How important is the anterolateral complex following ACL injury ?

The majority of football players who sustain an anterior cruciate ligament (ACL) injury opt to have an ACL reconstruction (ACLR). While many are able to return to play without difficulty, the failure rate is high with up to 20% of players needing revision surgery. The results of these failures are multifactorial, but one of the concerns is lingering lateral rotatory instability which may not be completely restored with the ACL reconstruction. As a result, it has been suggested that surgery to address the anterolateral ligament complex (ALC) may help reduce the risk of re-injury. This FastFact highlights a review of recent concepts relating to the ALC and ACLR1.

The ALC plays a role in stabilising internal tibial rotation and encompasses several distinct layers. It includes the iliotibial band (ITB), deeper capsule-osseous layer, and the lateral capsular ligaments. There are two common techniques performed in conjunction with a standard ACLR that are utilised to restore the ALC, an anterolateral ligament (ALL) reconstruction or a modified Lemaire procedure. An anterolateral ligament reconstruction or a modified Lemaire, where a strip of the patient’s ITB is used.

Combining an ACL with either an ALL reconstruction or modified Lemaire has been shown to reduce re-rupture rates. In a prospective cohort study of 502 patients aged 16-30 years that participated in pivoting sports, the addition of an ALL reconstruction resulted in a 2.5-3.1x reduction in the risk of graft failure. A 2-year study following the addition of a modified Lemaire procedure to ACLR showed improved anterior tibial translation values with modified Lemaire and all patients returned to sport. There are no head-to-head clinical comparisons, but a robotic cadaver study found that both the modified Lemaire and ALL augmentation procedures (with an ACLR) restored anterior tibial translation similar to native knee, but that both led to over constraint in tibial internal rotation.

More data is needed before this type of procedure is universally adopted. There are however a few potential indications that may decrease risk of graft failure and revision surgery. These include in younger patients (<20-years-old), the presence of ligamentous hyperlaxity, those who engage in high risk activities or sports, or those undergoing revision ACL reconstruction.

Based on this review it seems likely that ALC reconstruction may help reduce the risk of reinjury following ACLR. The long-term clinical effects of augmentation with anterolateral complex reconstructions, however, remains to be determined. Biomechanical and early clinical data show that this type of procedure can help improve rotational stability following ACLR. Additional studies are necessary to determine long-term outcomes.

To learn more about injuries to the ACL please complete the ‘ACL module’ in the FIFA Diploma in Football Medicine.

Reference
1. Lau BC, Rames J, Belay E, Riboh JC, Amendola A, Lassiter T. Anterolateral Complex Reconstruction Augmentation of Anterior Cruciate Ligament Reconstruction: Biomechanics, Indications, Techniques, and Clinical Outcomes. Journal Bone and Joint Surgery Reviews. [Epub prior to publication].

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L INTERVENTION CHIRURGICALE EN CAS DE LESION DU LCA N EST PAS SYSTEMATIQUE.MAIS DANS CERTAINS CAS NOTAMENT CHEZ LES SPORTIFS DE HAUT NIVEAU OU LA RECONSTRUCTION DU LCA S IMPOSE LE CHIRURGIEN DOIT AVOIR A L ESPRIT LE ROLE PRIMORDIAL ET FONDAMENTAL DU LIGAMENT ANTERO LATERAL QUI EST RESPONSSABLE DE LA STABILITE DU GENOU.
PLUSIEURS CAS DE RECONSTRUCTION DULCA ECHOUENT PARCE QUE LE CHIRURGIEN NE TIENT PAS EN COMPTE UNE EVENTUELLE LESION DU LIGAMENT ANTERO LATERAL
DONC VIGILANCE EN CAS DE RECONSTRUCTION DU LCA