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Journal ArticleDOI

Anatomy of the anterolateral ligament of the knee

TL;DR: The ALL was found to be a distinct ligamentous structure at the anterolateral aspect of the human knee with consistent origin and insertion site features, and is hypothesized to control internal tibial rotation and thus to affect the pivot shift phenomenon, although further studies are needed to investigate its biomechanical function.
Abstract: In 1879, the French surgeon Segond described the existence of a 'pearly, resistant, fibrous band' at the anterolateral aspect of the human knee, attached to the eponymous Segond fracture. To date, the enigma surrounding this anatomical structure is reflected in confusing names such as '(mid-third) lateral capsular ligament', 'capsulo-osseous layer of the iliotibial band' or 'anterolateral ligament', and no clear anatomical description has yet been provided. In this study, the presence and characteristics of Segond's 'pearly band', hereafter termed anterolateral ligament (ALL), was investigated in 41 unpaired, human cadaveric knees. The femoral and tibial attachment of the ALL, its course and its relationship with nearby anatomical structures were studied both qualitatively and quantitatively. In all but one of 41 cadaveric knees (97%), the ALL was found as a well-defined ligamentous structure, clearly distinguishable from the anterolateral joint capsule. The origin of the ALL was situated at the prominence of the lateral femoral epicondyle, slightly anterior to the origin of the lateral collateral ligament, although connecting fibers between the two structures were observed. The ALL showed an oblique course to the anterolateral aspect of the proximal tibia, with firm attachments to the lateral meniscus, thus enveloping the inferior lateral geniculate artery and vein. Its insertion on the anterolateral tibia was grossly located midway between Gerdy's tubercle and the tip of the fibular head, definitely separate from the iliotibial band (ITB). The ALL was found to be a distinct ligamentous structure at the anterolateral aspect of the human knee with consistent origin and insertion site features. By providing a detailed anatomical characterization of the ALL, this study clarifies the long-standing enigma surrounding the existence of a ligamentous structure connecting the femur with the anterolateral tibia. Given its structure and anatomic location, the ALL is hypothesized to control internal tibial rotation and thus to affect the pivot shift phenomenon, although further studies are needed to investigate its biomechanical function.
Citations
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Journal ArticleDOI
TL;DR: This study demonstrates that a combined reconstruction can be an effective procedure without specific complications at a minimum follow-up of 2 years and is demonstrated to improve the results of ACL treatment.
Abstract: Background:The anterolateral ligament has recently been identified as an important structure involved in rotational laxity after anterior cruciate ligament (ACL) rupture. Results of a combined ACL and anterolateral ligament (ALL) reconstruction technique have never been reported.Purpose:To report subjective and objective outcomes after combined ACL and minimally invasive ALL reconstruction with a minimum 2-year follow-up.Study Design:Case series; Level of evidence, 4.Methods:A total of 92 patients underwent a combined ACL and ALL reconstruction. Indications for a combined procedure were associated Segond fracture, chronic ACL lesion, grade 3 pivot shift, high level of sporting activity, pivoting sports, and radiographic lateral femoral notch sign. Patients were assessed pre- and postoperatively with objective and subjective International Knee Documentation Committee (IKDC) score, Lysholm score, and Tegner activity scale. Instrumented knee testing was performed with the Rolimeter arthrometer. The Knee inju...

380 citations


Cites background from "Anatomy of the anterolateral ligame..."

  • ...An identifiable ALL has only recently been described by several authors.(4,8,11,15,50) Its existence was suspected as early as 1879, when Segond(40) described the now-eponymous avulsion fractures of the proximal tibia above and behind the Gerdy tubercle....

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Journal ArticleDOI
TL;DR: In the eight knees in which it was measured, the anterolateral ligament was isometric from 0° to 60° of flexion of the knee, then slackened when the knee flexed further to 90° and was lengthened by imposing tibial internal rotation.
Abstract: There have been differing descriptions of the anterolateral structures of the knee, and not all have been named or described clearly. The aim of this study was to provide a clear anatomical interpretation of these structures. We dissected 40 fresh-frozen cadaveric knees to view the relevant anatomy and identified a consistent structure in 33 knees (83%); we termed this the anterolateral ligament of the knee. This structure passes antero-distally from an attachment proximal and posterior to the lateral femoral epicondyle to the margin of the lateral tibial plateau, approximately midway between Gerdy’s tubercle and the head of the fibula. The ligament is superficial to the lateral (fibular) collateral ligament proximally, from which it is distinct, and separate from the capsule of the knee. In the eight knees in which it was measured, we observed that the ligament was isometric from 0° to 60° of flexion of the knee, then slackened when the knee flexed further to 90° and was lengthened by imposing tibial internal rotation. Cite this article: Bone Joint J 2014;96-B:325–31.

361 citations

Journal ArticleDOI
TL;DR: In a high-risk population of young patients participating in pivoting sports, the rate of graft failure with HT+ALL grafts was 2.5 times less than with B-PT-B grafts and 3.1 timesLess than with 4HT grafts, which is associated with higher odds of returning to preinjury levels of sport.
Abstract: Background:Graft failure and low rates of return to sport are major concerns after anterior cruciate ligament (ACL) reconstruction, particularly in a population at risk.Purpose:To evaluate the asso...

333 citations


Cites background from "Anatomy of the anterolateral ligame..."

  • ...It is for this reason that there is currently great interest in the role of the anterolateral structures of the knee in controlling rotatory laxity and their ability to share loads with the ACL graft.(5,18,39,44) However, there are concerns, based on past studies and current expert opinion, that lateral extra-articular reconstruction is nonanatomic and may potentially overconstrain the joint because of altered biomechanics....

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Journal ArticleDOI
TL;DR: The biomechanical analysis suggests that most traditional soft tissue grafts are sufficient for ALL reconstruction, and defined ALL attachment locations can be reproducibly identified with intraoperative landmarks or radiographs.
Abstract: Background:Recent publications have described significant variability in the femoral attachment and overall anatomy of the anterolateral ligament (ALL). Additionally, there is a paucity of data describing its structural properties.Purpose:Quantitative data characterizing the anatomic and radiographic locations and the structural properties of the ALL may be used to guide graft selection and placement and to facilitate the future development of an evidence-based approach to ALL reconstructions.Study Design:Descriptive laboratory study.Methods:Identification of the ALL was performed by a combined outside-in and inside-out anatomic dissection of 15 nonpaired fresh-frozen cadaveric knees. Quantitative anatomic relationships were calculated using a 3-dimensional coordinate measuring device. Measurements on anteroposterior (AP) and lateral radiographs were obtained by use of a picture archiving and communications system program. Structural properties were characterized during a single pull-to-failure test using...

298 citations


Cites background or result from "Anatomy of the anterolateral ligame..."

  • ...The present study clarifies previous anatomic studies of the ALL that have disagreed regarding the location of the femoral attachment.(1,3,5,9,10,17,27) The femoral attachment was described by Claes et al(3) and Vincent et al(27) to be anterior and distal to the femoral FCL attachment, while Caterine et al,(1) Dodds et al,(5) Rezansoff et al,(17) and Helito et al(9,10) subsequently described attachments ranging from anterior-distal to posterior-proximal to the femoral origin of the FCL....

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  • ...However, tibial attachments were consistently described across investigations to be approximately midway between the center of the Gerdy tubercle and the fibular head, with some minor variability regarding associations and attachments to the lateral meniscus.(1,3,5,9,10,27) Clearly, there remain discrepancies as to the ALL’s anatomic locations and quantitative characteristics....

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  • ...More recently, authors have proposed a direct link between the ALL tibial attachment and Segond fractures.(2,3,5) The present study supports these results, reproducing the work of Segond by eliciting an avulsion fracture on the anterolateral tibia via the ALL attachment in 6 of the 15 specimens....

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  • ...Anatomically, these clinical observations have stimulated further research on the structural components and stabilizing contributions of the anterolateral region of the knee, which has led to the subsequent ‘‘rediscovery’’ and detailed characterization of the anterolateral ligament (ALL).(3) Furthermore, a close association of ALL injuries with ACL tears, along with residual anterolateral rotatory instability on the pivot shift test, has led to In-Depth...

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  • ...Previous literature has noted that fibers of the ALL become taut with an applied internal rotation between 30 and 60 of knee flexion.(3) Through use of both an outside-in and inside-out anatomic dissection in combination with an applied internal rotation, tensioned fibers of the lateral capsule coursing from posterior and proximal to the lateral femoral epicondyle to the area between the Gerdy tubercle and the anterior margin of the fibular head were identified as the ALL (Figure 1)....

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Journal ArticleDOI
TL;DR: The addition of LET to a single-bundle hamstring tendon autograft ACLR in young patients at high risk of failure results in a statistically significant, clinically relevant reduction in graft rupture and persistent rotatory laxity at 2 years after surgery.
Abstract: Background:Persistent anterolateral rotatory laxity after anterior cruciate ligament (ACL) reconstruction (ACLR) has been correlated with poor clinical outcomes and graft failure.Hypothesis:We hypo...

284 citations


Additional excerpts

  • ...01 Exposure to sport, mo, median (IQR) 13 (4-16) 13 (5-15) ....

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  • ...52 Time to RTS, mo, median (IQR) 11 (8-14) 11 (8-17) ....

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  • ...05 Medial 75 (24) 91 (20) Lateral 36 (12) 24 (8) Both 19 (6) 18 (6) Change in rehabilitation due to meniscal repair, n (%) 51 (16) 50 (16) ....

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References
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Journal ArticleDOI
TL;DR: Based on the clinical and operative findings in sixty-eight knees with acute tears of the medial compartment and cruciate ligaments, a standardized terminology and classification of knee ligament instability is presented.
Abstract: Based on the clinical and operative findings in sixty-eight knees with acute tears of the medial compartment and cruciate ligaments, a standardized terminology and classification of knee ligament instability is presented. With an intact posterior cruciate ligament, anteromedial, anterolateral, or posterolateral rotatory instability may occur, but not true posteromedial rotatory instability. With the posterior cruciate ligament ruptured, straight anterior, posterior, medial, or lateral instability may be found.

785 citations


"Anatomy of the anterolateral ligame..." refers background in this paper

  • ...However, the notion of this structure was eventually forgotten, until Jack Hughston published his findings on rotatory knee instability patterns in the late 1970s (Hughston et al. 1976a,b)....

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  • ...These sporadic reports mention the ‘anterior band of the lateral collateral ligament’ (Irvine et al. 1987), the ‘(mid-third) lateral capsular ligament’ (Hughston et al. 1976b; Johnson, 1979; Haims Correspondence Steven Claes, Department of Orthopedic Surgery & Traumatology, University Hospitals…...

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  • ...…closest description of an ALL-like structure in the current literature would be the one by Jack Hughston, depicting the ‘middlethird of the lateral capsular ligament’ as attaching ‘proximally to the lateral epicondyle of the femur and distally at the tibial joint margin’ (Hughston et al. 1976b)....

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  • ...It was thought to play an important role in the so-called ‘anterolateral instability’ (ALRI) pattern of the knee (Hughston et al. 1976b; Norwood et al. 1979), a clinical term which has become obsolete with the advent of knee arthroscopy (and its inherent predominance in the diagnosis of…...

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  • ...According to Hughston, this capsular ligament is ‘strong and supported superficially by the iliotibial band’ (Hughston et al. 1976a)....

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Journal ArticleDOI
TL;DR: The medial knee ligament structures have a consistent attachment pattern and a third osseous prominence, the gastrocnemius tubercle, which corresponded to the attachment site of the medial gastrocmius tendon, was identified.
Abstract: Background: While the anatomy of the medial part of the knee has been described qualitatively, quantitative descriptions of the attachment sites of the main medial knee structures have not been reported. The purpose of the present study was to verify the qualitative anatomy of medial knee structures and to perform a quantitative evaluation of their anatomic attachment sites as well as their relationships to pertinent osseous landmarks. Methods: Dissections were performed and measurements were made for eight nonpaired fresh-frozen cadaveric knees with use of an electromagnetic three-dimensional tracking sensor system. Results: In addition to the medial epicondyle and the adductor tubercle, a third osseous prominence, the gastrocnemius tubercle, which corresponded to the attachment site of the medial gastrocnemius tendon, was identified. The average length of the superficial medial (tibial) collateral ligament was 94.8 mm. The superficial medial collateral ligament femoral attachment was 3.2 mm proximal and 4.8 mm posterior to the medial epicondyle. The superficial medial collateral ligament had two separate attachments on the tibia. The distal attachment of the superficial medial collateral ligament on the tibia was 61.2 mm distal to the knee joint. The deep medial collateral ligament consisted of meniscofemoral and meniscotibial portions. The posterior oblique ligament femoral attachment was 7.7 mm distal and 6.4 mm posterior to the adductor tubercle and 1.4 mm distal and 2.9 mm anterior to the gastrocnemius tubercle. The medial patellofemoral ligament attachment on the femur was 1.9 mm anterior and 3.8 mm distal to the adductor tubercle. Conclusions: The medial knee ligament structures have a consistent attachment pattern. Clinical Relevance: Identification of the gastrocnemius tubercle and the quantitative relationships presented here will be useful in the study of anatomic repairs and reconstructions of complex ligamentous injuries that involve the medial knee structures.

694 citations


"Anatomy of the anterolateral ligame..." refers background in this paper

  • ...In this view, the ALL can be regarded as the lateral counterpart of the deep medial collateral ligament (dMCL) (LaPrade et al. 2007)....

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  • ...With both the LCL and ALL being part of Layer III, and given the fact that the femoral origins of ALL and LCL are so closely associated, we propose to envelop both structures in the term ‘lateral collateral ligament complex’ (LCLC), as has been previously introduced for the medial collateral ligaments (Robinson et al. 2004; LaPrade et al. 2007)l....

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Journal ArticleDOI
TL;DR: Anterolateral rotatory subluxation is present when the anterior drawer test with the tibia in neutral rotation demonstrates that the lateral tibial condyle appears to become more prominent or that both condyles appear to become equally prominent.
Abstract: Lateral instability of the knee is less frequent but more disabling than medial instability of a comparable amount. At the same time the diagnostic tests for lateral instability are more subtle and more frequently misinterpreted. Posterolateral rotatory subluxation is demonstrated by an apparently positive posterior drawer test with the tibia in neutral rotation or by the external rotation-recurvatum test with the knee in extension. Anterolateral rotatory subluxation is present when the anterior drawer test with the tibia in neutral rotation demonstrates that the lateral tibial condyle appears to become more prominent or that both condyles appear to become equally prominent.

678 citations


"Anatomy of the anterolateral ligame..." refers background in this paper

  • ...However, the notion of this structure was eventually forgotten, until Jack Hughston published his findings on rotatory knee instability patterns in the late 1970s (Hughston et al. 1976a,b)....

    [...]

  • ...These sporadic reports mention the ‘anterior band of the lateral collateral ligament’ (Irvine et al. 1987), the ‘(mid-third) lateral capsular ligament’ (Hughston et al. 1976b; Johnson, 1979; Haims Correspondence Steven Claes, Department of Orthopedic Surgery & Traumatology, University Hospitals…...

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  • ...…closest description of an ALL-like structure in the current literature would be the one by Jack Hughston, depicting the ‘middlethird of the lateral capsular ligament’ as attaching ‘proximally to the lateral epicondyle of the femur and distally at the tibial joint margin’ (Hughston et al. 1976b)....

    [...]

  • ...It was thought to play an important role in the so-called ‘anterolateral instability’ (ALRI) pattern of the knee (Hughston et al. 1976b; Norwood et al. 1979), a clinical term which has become obsolete with the advent of knee arthroscopy (and its inherent predominance in the diagnosis of…...

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  • ...Its insertion on the anterolateral tibia was grossly located midway between Gerdy’s tubercle and the tip of the fibular head, definitely separate from the iliotibial band (ITB)....

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Journal ArticleDOI
TL;DR: The lateral structures of the knee can be divided into three distinct layers: the deepest layer, the lateral part of the capsule, divides into two laminae just posterior to the overlying iliotibial tract and the lateral collateral, the fabellofibular, and the arcuate ligaments.
Abstract: The lateral structures of the knee can be divided into three distinct layers. The deepest layer, the lateral part of the capsule, divides into two laminae just posterior to the overlying iliotibial tract. These laminae encompass three ligaments: the lateral collateral, the fabellofibular, and the arcuate ligaments. Three major anatomical variations are seen: reinforcement of the capsule by the arcuate ligament alone (13 per cent), by the fabellofibular ligament alone (20 per cent), and by both ligaments (67 per cent). One can predict which variation will be seen in a given patient from the information provided by a radiograph and by physical examination.

413 citations


"Anatomy of the anterolateral ligame..." refers background in this paper

  • ...…between the distal ITB and the ALL: the center of their respective insertion sites are separated by more than 20 mm on the proximal tibia, and as (Seebacher et al. 1982) have shown, the only connection between the ITB (Layer I) and the deepest layer (Layer III) occurs at the patellar retinaculum…...

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  • ...With the ITB reflected, the ‘superficial lamina of the capsule’ (Seebacher et al. 1982) was visualized....

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  • ...Indeed, according to Seebacher et al. (1982), the ITB forms the most superficial distinct tissue layer (Layer I) on the lateral aspect of the knee, only attached to the deeper Layer II anteriorly at the lateral patellar retinaculum....

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  • ...Whereas Segond described a ‘pearly, fibrous band’ attached to his flake fracture, later literature has only rarely mentioned the presence of a ligamentous structure connecting the femur with the anterolateral tibia....

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  • ...…band of the lateral collateral ligament’ (Irvine et al. 1987), the ‘(mid-third) lateral capsular ligament’ (Hughston et al. 1976b; Johnson, 1979; Haims Correspondence Steven Claes, Department of Orthopedic Surgery & Traumatology, University Hospitals Leuven, Weligerveld 1 B-3212 Pellenberg,…...

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Journal ArticleDOI
TL;DR: The anterolateral ligament may play a role in preventing anterior tibial translation and the role, if any, of this structure in meniscal stability and the pathology of meniscal tears remain unclear.
Abstract: Purpose The functional anatomy of the knee is frequently studied but remains incompletely understood. Numerous authors have described a structure in the lateral knee connecting the lateral femoral condyle with the lateral meniscus and tibial plateau. The goal of this study is to define the incidence, anatomy, and histology of this structure, the anterolateral ligament.

368 citations


"Anatomy of the anterolateral ligame..." refers background or result in this paper

  • ...Although Vincent et al. (2012) provide a schematic diagram of the ALL and its suggested relation with wellknown lateral stabilizing structures, our findings do not agree with their description....

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  • ...The structure was easily distinguishable from the thinner joint capsule lying anterior to it (Fig....

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  • ...…338803; E: steven.claes@uzleuven.be Accepted for publication 11 July 2013 Article published online 1 August 2013 © 2013 Anatomical Society et al. 2003; Moorman & LaPrade, 2005), ‘anterior oblique band’ (Campos et al. 2001) or the ‘anterolateral ligament’ (Vieira et al. 2007; Vincent et al. 2012)....

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  • ...Recently, Vincent et al. (2012) reported their observations during total knee arthroplasty procedures, when the authors noticed ‘a relatively consistent structure in the lateral knee, linking the lateral femoral condyle, the lateral meniscus, and the lateral tibial plateau’ (Vincent et al. 2012)....

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  • ...By providing a detailed anatomical characterization of the ALL, this study clarifies the long-standing enigma surrounding the existence of a ligamentous structure connecting the femur with the anterolateral tibia....

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