Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Review
. 2019 Dec;12(4):472-478.
doi: 10.1007/s12178-019-09587-x.

Anterior Cruciate Ligament Injury and the Anterolateral Complex of the Knee-Importance in Rotatory Knee Instability?

Elan J Golan  1 , Robert Tisherman  1   2 , Kevin Byrne  1 , Theresa Diermeier  1   3 , Ravi Vaswani  1 , Volker Musahl  4   5
Affiliations
Review

Anterior Cruciate Ligament Injury and the Anterolateral Complex of the Knee-Importance in Rotatory Knee Instability?

Elan J Golan et al. Curr Rev Musculoskelet Med. 2019 Dec.

Abstract

Purpose of review: In the setting of rotatory knee instability following anterior cruciate ligament (ACL) reconstruction, there has been a resurgence of interest in knee's anterolateral complex (ALC). Reconstruction or augmentation of the ALC with procedures such as a lateral extra-articular tenodesis (LET) has been proposed to reduce rotatory knee instability in conjunction with ACL reconstruction. The current review investigates the recent literature surrounding the role of the ALC in preventing rotatory knee instability.

Recent findings: The knee's anterolateral complex (ALC) is a complex structure composed of the superficial and deep portions of the iliotibial band, the capsulo-osseous layer, and the anterolateral capsule. Distally, these various layers merge to form a single functional unit which imparts stability to the lateral knee. While the iliotibial band and the capsule-osseous layer have been shown to be primary restraints to rotatory motion after ACL injury, the biomechanical role of the anterolateral capsule remains unclear. Biomechanical studies have shown that the anterolateral capsule and the anterolateral thickening of this capsule act as a sheet of fibrous tissue which does not resist motion around the knee as other longitudinally oriented ligaments do. Augmentation of the ALC, with LET, has been performed globally for over 30 years. This procedure can decrease rotatory knee instability, but long-term studies have found little difference in patient-reported outcomes, osteoarthritis, or ACL reconstruction failure with the addition of LET. Further research is needed to clarify indications for the clinical use of ALC-based procedures.

Keywords: ACL; Anterolateral capsule; Extra-articular tenodesis; Rotatory stability.

PubMed Disclaimer

Conflict of interest statement

Volker Musahl, Elan Golan, Robert Tischman, Theresa Diermeier, Ravi Vaswani, and Kevin Byrne declare that they have no conflict of interest.

Figures

Fig. 1
Fig. 1
Lateral view on a left knee of a 46-year-old specimen. To enable visualization of the anterolateral structures, the iliotibial band was carefully dissection from the underlying tissue, a starting proximally and b ending with the transection from the Gerdy tubercle. ALC, anterolateral capsule; FH, fibula head; ITB, iliotibial band; LCL, lateral collateral ligament. (Adapted from Guenther D et al. The Anterolateral Capsule of the Knee Behaves Like a Sheet of Fibrous Tissue. The American Journal of Sports Medicine. 2012; 45(4), 849–855. 10.1177/0363546516674477)
Fig. 2
Fig. 2
In situ forces in response to a a 134-N anterior tibial load and b a 7-Nm internal tibial torque in the intact knee and in response to c a 134 anterior tibial load and d a 7-Nm internal tibial roque in the ACL-deficient knee. ACL, anterior cruciate ligament; ALC, anterolateral capsule; ALC Sep, anterolateral capsule separation (forces transmitted between anterolateral capsular regions); LCL, lateral collateral ligament. The areas shaded represent the SDs. (Adapted from Guenther D et al. The Anterolateral Capsule of the Knee Behaves Like a Sheet of Fibrous Tissue. The American Journal of Sports Medicine. 2012; 45(4), 849–855. 10.1177/0363546516674477)
See this image and copyright information in PMC

References

    1. Ariel de Lima D, Helito CP, Lacerda de Lima L, de Castro Silva D, Costa Cavalcante ML, Dias Leite JA. Anatomy of the anterolateral ligament of the knee: a systematic review. Arthroscopy. 2019. - PubMed
    1. Astur DC, Santos CV, Aleluia V, Astur Neto N, Arliani GG, Kaleka CC, Skaf A, Cohen M. Characterization of cruciate ligament impingement: the influence of femoral or tibial tunnel positioning at different degrees of knee flexion. Arthroscopy. 2013;29:913–919. - PubMed
    1. Bedi A, Maak T, Musahl V, Citak M, O’Loughlin PF, Choi D, Pearle AD. Effect of tibial tunnel position on stability of the knee after anterior cruciate ligament reconstruction: is the tibial tunnel position most important? Am. J. Sports Med. 2011;39:366–373. - PubMed
    1. Bell KM, Rahnemai-Azar AA, Irarrazaval S, Guenther D, Fu FH, Musahl V, Debski RE. 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. 2018;36:847–853. - PubMed
    1. •• Bryant D, Getgood A, Litchfield R, McCormack RG, Heard M, Macdonald PB, Spalding T, Verdonk P, Peterson D, Bardana D, Rezansoff A, Group SS. Predictors of poor outcome Following ACL reconstruction with or without lateral extra-articular tenodesis: the stability experience. In: ISAKOS Biennial Congress.; 2019:Paper #130. Study constitutes the first randomized, high level investigation of outcomes following the addition of a LET procedure to ACL reconstruction