracture: a bony injury of the anterolateral ligament of the knee. Arthroscopy 30:1475–1482CrossRefPubMedGoogle Scholar
  7. 7.
    Claes S, Vereecke E, Maes M, Victor J, Verdonk P, Bellemans J (2013) Anatomy of the anterolateral ligament of the knee. J Anat 223:321–328CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    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 25:1078–1085CrossRefPubMedGoogle Scholar
  9. 9.
    Daggett M, Busch K, Sonnery-Cottet B (2016) Surgical dissection of the anterolateral ligament. Arthrosc Tech 5:e185–e188CrossRefPubMedPubMedCentralGoogle Scholar
  10. 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. 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
  12. 12.
    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:325–331CrossRefGoogle Scholar
  13. 13.
    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 33:147–154CrossRefPubMedGoogle Scholar
  14. 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
  15. 15.
    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 45:849–855CrossRefPubMedGoogle Scholar
  16. 16.
    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 1:2325967113513546CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    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 33:140–146CrossRefPubMedGoogle Scholar
  18. 18.
    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 25:1009–1014CrossRefPubMedGoogle Scholar
  19. 19.
    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 34:251–260CrossRefPubMedGoogle Scholar
  20. 20.
    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 31:2022–2034CrossRefPubMedGoogle Scholar
  21. 21.
    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 33:595–604CrossRefPubMedGoogle Scholar
  22. 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
  23. 23.
    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 45:3081–3088CrossRefPubMedGoogle Scholar
  24. 24.
    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 45:3089–3097CrossRefPubMedGoogle Scholar
  25. 25.
    Inderhaug E, Stephen JM, Williams A, Amis AA (2017) Biomechanical comparison of anterolateral procedures combined with anterior cruciate ligament reconstruction. Am J Sports Med 45:347–354CrossRefPubMedGoogle Scholar
  26. 26.
    Kaplan EB (1958) The iliotibial tract; clinical and morphological significance. J Bone Jt Surg Am 40-A:817–832CrossRefGoogle Scholar
  27. 27.
    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 43:1606–1615CrossRefPubMedGoogle Scholar
  28. 28.
    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 44:345–354CrossRefPubMedGoogle Scholar
  29. 29.
    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 43:354–362CrossRefPubMedGoogle Scholar
  30. 30.
    Klos B, Scholtes M, Konijnenberg S (2017) High prevalence of all complex Segond avulsion using ultrasound imaging. Knee Surg Sports Traumatol Arthrosc 25:1331–1338CrossRefPubMedGoogle Scholar
  31. 31.
    Lobenhoffer P, Posel P, Witt S, Piehler J, Wirth CJ (1987) Distal femoral fixation of the iliotibial tract. Arch Orthop Trauma Surg 106:285–290CrossRefPubMedGoogle Scholar
  32. 32.
    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 475:2401–2408CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Lubowitz JH, Provencher MT, Brand JC, Rossi MJ (2014) The knee anterolateral ligament. Arthroscopy 30:1385–1388CrossRefPubMedGoogle Scholar
  34. 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
  35. 35.
    Muller W (1984) Functional anatomy and clinical findings of the knee joint. Helv Chir Acta 51:505–514PubMedGoogle Scholar
  36. 36.
    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 44:3126–3131CrossRefPubMedGoogle Scholar
  37. 37.
    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 24:2–3CrossRefPubMedGoogle Scholar
  38. 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
  39. 39.
    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 99:305–314CrossRefGoogle Scholar
  40. 40.
    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) CrossRefPubMedGoogle Scholar
  41. 41.
    Pearl AJ, Bergfeld JA (1992) Extra-articular reconstruction in the anterior cruciate ligament deficient knee. Am Orthop Soc Sports MedGoogle Scholar
  42. 42.
    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 38:1094–1102CrossRefPubMedGoogle Scholar
  43. 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
  44. 44.
    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 25:1086–1092CrossRefPubMedGoogle Scholar
  45. 45.
    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 44:2546–2556CrossRefPubMedGoogle Scholar
  46. 46.
    Seebacher JR, Inglis AE, Marshall JL, Warren RF (1982) The structure of the posterolateral aspect of the knee. J Bone Jt Surg Am 64:536–541CrossRefGoogle Scholar
  47. 47.
    Segond P (1879) Recherches cliniques et experimentales sur les epanchements sanguins du genou par entorse. Progres Medical. http://www.patrimoine.edilivre.com/
  48. 48.
    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 43:905–911CrossRefPubMedGoogle Scholar
  49. 49.
    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) CrossRefPubMedGoogle Scholar
  50. 50.
    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 32:898–905CrossRefPubMedGoogle Scholar
  51. 51.
    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 44:1209–1214CrossRefPubMedGoogle Scholar
  52. 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
  53. 53.
    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 43:1598–1605CrossRefPubMedGoogle Scholar
  54. 54.
    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 43:2189–2197CrossRefPubMedGoogle Scholar
  55. 55.
    Terry GC, Hughston JC, Norwood LA (1986) The anatomy of the iliopatellar band and iliotibial tract. Am J Sports Med 14:39–45CrossRefPubMedGoogle Scholar
  56. 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
  57. 57.
    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 98:937–943CrossRefGoogle Scholar
  58. 58.
    Vieira EL, Vieira EA, da Silva RT, Berlfein PA, Abdalla RJ, Cohen M (2007) An anatomic study of the iliotibial tract. Arthroscopy 23:269–274CrossRefPubMedGoogle Scholar
  59. 59.
    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 20:147–152CrossRefPubMedGoogle Scholar
  60. 60.
    Webster KE, Feller JA (2016) Exploring the high reinjury rate in younger patients undergoing anterior cruciate ligament reconstruction. Am J Sports Med 44:2827–2832CrossRefPubMedGoogle Scholar
  61. 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
  62. 62.
    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 43:2545–2552CrossRefPubMedGoogle Scholar

Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2018

Authors and Affiliations

  1. 1.Fowler Kennedy Sport Medicine ClinicUniversity of Western OntarioLondonCanada
  2. 2.International Knee and Joint CentreAbu DhabiUAE
  3. 3.Melbourne Orthopaedic GroupMelbourneAustralia
  4. 4.Imperial College LondonLondonUK
  5. 5.AZ HerentalsHerentalsBelgium
  6. 6.Western Michigan UniversityKalamazooUSA
  7. 7.University of Pittsburgh Medical CentrePittsburghUSA

Personalised recommendations