The anterolateral ligament of the knee joint: a review of the anatomy, biomechanics, and anterolateral ligament surgery

AbstractResidual knee instability and low rates of return to previous sport are major concerns after anterior cruciate ligament (ACL) reconstruction. To improve outcomes, surgical methods, such as the anatomical single-bundle technique or the double-bundle technique, were developed. However, these reconstruction techniques failed to adequately overcome these problems, and, therefore, new potential answers continue to be of great interest. Based on recent anatomical and biomechanical studies emphasizing the role of the anterolateral ligament (ALL) in rotational stability, novel surgical methods including ALL reconstruction and anterolateral tenodesis have been introduced with the possibility of resolving residual instability after ACL reconstruction. However, there is still little consensus on many aspects of the ALL, including: several anatomical issues, appropriate indications for ALL surgery, and the optimal surgical method and graft choice for reconstruction surgery. Therefore, further studies are necessary to advance our knowledge of the ALL and its contribution to knee stability.

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Review Article: Anatomic Double Bundle Anterior Cruciate Ligament Reconstruction

Journal of Orthopaedic Surgery ◽

10.1177/230949900701500219 ◽

2007 ◽

Vol 15 (2) ◽

pp. 216-221 ◽

Cited By ~ 34

Author(s):

W Shen ◽

S Jordan ◽

F Fu

Keyword(s):

Anterior Cruciate Ligament ◽

Acl Reconstruction ◽

Clinical Investigation ◽

Cruciate Ligament ◽

Double Bundle ◽

Rotational Stability ◽

Single Bundle ◽

Osteoarthritic Change ◽

Anterior Cruciate ◽

Double Bundle Acl Reconstruction

The anterior cruciate ligament (ACL) consists of 2 bundles: a slightly larger anteromedial bundle and a posterolateral bundle, named according to their relative tibial insertion sites. Both bundles are crucial to knee stability. Although it is more technically demanding, a double bundle ACL reconstruction restores the knee biomechanics better and provides more rotational stability than a single bundle ACL reconstruction. Intermediate and long-term clinical investigation including the measurement of rotational laxity and the evaluation of osteoarthritic change is needed to confirm biomechanical and short-term clinical outcomes.

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Anterolateral ligament of the knee: back to the future in anterior cruciate ligament reconstruction

Orthopedic Reviews ◽

10.4081/or.2015.5773 ◽

2015 ◽

Vol 7 (2) ◽

Cited By ~ 12

Author(s):

Davide Edoardo Bonasia ◽

Andrea D'Amelio ◽

Pietro Pellegrino ◽

Federica Rosso ◽

Roberto Rossi

Keyword(s):

Anterior Cruciate Ligament ◽

Acl Reconstruction ◽

Cruciate Ligament ◽

Double Bundle ◽

Anterolateral Ligament ◽

Rotational Instability ◽

Small Subset ◽

Acl Injuries ◽

Anterior Cruciate ◽

Double Bundle Acl Reconstruction

Although the importance of the anterolateral stabilizing structures of the knee in the setting of anterior cruciate ligament (ACL) injuries has been recognized since many years, most of orthopedic surgeons do not take into consideration the anterolateral structures when performing an ACL reconstruction. Anatomic single or double bundle ACL reconstruction will improve knee stability, but a small subset of patients may experience some residual anteroposterior and rotational instability. For this reason, some researchers have turned again towards the anterolateral aspect of the knee and specifically the anterolateral ligament. The goal of this review is to summarize the existing knowledge regarding the anterolateral ligament of the knee, including anatomy, histology, biomechanics and imaging. In addition, the most common anterolateral reconstruction/tenodesis techniques are described together with their respective clinical outcomes.

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Rotational stability after ACL reconstruction using anatomic double bundle technique versus anatomic single bundle technique plus anterolateral ligament augmentation

Journal of Arthroscopy and Joint Surgery ◽

10.1016/j.jajs.2019.01.006 ◽

2019 ◽

Vol 6 (2) ◽

pp. 108-113 ◽

Cited By ~ 1

Author(s):

Begad Hesham Abdelrazek ◽

Ahmed Mahmoud Gad ◽

Ahmed Abdel-Aziz

Keyword(s):

Acl Reconstruction ◽

Double Bundle ◽

Anterolateral Ligament ◽

Rotational Stability ◽

Single Bundle ◽

Double Bundle Technique ◽

Ligament Augmentation

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Clinical Outcome Evaluation of Anatomic Anterior Cruciate Ligament Reconstruction With Tunnel Positioning Using Gold Standard Techniques: A Systematic Review and Meta-analysis

Orthopaedic Journal of Sports Medicine ◽

10.1177/23259671211013327 ◽

2021 ◽

Vol 9 (6) ◽

pp. 232596712110133

Author(s):

Tiago Lazzaretti Fernandes ◽

Hugo Henrique Moreira ◽

Renato Andrade ◽

Sandra Umeda Sasaki ◽

Wanderley Marques Bernardo ◽

...

Keyword(s):

Acl Reconstruction ◽

Gold Standard ◽

Functional Outcomes ◽

Cruciate Ligament ◽

Meta Analysis ◽

Double Bundle ◽

Risk Difference ◽

Single Bundle ◽

Anatomic Acl Reconstruction ◽

Anterior Cruciate

Background: There have been conflicting results about the theoretical advantages of anatomic double-bundle anterior cruciate ligament (ACL) reconstruction. Purpose: To evaluate the clinical and functional outcomes comparing anatomic single- versus double-bundle techniques, anatomic versus nonanatomic techniques, and transportal versus outside-in tunnel drilling for ACL reconstruction. Study Design: Systematic review; Level of evidence, 3. Methods: A search was performed in the MEDLINE and EMBASE databases up to August 2018 for clinical trials comparing anatomic ACL reconstruction (with tunnel positioning demonstrated using gold standard radiologic techniques) with another technique, with a minimum functional and biomechanical follow-up of 6 months. A meta-analysis was performed to compare clinical and functional outcomes between anatomic single- versus double-bundle reconstruction and between anatomic versus nonanatomic techniques, using the risk difference or the mean difference. Risk of bias of the included studies was assessed using the Newcastle-Ottawa Scale for cohort and case-control studies and the Cochrane Risk of Bias tool and Jadad Score for randomized controlled trials. Results: Included were 15 studies comprising 1290 patients (follow-up, 12-36 months). No significant differences favoring anatomic double-bundle over anatomic single-bundle reconstruction or outside-in over transportal techniques were found. The meta-analyses showed significant differences in the International Knee Documentation Committee (IKDC) objective score (risk difference, –0.14; 95% confidence interval, –0.27 to –0.01) favoring anatomic over nonanatomic reconstruction. No statistically significant differences were found between anatomic and nonanatomic surgical techniques on other functional scores or clinical examination outcomes, including the IKDC subjective score, Lysholm score, Tegner score, KT-1000 arthrometer test, or pivot-shift test. Conclusion: Double-bundle reconstruction was not superior to the single-bundle technique in clinical and functional outcomes. Anatomic ACL reconstruction shows significantly superior results over nonanatomic ACL reconstruction, reinforcing the anatomic technique as the gold standard choice for clinical practice.

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Biomechanical Evaluation of Different Techniques in Double Bundle Anterior Cruciate Ligament Reconstruction Using Finite Element Analysis

Journal of Biomimetics Biomaterials and Tissue Engineering ◽

10.4028/www.scientific.net/jbbte.13.55 ◽

2012 ◽

Vol 13 ◽

pp. 55-68 ◽

Cited By ~ 4

Author(s):

Rong Ying Huang ◽

Hong Guang Zheng ◽

Qiang Xu

Keyword(s):

Finite Element ◽

Anterior Cruciate Ligament ◽

Soft Tissues ◽

Cruciate Ligament ◽

Tibial Tunnel ◽

Double Bundle ◽

Rotational Stability ◽

Single Bundle ◽

Element Analysis ◽

Anterior Cruciate

Anterior cruciate ligament injuries commonly in traffic accident, sports activities and extreme sports. Anterior cruciate ligament reconstruction is a common practice to help the patients restore the knee stability. However, there is no previous comparison study of single bundle reconstruction, double-femoral double-tibial tunnel reconstruction, single-femoral double-tibial tunnel reconstruction, and double-femoral single-tibial tunnel reconstruction with respect to biomechanical characteristics such as rotational stability, force and stress inside the ligament and grafts, stresses inside the soft tissues. In this study, we developed a pair of three-dimensional finite element models of a lower extremity including femur, tibia, fibula, cartilage, meniscus, and four major ligaments at 0°，25°，60° and 80°of knee flexion. Based on the intact models, single bundle reconstruction, double-femoral double-tibial tunnel reconstruction, single-femoral double-tibial tunnel reconstruction, and double-femoral single-tibial tunnel reconstruction models were also developed. Then, the anterior tibial translations, the forces and stresses inside the ACL and ACL replacements, as well as the stresses inside the menisci, femoral and tibial cartilage were predicted under a combined rotatory load of 10Nm valgus moment and 5 Nm internal torque, respectively using finite element analysis. The rotational stability, ligament forces and stresses in the menisci, femoral and tibial cartilage following double bundle augmentation were superior to the other reconstruction techniques, while there is little advantage in ligament stress compared to that of the single bundle reconstruction. We conclude that double-femoral double-tibial tunnel reconstruction may have advantages with regard to biomechanical characteristics such as rotational stability, force inside the ligament and grafts, stresses inside the soft tissues.

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Double-Bundle Versus Single-Bundle Anterior Cruciate Ligament Reconstruction: A Prospective Randomized Study With 10-Year Results

The American Journal of Sports Medicine ◽

10.1177/0363546517712231 ◽

2017 ◽

Vol 45 (11) ◽

pp. 2578-2585 ◽

Cited By ~ 30

Author(s):

Sally Järvelä ◽

Tommi Kiekara ◽

Piia Suomalainen ◽

Timo Järvelä

Keyword(s):

Acl Reconstruction ◽

Screw Fixation ◽

Cruciate Ligament ◽

Double Bundle ◽

Single Bundle ◽

Significant Group ◽

Kt 1000 ◽

Anterior Cruciate ◽

Double Bundle Acl Reconstruction

Background: A long-term follow-up comparing double-bundle and single-bundle techniques for anterior cruciate ligament (ACL) reconstruction has not been reported before. Hypothesis: Double-bundle ACL reconstruction may have fewer graft ruptures, lower rates of osteoarthritis (OA), and better stability than single-bundle reconstruction. Study Design: Randomized controlled trial; Level of evidence, 2. Methods: Ninety patients were randomized for double-bundle ACL reconstruction with bioabsorbable screw fixation (DB group; n = 30), single-bundle ACL reconstruction with bioabsorbable screw fixation (SBB group; n = 30), and single-bundle ACL reconstruction with metallic screw fixation (SBM group; n = 30). Evaluation methods consisted of a clinical examination, KT-1000 arthrometer measurements, International Knee Documentation Committee (IKDC) and Lysholm knee scores, and a radiographic examination of both the operated and contralateral knees. Results: Eighty-one patients (90%) were available at the 10-year follow-up. Eleven patients (1 in the DB group, 7 in the SBB group, and 3 in the SBM group) had a graft failure during the follow-up and went on to undergo revision ACL surgery ( P = .043). In the remaining 70 patients at 10 years, no significant group differences were found in the pivot-shift test findings, KT-1000 arthrometer measurements, or knee scores. The most OA findings were found in the medial compartment of the knee, with 38% of the patients in the operated knee and 28% of the patients in the contralateral nonoperated knee. However, no significant group difference was found. The most severe OA changes were in the patients who had the longest delay from the primary injury to ACL reconstruction ( P = .047) and in the patients who underwent partial meniscal resection at the time of ACL reconstruction ( P = .024). Conclusion: Double-bundle ACL reconstruction resulted in significantly fewer graft failures than single-bundle ACL reconstruction during the follow-up. Knee stability and OA rates were similar at 10 years. The most severe OA changes were found in the patients who had the longest delay from the primary injury to ACL reconstruction and in the patients who underwent partial meniscal resection at the time of ACL reconstruction.

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Biomechanical Difference between Conventional Transtibial Single-Bundle and Anatomical Transportal Double-Bundle Anterior Cruciate Ligament Reconstruction Using Three-Dimensional Finite Element Model Analysis

Journal of Clinical Medicine ◽

10.3390/jcm10081625 ◽

2021 ◽

Vol 10 (8) ◽

pp. 1625

Author(s):

Jae Gyoon Kim ◽

Kyoung Tak Kang ◽

Joon Ho Wang

Keyword(s):

Anterior Cruciate Ligament ◽

Acl Reconstruction ◽

Knee Flexion ◽

Cruciate Ligament ◽

Three Dimensional ◽

Element Model ◽

Double Bundle ◽

Contact Stresses ◽

Single Bundle ◽

Anterior Cruciate

The purpose of our study was to analyze the graft contact stress at the tunnel after transtibial single-bundle (SB) and transportal double-bundle (DB) anterior cruciate ligament (ACL) reconstruction. After transtibial SB (20 cases) and transportal DB (29 cases) ACL reconstruction, the three-dimensional image of each patient made by postoperative computed tomography was adjusted to the validation model of a normal knee and simulated SB and DB ACL reconstructions were created based on the average tunnel position and direction of each group. We also measured graft and contact stresses at the tunnel after a 134 N anterior load from 0° to 90° flexion. The graft and contact stresses became the greatest at 30° and 0° flexion, respectively. The total graft and contact stresses after DB ACL reconstruction were greater than those after SB ACL reconstruction from 0° to 30° and 0° to 90° knee flexion, respectively. However, the graft and contact stresses of each graft after DB ACL reconstruction were less than those after SB ACL reconstruction. In conclusion, the total graft and total contact stresses after DB ACL reconstruction are higher than those after SB ACL reconstruction from 0° to 30° and 0° to 90° knee flexion, respectively. However, the stresses of each graft after DB ACL reconstruction are about half of those after SB ACL reconstruction.

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Single-Bundle versus Double-Bundle Anterior Cruciate Ligament Reconstruction: A Prospective Randomized Controlled Trial with 6-Year Follow-up

The Journal of Knee Surgery ◽

10.1055/s-0037-1598176 ◽

2017 ◽

Vol 30 (09) ◽

pp. 898-904 ◽

Cited By ~ 10

Author(s):

Francesco Dini ◽

Laura de Girolamo ◽

Massimo Cattani ◽

Michele Rosa ◽

Paolo Adravanti

Keyword(s):

Anterior Cruciate Ligament ◽

Acl Reconstruction ◽

Femoral Tunnel ◽

Cruciate Ligament ◽

Double Bundle ◽

Lysholm Score ◽

Single Bundle ◽

Randomized Controlled ◽

Anterior Cruciate

AbstractSingle-bundle (SB) anterior cruciate ligament (ACL) reconstruction is increasingly used in a large number of patients and it allows obtaining very good clinical and subjective results; however, functional tests show a persistent rotational instability. Biomechanical studies seem to indicate that double-bundle (DB) ACL reconstruction allows to obtain increased anterior and rotational stability compared with SB. The aim of this prospective randomized controlled study was to compare the clinical outcome and the possible osteoarthritic evolution of patients treated either with a SB (freehand transtibial femoral tunnel) or with a DB technique (outside-in for posterolateral femoral tunnel/inside-out for anteromedial femoral tunnel) at a final follow-up of 6 years. A total of 60 patients with complete ACL rupture (age, 16–40 years) were prospectively randomized to SB (n = 30) or DB (n = 30) groups. Patients were evaluated preoperatively and after surgery at 6 months, 1, 3, and 6 years with Lysholm score, International Knee Documentation Committee (IKDC) form, and KT-2000 (Medmetric Corp). The degree of osteoarthritis (OA) based on the Kellgren–Lawrence grade was also assessed. No significant differences in background factors between the two groups were observed. Homogeneity was also found in term of preoperative Lysholm score, IKDC, and KT-2000 between SB and DB groups. After 6 months from surgery, both groups showed significant improvements for Lysholm, IKDC, and KT-2000 score with respect to preoperative observations (p < 0.001); however, no significant differences have been observed in term of postoperative values between SB and DB groups at each time point (6-year evaluation: Lysholm score 98.14 ± 10.03 and 97.22 ± 12.82; IKDC normal + nearly normal 95 and 100%; KT-2000 1.68 ± 1.26 and 1.03 ± 1.92 for SB and DB, respectively; all p > 0.05). At the final follow-up, three patients (11.11%) in the DB group and two patients (7.69%) in the SB group presented signs of OA progression. Our study did not reveal any advantages in using DB ACL reconstruction in mid- to long-term follow-up in term of clinical outcome and knee stability, as well as in term of OA progression.

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