This consensus paper, developed by the Anterolateral Ligament (ALL) Expert Group, provides an overview of the latest research on the ALL and presents agreed-upon guidelines for managing internal rotation and instability in anterior cruciate ligament (ACL)-deficient knees. The paper addresses various aspects, including:
- Anatomy: The ALL is consistently identified deep to the iliotibial band, originating just posterior and proximal to the lateral epicondyle and inserting approximately 21.6 mm posterior to Gerdy’s tubercle and 4–10 mm below the tibial joint line.
- Radiographic Landmarks: On lateral radiographic views, the femoral origin is located in the postero-inferior quadrant, and the tibial attachment is near the center of the proximal tibial plateau.
- Biomechanics: Favorable isometry during ALL reconstruction is achieved when the femoral position is proximal and posterior to the lateral epicondyle, with the ALL being tight upon extension and lax upon flexion.
- Diagnosis: The ALL can be visualized using ultrasound or T2-weighted coronal MRI scans with proton density fat-suppressed evaluation.
- Lesion Classification: ALL injuries are often associated with Segond fractures and commonly occur alongside acute ACL injuries.
- Surgical Technique and Outcomes: For high-risk patients, combined ACL and ALL reconstruction improves rotational control and reduces the rate of re-rupture without increasing postoperative complication rates compared to ACL-only reconstruction.
The consensus emphasizes that recognizing and addressing ALL lesions can enhance rotational stability in ACL-deficient knees.
Professor Wilson’s Comments
“As with all consensus documents, this was a very important piece of work that helps guide surgeons on current thinking and the latest treatment approaches — clarifying what is established, what is new, and when and where each technique should be applied.
The anterolateral ligament (ALL) was first brought back into prominence through the work of Steven Claes and Johan Bellemans, forming part of Steven’s PhD. Their findings even made it into the newspapers, as it came as a major surprise to the medical world that surgeons had, in effect, rediscovered a “new” ligament!
Historically, the ligament had first been described by Paul Segond, a French gynaecologist, at the turn of the 20th century. He identified a characteristic type of fracture associated with a specific ligament injury, which became known as the Segond fracture. Today, when we see this fracture on an X-ray, we immediately know that the patient has almost certainly ruptured their ACL.
I was particularly inspired by Steven Claes’ presentation of his PhD, where he explained the biomechanics and anatomy of the anterolateral ligament in great detail. This prompted me to apply the all-inside technique to create an anterolateral ligament reconstruction using a free graft — something that became standard practice in my own surgical work, with consistently excellent results.
Patrice Sonnery-Cottet, a close friend and one of the highest-volume ligament surgeons in Europe, also performs a form of anterolateral or lateral extra-articular tenodesis. He hosted a meeting where we all came together to discuss the importance of adding an extra-articular procedure and to develop clear guidelines for surgeons on how and when to perform it.
I was very proud to be invited to contribute to this exceptional consensus group — another truly collaborative effort that has helped guide surgeons and benefited patients worldwide.”Link to the full paper: Anterolateral Ligament Expert Group Consensus Paper on the Management of Internal Rotation and Instability of the Anterior Cruciate Ligament-Deficient Knee
