Anterolateral Ligament Expert Group consensus paper on the management of internal rotation and instability of the anterior cruciate ligament - deficient knee

Abstract

Purpose of this paper is to provide an overview of the latest research on the anterolateral ligament (ALL) and present the consensus of the ALL Expert Group on the anatomy, radiographic landmarks, biomechanics, clinical and radiographic diagnosis, lesion classification, surgical technique and clinical outcomes. A consensus on controversial subjects surrounding the ALL and anterolateral knee instability has been established based on the opinion of experts, the latest publications on the subject and an exchange of experiences during the ALL Experts Meeting (November 2015, Lyon, France). The ALL is found deep to the iliotibial band. The femoral origin is just posterior and proximal to the lateral epicondyle; the tibial attachment is 21.6 mm posterior to Gerdy’s tubercle and 4–10 mm below the tibial joint line. On a lateral radiographic view the femoral origin is located in the postero-inferior quadrant and the tibial attachment is close to the centre of the proximal tibial plateau. Favourable isometry of an ALL reconstruction is seen when the femoral position is proximal and posterior to the lateral epicondyle, with the ALL being tight upon extension and lax upon flexion. The ALL can be visualised on ultrasound, or on T2-weighted coronal MRI scans with proton density fat-suppressed evaluation. The ALL injury is associated with a Segond fracture, and often occurs in conjunction with acute anterior cruciate ligament (ACL) injury. Recognition and repair of the ALL lesions should be considered to improve the control of rotational stability provided by ACL reconstruction. For high-risk patients, a combined ACL and ALL reconstruction improves rotational control and reduces the rate of re-rupture, without increased postoperative complication rates compared to ACL-only reconstruction. In conclusion this paper provides a contemporary consensus on all studied features of the ALL. The findings warrant future research in order to further test these early observations, with the ultimate goal of improving the long-term outcomes of ACL-injured patients. Level of evidence Level V—Expert opinion.

Repair of antero lateral ligament injuries in acute anterior cruciate ligament tears: an in vivo study using navigation

“…This study found that ALL was the primary restraint to tibial rotation, while ACL was the primary restraint to anterior tibial translation. These findings seem to agree with other previous studies confirming that ACL and lateral structure function in a synergistic relationship to control pivot-shift phenomenon (15)(16)(17). Another important finding of the present study relates to the identification of the anterolateral capsule and ligament…”

Combined ACL reconstruction and Segond fracture fixation fails to abolish anterolateral rotatory instability

“…However, it is recognised that in the presence of injury to the anterolateral structures of the knee, isolated ACLR fails to restore normal knee kinematics unless ALL reconstruction or another type of lateral extra-articular tenodesis type procedure is performed 23. In a recent Expert Group consensus paper, SF has recently been described as one of the indications for ALL reconstruction 24. In this case, it was assumed that reduction and fixation of the SF, in addition to ACLR, would therefore abolish the abnormal kinematics known to occur because of injury to the anterolateral knee structures.…”

Anterolateral Ligament (ALL) — Myth or Reality?

“…21 The Anterolateral Ligament Expert Group concluded in a recent paper that there is a consensus that the ALL is a triangular, anterolateral structure found deep to the iliotibial band, admitting that there is a lot of debate concerning the exact specifications of the ligament. 24 …”

“…40 The consensus of the ALL Expert Group stated that the mean load to failure is around 180 N, the mean stiffness is 31 N/mm, and the ALL acts as a restraint for the internal rotation of the tibia and affects the pivot shift in the ACLdeficient knee. 24 …”