Overview of the anterolateral complex of the knee

Table 1 List of 14-criteria divided into major and minor criteria to be consider when evaluating the need for performing a lateral tenodesis or anterolateral ligament reconstruction procedures

Major Criteria	Minor Criteria
ACL revision; pivot shift grade IIIpivot sports; competitive athlete or “elite”; age: ≤ 25 yr old	Hyperlaxity/recurvatum ≥ 10°; KT-1000 ≥ 8 mm side-side difference; instability ≥ 6 mo; medial meniscectomy and/or lateral meniscus root lesion; contralateral knee instability; Bmi ≥ 30; tibial plateau slope ≥ 10°; severe anterior tibial translation; presence of a ‘‘lateral femoral notch sign’’ or an impaction of the lateral femoral condyle[39]; segond fracture

ACL: Anterior cruciate ligament; BMI: Body mass index.

Table 2 Anterolateral ligament reconstruction techniques

Ref.	Graft	Direction	Fixation site	Fixation angle	Graft fixation
Grassi et al[43]	ITB	Deep to the LCL	Proximal and posterior to the lateral femoral epicondyle	Neutral rotation/0°-90°	Interference screw
Mahmoud et al[47]	ITB	Deep to the LCL and then passed through the lateral distal intermuscular septum from posterior to anterior and adjacent to the femur	-	Neutral rotation/around 50° flexion	ITB is sutured to itself at physiological tension
Arnold et al[48]	ITB	Under the LCL and the Popliteus tendon	-	External rotation/90°-100°	Sutured with periosteal stitches to GT
Porter et al[49]	ITB	Around the proximal LCL	Posterior to the Gerdy tubercle	Neutral rotation/35°	Interference screw
Losee et al[50]	ITB	Deep to the LCL	The femoral tunnel originated at the attachment point of the lateral gastrocnemius and ended antero-distal to the LCL femoral insertion site	External rotation/30°	Sutured at the Gerdy tubercle
Dejour et al[42]	ITB	Over the LCL	Anterior to the junction of the femoral shaft and lateral femoral condyle	External rotation/30°	1 Cancellous screws
Ellison et al[51]	ITB	Deep to the LCL	Slightly anterior to its original harvest site at the Gerdy tubercle	External rotation/90°	Interference screw
Lee et al[52]	Allograft	Over the LCL	Femur: Proximal and posterior to the lateral femoral epicondyle/Tibia: Between the fibular head and Gerdy tubercle at approximately 10 mm below the joint line	Neutral rotation/30°	2 Interferences screws1
Sonnery-Cottet et al[41]	Gracillis (ACL and ALL)	Single femoral tunnel/graft is routed deep to the iliotibial band from the femur to the tibia, shuttled through a tibial bony tunnel and back proximally to the femur	Proximal and posterior to the lateral femoral epicondyle	Neutral rotation/extension	Fixed to the ACL graft
Dejour et al[42]	Double hamstrings (ACL and ALL)	Over-the-top	Proximal and posterior to the lateral femoral epicondyle	90	Stapples

ITB: Reflected iliotibial band; LCL: Lateral collateral ligament; GT: Gerdy’s tubercle; ACL: Anterior cruciate ligament; ALL: Anterolateral ligament.