Anterolateral Ligament of the Knee Shows Variable Anatomy in Pediatric Specimens
Anterolateral Ligament of the Knee Shows Variable Anatomy in Pediatric Specimens
( P R I S M ) 0 1 2 3 4 5 6 7
Kevin G. Shea 0 1 2 3 4 5 6 7
Matthew D. Milewski 0 1 2 3 4 5 6 7
Peter C. Cannamela BS 0 1 2 3 4 5 6 7
Theodore J. Ganley 0 1 2 3 4 5 6 7
Peter D. Fabricant 0 1 2 3 4 5 6 7
Elizabeth B. Terhune BS 0 1 2 3 4 5 6 7
Alexandra C. Styhl 0 1 2 3 4 5 6 7
Allen F. Anderson 0 1 2 3 4 5 6 7
John D. Polousky 0 1 2 3 4 5 6 7
0 T. J. Ganley Children's Hospital of Philadelphia , Philadelphia, PA , USA
1 M. D. Milewski Connecticut Children's Medical Center , Hartford, CT , USA
2 K. G. Shea, P. C. Cannamela (&) St Luke's Sports Medicine , 600 Robbins Road, Boise, ID 83702 , USA
3 J. D. Polousky Children's Health Specialty Center Plano Campus, Andrews Institute/Children's Health , Plano, TX , USA
4 A. F. Anderson Tennessee Orthopaedic Alliance , Clarksville, TN , USA
5 A. C. Styhl University of Washington School of Medicine , Seattle, WA , USA
6 E. B. Terhune Georgetown University School of Medicine , Washington, DC , USA
7 P. D. Fabricant Hospital for Special Surgery , New York, NY , USA
Background Anterior cruciate ligament (ACL) reconstruction failure rates are highest in youth athletes. The role of the anterolateral ligament in rotational knee stability is of increasing interest, and several centers are exploring combined ACL and anterolateral ligament reconstruction for these young patients. Literature on the anterolateral ligament of the knee is sparse in regard to the pediatric population. A single study on specimens younger than age 5 years demonstrated the presence of the anterolateral ligament in only one of eight specimens; therefore, much about the prevalence and anatomy of the anterolateral ligament in pediatric specimens remains unknown. Questions/purposes We sought to (1) investigate the presence or absence of the anterolateral ligament in prepubescent anatomic specimens; (2) describe the anatomic relationship of the anterolateral ligament to the lateral collateral ligament; and (3) describe the anatomic relationship between the anterolateral ligament and the physis. Methods Fourteen skeletally immature knee specimens (median age, 8 years; range, 7-11 years) were dissected (12 male, two female specimens). The posterolateral structures were identified in all specimens, including the lateral collateral ligament and popliteus tendon. The presence or absence of the anterolateral ligament was documented in each
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Each author certifies that his or her institution approved or waived
approval for the human protocol for this investigation and that all
investigations were conducted in conformity with ethical principles of
This study was performed at St Luke’s Hospital, Boise, ID, USA.
specimen, along with origin, insertion, and dimensions, when
applicable. The relationship of the anterolateral ligament
origin to the lateral collateral ligament origin was recorded.
Results The anterolateral ligament was identified in nine
of 14 specimens. The tibial attachment point was
consistently located in the same region on the proximal tibia,
between the fibular head and Gerdy’s tubercle; however, the
femoral origin of the anterolateral ligament showed
considerable variation with respect to the lateral collateral
ligament origin. The median femoral origin of the
anterolateral ligament was 10 mm (first interquartile 6 mm, third
interquartile 13) distal to the distal femoral physis, whereas
its median insertion was 9 mm (first interquartile 5 mm, third
interquartile 11 mm) proximal to the proximal tibial physis.
Conclusions The frequency of the anterolateral ligament
in pediatric specimens we observed was much lower than
other studies on adult specimens; future studies might
further investigate the prevalence, development, and
functional role of the anterolateral ligament of the knee.
Clinical Relevance This study expands our understanding
of the anterolateral ligament and provides important
anatomic information to surgeons considering anterolateral
ligament reconstruction concomitantly with primary or
revision ACL reconstruction in pediatric athletes.
Originally identified as a ‘‘pearly, fibrous band’’ by Segond
in 1879 [
], the anterolateral ligament of the knee has
been recognized as a stabilizing structure thought to resist
internal rotation of the tibia for over a century. However,
with increasing numbers of young athletes sustaining
anterior cruciate ligament (ACL) injury [
concerns of insufficient rotational stability after ACL
5, 15, 19, 22
], the anterolateral ligament
has garnered increasing interest over the past decade.
Recent anatomic and biomechanical studies have
investigated the role the anterolateral ligament plays in knee
6, 15, 21, 27, 29
], and although its contributions
are not yet completely understood [
], several surgical
techniques have been developed in attempts of restoring
normal knee function and kinematics provided by the
anterior cruciate and anterolateral structures [
8, 13, 26
An enhanced understanding of lateral knee anatomy is
valuable as the indications for anterolateral ligament repair
and reconstruction continue to evolve. Previous studies on
adult specimens have agreed it is a consistently present
structure in the skeletally mature [
2, 6, 10, 18
], but have
reached varying conclusions on the anatomic origin of the
anterolateral ligament in relation to the lateral collateral
ligament. Thus, for surgeons who are considering
anterolateral ligament reconstruction, it is not clear what
constitutes an anatomic reconstruction. Additionally, there
is a dearth of research on the anterolateral ligament in
pediatric specimens. One small anatomic series in very
young specimens (ages 3 months to 10 years) identified the
anterolateral ligament in only one of eight available
specimens , meaning indications for reconstruction in
pediatric patients are even more ambiguous than in the
The purposes of this study were, therefore, to (1)
investigate the presence or absence of the anterolateral
ligament in prepubescent anatomic specimens; (2) describe
the anatomic relationship of the anterolateral ligament to
the lateral collateral ligament; and (3) describe the
anatomic relationship between the anterolateral ligament and
Methods and Materials
Our institutional review board was consulted before the
initiation of this study. Because this study included access
to cadaveric specimens without any patient identifiers or
contact with the family, institutional review board approval
was not deemed necessary. The specimens were provided
by an allograft harvesting facility, which had received
family consent for use of tissue for research purposes
(AlloSource, Centennial, CO, USA).
Fourteen skeletally immature knees (12 male and two
female; median age, 8 years; range, 7–11 years) were
examined by gross dissection with a group of
fellowshiptrained orthopaedic surgeons (KGS, PDF, JDP, TJG,
MDM, AFA) all with clinical, surgical, and
anatomic-dissection experience on knee specimens. The dissections for
each specimen were done by groups of two to three
surgeons, and each final dissection and marker placement was
reviewed and agreed on by the entire group of surgeons.
After anterolateral ligament identification, metallic pins
were placed at the center of each ligament origin.
Anterolateral ligament dimensions were directly measured
both at the time of dissection and by photographs with a
ruler in the field. CT scans with 2-mm slices were
subsequently taken using a GE (Cincinnati, OH, USA) Litespeed
16-slice scanner to evaluate the precise femoral origin and
tibial insertion of the anterolateral ligament in each
Images were analyzed by two of the authors (KGS,
PCC) using OsiriX (Bern, Switzerland) imaging software
Distance to the femoral and tibial physes was measured
in the coronal plane. Using the image in which the metallic
marker of the anterolateral ligament attachment was
visible, the distance from the lateral aspect of the physis to the
anterolateral ligament attachment was measured. This was
done for both the femoral and tibial attachments of the
In the sagittal plane, the location of each pin (on the
lateral surface of the femoral condyle) was marked and
images from the same CT scan series were overlaid. This
produced a single image in which the widest portion of the
femoral condyle, the posterior cortical line, and pin
locations were all visible (Fig. 1). This generated a simulated
intraoperative lateral fluoroscopic view frequently used by
surgeons to localize and confirm placement of surgically
reconstructed ligaments. This sequence was repeated for all
Location of the anterolateral ligament and lateral
collateral ligament femoral origins was measured in the
sagittal plane as follows:
Percent AP measurements were obtained by measuring
across the lateral femoral condyle perpendicular to the
posterior cortical line. First, the total AP distance
(depth) of the lateral femoral condyle was measured.
Then the distance from the ligament origin (either
anterolateral ligament or lateral collateral ligament) to
the most posterior aspect of the lateral femoral condyle
was measured, and percent AP value was calculated by
dividing this value by the total depth of the respective
condyle and multiplying by 100 (Fig. 2). A
measurement of 0% AP would thus correspond to a
ligament origin at the most posterior aspect of the
condyle, whereas an origin measuring 100% AP would
be at the anterior most aspect of the femoral condyle.
Percent proximal-distal measurements were obtained
by measuring the proximal distal distance (height) of
the lateral femoral condyle parallel to the posterior
cortical line. The height of the condyle was measured
from the most proximal point of the posterior aspect of
the physis to the most distal aspect of the lateral
femoral condyle. This posterior point of the physis was
selected, because it was one of the most consistent
landmarks on these images. Distance from the ligament
origin to the most proximal, posterior aspect of the
physis was then measured, divided by the height of its
respective condyle, and multiplied by 100 to yield a
percent proximal distal (Fig. 3). A measurement of 0%
proximal distal corresponds to a point at the distal
femoral physis, whereas a measurement of 100%
proximal distal corresponds to a point at the most
distal aspect of the condyle.
Lateral femoral condyle ossified condylar areas were
calculated by multiplying the measured lateral femoral
condyle depth by the corresponding lateral femoral
condyle height (see measurements in Fig. 1). This was
performed to quantify the size and development of each
pediatric knee specimen and allow for reporting of
Fig. 2 Line A shows the total depth of the lateral femoral condyle.
Line B shows the distance from a ligament origin to the most
posterior aspect of the lateral femoral condyle. Length of Line B was
divided by the length of Line A and multiplied by 100 to determine %
AP. Point shown in figure measures approximately 30% AP.
Of the 14 knee specimens in the study, nine were found to
have an anterolateral ligament. When sorted by ossified
condylar area and dichotomized, an anterolateral ligament
was identified in all seven of the knees in the larger half of
specimens, whereas only two of seven knees in the smaller
half of specimens had an identifiable anterolateral ligament
(Table 1). The identified ligaments varied in appearance,
ranging from a thin, sheet-like structure in some specimens
to a well-defined ‘‘pearly band’’ in others (Fig. 4). AP
measurements resulted in a median of 33% (first
interquartile 29%, third interquartile 35%) AP for the
anterolateral ligament origin midpoint (Table 2) and 29%
(first interquartile 25%, third interquartile 31%) for the
lateral collateral ligament origin (Table 3). Proximal distal
measurements resulted in medians of 43% (first
interquartile 23%, third interquartile 47%) proximal distal
for the anterolateral ligament origin (Table 4) and 37%
(first interquartile 36%, third interquartile 43%) for the
lateral collateral ligament origin (Table 5).
The location of the anterolateral ligament origin in
relation to the lateral collateral ligament markedly varied
Anterolateral ligaments were found in nine of 14 knee specimens: the
smaller group of specimens (upper half of table) demonstrated the
anterolateral ligament in two of seven specimens; the larger group of
specimens (lower half of table) demonstrated the anterolateral
ligament in seven of seven specimens; L = left; R = right; F = female;
M = male.
(Figs. 5, 6). Three anterolateral ligament origins were
located distal and anterior from their respective lateral collateral
ligament origins. In two specimens the anterolateral
ligament and lateral collateral ligament shared the same origin
location. Two anterolateral ligament origins were proximal
and posterior to their lateral collateral ligament origins, one
anterolateral ligament was anterior to the lateral collateral
ligament, and one anterolateral ligament was proximal and
anterior to its lateral collateral ligament origin.
The median anterolateral ligament femoral origin was
10 mm (first interquartile 6 mm, third interquartile 13 mm)
distal to the femoral physis, whereas the median tibial
insertion was found to be 9 mm (first interquartile 5 mm,
third interquartile 11 mm) proximal to the tibial physis
(Table 6). The median length of the anterolateral ligament
was 33 mm (first interquartile 31 mm, third interquartile 36
mm). The median width at the femoral origin point was 3
mm (first interquartile 2 mm, third interquartile 4 mm), and
the median width at the tibial insertion point was 4 mm
(first interquartile 3 mm, third interquartile 6 mm).
The anterolateral ligament has been demonstrated to be a
rotational stabilizer of the knee [
] and several recent
Fig. 4A–D The figure demonstrates that the structural appearance of
the anterolateral ligament (ALL) varied in pediatric specimens. (A)
Left knee, 8-year-old boy; anterolateral ligament origin is proximal
and posterior to the lateral collateral ligament (LCL) origin. The
femoral attachment points of the lateral collateral ligament and
anterolateral ligament are on the right in this photograph. (B) Right
knee, 11-year-old boy; anterolateral ligament origin is proximal and
posterior to the lateral collateral ligament. The femoral attachments of
the lateral collateral ligament and anterolateral ligament are in the
studies have described its anatomy and structure in adults
1–3, 6, 9, 10, 18, 20
]. However, the presence and anatomy
of the anterolateral ligament in the pediatric population are
not well described. The current study identified the
anterolateral ligament in eight of 14 specimens, which
demonstrated considerable variation in the anterolateral
ligament’s anatomic relationship to the lateral collateral
ligament and a close relationship between the anterolateral
ligament femoral origin and the distal femoral physis.
This study has several limitations. A larger series of
specimens would add meaningful data to this study, and
given the small cohort in our study, statistical analysis and
conclusions were deemed inappropriate. Additionally, our
study only included two female specimens meaning the
results may not be generalizable to female patients;
upper region of the photo. (C) Left knee, 10-year-old boy;
anterolateral ligament and lateral collateral ligament share the same origin.
The femoral attachment point of the lateral collateral ligament and
anterolateral ligament are on the right in this photograph. (D) Right
knee, 11-year-old boy; anterolateral ligament origin is proximal and
anterior to the lateral collateral ligament. The femoral attachments of
the lateral collateral ligament and anterolateral ligament are in the
upper left region of the photograph.
however, access to pediatric specimens is severely limited.
Access to older specimens and additional female
specimens, including those closer to skeletal maturity, would
also improve the study and provide more information about
the development of these structures in older patients.
Having multiple surgeons performing the dissections may
increase the variation in anatomic identification of
structures. To mitigate this bias, each dissection was reviewed
by the group of surgeons to confirm dissected structures
and placement of markers at specific landmarks.
In contrast to a previous study of very young (age 3
months to 10 years) pediatric knee specimens, which
identified the anterolateral ligament in only one of eight
], this series demonstrated the presence of an
anterolateral ligament in nine of 14 specimens. This series was an
% AP is equal to the distance from the posterior aspect of the femoral
condyle to the anterolateral ligament origin divided by the total AP
distance of the condyle multiplied by 100.
% Proximal distal is equal to the distance from the proximal aspect of
the femoral epiphysis to the anterolateral ligament origin divided by
the total height of the epiphysis multiplied by 100.
older group of specimens, suggesting that the ligament may
become more distinct as it develops over time. Although
some recent studies have found the anterolateral ligament
in less than 50% of specimens [
17, 20, 21
], adult cadaveric
studies have generally shown it to be present in a much
higher percentage of specimens; Dodds et al. [
the anterolateral ligament in 33 of 40 specimens (83%),
Claes et al. [
] in 40 of 41 specimens (98%), Vincent et al.
] in 40 of 40 specimens (100%), and Daggett et al. [
52 of 52 specimens (100%). Most studies agree that the
tibial insertion of the anterolateral ligament can
consistently be found approximately halfway between the Gerdy
tubercle and the anterior margin of the fibular head
1, 2, 6, 9, 10, 18, 31
]. However, there have been
conflicting reports on the anatomy of its femoral origin
2, 6, 18, 20
] and debate on its relative importance in knee
stability and kinematics [
11, 15, 17, 21
]. Although rarely
reported and difficult to quantify, the structure of the
anterolateral ligament also seems to vary [
] with some
studies and dissection photographs showing a thin
‘‘sheetlike’’ structure [
3, 6, 16
] and others appearing as more of a
thick band [
2, 5, 20
]. When ordered according to ossified
condylar area, the anterolateral ligament was identified in
all seven of the larger specimens, but only two of the seven
smaller specimens. Taken together with the understanding
that the anterolateral ligament appears to be present in the
vast majority of adult specimens [
], the anterolateral
ligament may be a structure that develops throughout the
The current study demonstrated considerable variation
in the location of the anterolateral ligament origin with
respect to the lateral collateral ligament origin. With
respect to the lateral collateral ligament origin, these
specimens showed that the anterolateral ligament
originated in several different patterns including (1) distal and
anterior to the lateral collateral ligament origin; (2)
common anterolateral ligament and lateral collateral ligament
origin; (3) proximal and posterior to the lateral collateral
ligament origins; (4) anterior to the lateral collateral
ligament; and (5) proximal and anterior to its lateral collateral
ligament origin. This variation has also been identified in
adult cadaveric studies with Claes et al. [
] identifying the
anterolateral ligament origin as anterior to the lateral
collateral ligament origin and Dodds et al. [
] localizing the
anterolateral ligament origin as proximal and posterior to
the lateral collateral ligament origin. Rezansoff et al. [
described two anatomic variants–one anterior-distal to the
lateral collateral ligament and one posterior-proximal to the
lateral collateral ligament–in a study of 13 knees, whereas
Runer et al. [
] also described two variants–one proximal
and posterior to the lateral collateral ligament origin and
one sharing the lateral collateral ligament origin. In the
current study, the authors found the anterolateral ligament
to be an inconsistent structure with regard to its presence,
structure, and its femoral origin in prepubescent pediatric
knee specimens. Given that multiple femoral origins have
been reported in the adult literature, it seems likely that the
anatomic relationship of the lateral collateral ligament and
anterolateral ligament might vary as was found in our study
of pediatric specimens.
The anterolateral ligament origin showed a close
relationship to the femoral physis (median 10 mm distal) as did
the anterolateral ligament insertion to the tibial physis
(median 9 mm proximal). Surgeons considering
anterolateral ligament reconstruction in prepubescent patients
should be aware of this anatomic relationship. Physicians
should be especially careful of causing iatrogenic damage
to the distal femoral physis because its undulating structure
may confound its relation to the anterolateral ligament
origin and ligament reconstructions have the potential to
cause growth disturbance [
Recently, the anterolateral ligament’s status as a true
ligament and furthermore its clinical relevance has been
called into question [
]; therefore, continued research
on the development, structure, and function of the
anterolateral ligament in children is needed to further clarify the
anatomic role and indications, if any, for combined ACL/
anterolateral ligament reconstructions in young athletes.
This study expands our understanding of the anterolateral
Dimensions of the anterolateral ligament were measured during dissections and by photographs with a ruler in the field; distance to the femoral
and tibial physes was measured in the coronal plane; using the image in which the metallic marker of the anterolateral ligament attachments was
visible, the distance from the lateral aspect of the physis to the anterolateral ligament attachment was measured; this was done for both the
femoral and tibial attachments of the anterolateral ligament; no tibial pin was placed for the anterolateral ligament of Specimen 3; N/A = no pin
was placed in this specimen.
ligament and provides important anatomic information to
surgeons considering anterolateral ligament reconstruction
concomitantly with primary or revision ACL
reconstruction in pediatric athletes.
Acknowledgments We thank Allosource (Centennial, CO, USA)
for the donation of the cadaveric specimens and nonfinancial research
support. We also thank Tom Cycyota and Todd Huft (AlloSource) for
their assistance, organization, and support of the dissections.
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