In the same way as we have a posterolateral corner of the knee I’m sure we are now moving into an era where we’re going to talk about the anterolateral corner of the knee.
The important structures in this corner include the anterolateral ligament at the front of the triangle, with the back of the triangle being the lateral collateral ligament and the inferior part being the capsule.
Sceptics continue to ask how is it possible to find a new ligament? Nonetheless our fraternity did not appreciate the medial patellofemoral ligament (MPFL) until 2000 - and since 2000 surgeons have developed surgical techniques for MPFL reconstruction and helped a lot of patellar patients. But we have at last come to appreciate the relationship of the ALL to a condition that we have known for a long time - and that is the 'Segond fracture' - that subtle avulsion fracture on the lateral aspect of the tibial plateau so often associated with ACL injury. You can see the little flake of bone on the lateral aspect of the X-ray (to the left of the first picture).
Paul Segond - who was actually a gynaecologist - in 1879 dissected the tissue out that was attached to that bony fragment and presented his findings at that time in one of the French scientific journals, but the true importance failed to be understood. The photo on the right shows how they re-created Segond's discoveries in LaPrade’s laboratory in Vail with an experimental dissection.
But Steven Claes’ work in the last few years (ref 2, 4) really has led the way on the anatomy, and his paper which was published in the Journal of Anatomy in 2013 has already become a classic. Some great evidence is emerging from his work with Rob LaPrade from the Steadman Hawkins Philippon Institute in Vail, Colorado - where they’ve repeated the anatomical and biomechanical studies.
When I was in Warsaw in 2013 a very senior Consultant Radiologist said that she had been seeing this injury for many, many years and she was just waiting and wondering why surgeons hadn’t picked it up because she could clearly see a structure that was being injured on a regular basis. So, who get’s it?
Well we know all about extraarticular structures and we’ve had extraarticular reconstructions for many, many years and there are many good papers. Werner Muller was a leading European surgeon who realised the importance of these, and was really one of the first people to really think about structures on the lateral side such as the ALL. Jack Hughston - another father figure of sports knee surgery - also realised their importance and developed his own techniques for tightening these structures. And then the procedure that we’ve all been doing for many years is the MacIintosh – which involves a big incision, taking a strip out of the existing ITB to tether the side of the knee - and I just was never happy with that as a reconstruction.
1. Behavior of the anterolateral structures of the knee during internal rotation. Lutz C, Sonnery-Cottet B, Niglis L, Freychet B, Clavert P, Imbert P.Orthop Traumatol Surg Res. 2015 Sep;101(5):523-8.
2. Anatomy of the anterolateral ligament of the knee. Claes S, Vereecke E, Maes M, Victor J, Verdonk P, Bellemans J.J Anat. 2013 Oct;223(4):321-8. (FULL PAPER - FREE)
3. Arthroscopic Identification of the Anterolateral Ligament of the Knee. Sonnery-Cottet B, Archbold P, Rezende FC, Neto AM, Fayard JM, Thaunat M1. Arthrosc Tech. 2014 Jun 9;3(3):389-92. (FULL PAPER - FREE)
4. The Segond fracture: a bony injury of the anterolateral ligament of the knee. Claes S, Luyckx T, Vereecke E, Bellemans J.Arthroscopy. 2014 Nov;30(11):1475-82.
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After ACL reconstruction, 63% of patients return to their pre-injury levels of sport - which means that 40% don’t and that's not good. The anterolateral ligament (ALL) could be key to improving those numbers.
Take a look at this cadaveric video of rotational stability of the knee before and after one cuts the reconstructed ALL. It shows clearly how much the rotation increases -
The 2015 study by Lutz, Sonnery-Cottet et al. describes two distinct anterolateral tissue layers that are tightened when going from neutral rotation of the tibia to internal rotation (ref 1):
Bertrand's insights into the anatomy of the ALL have added considerably to our understanding, and especially the matter of the ligament naturally being tight in extension and loose in flexion, and how this should be replicated in ALL repair (ref 3).
I think the indications for ALL reconstructions are large pivot shifts where the knee is very unstable – that’s what the video shows – all revision ACL surgeries, athletes, and poorly compliant patients.
Bertrand Sonnery-Cottet’s results are really amazing with a 2 year follow up of 92 cases combined ACL and ALL with only 1 failure.