Anterolateral complex injuries occur in the majority of ‘isolated’ anterior cruciate ligament ruptures

Abstract Purpose The anterolateral soft tissue envelope of the knee is frequently injured at the time of ACL rupture. This study aims to investigate the MRI injury patterns to the Anterolateral complex and their associations in patients with acute 'isolated ligament' ACL ruptures. Methods Professional athletes who underwent ACL reconstruction for complete ACL rupture between 2015 and 2019 were included in this study. Patients' characteristics and intraoperative findings were retrieved from clinical and surgical documentation. Preoperative MRIs were evaluated and the injuries to respective structures of the Anterolateral complex and their associations were recorded. Results Anterolateral complex injuries were noted in 63% of cases. The majority of injuries were to Kaplan Fibre (39% isolated injury and 19% combined with Anterolateral ligament injury). There was a very low incidence of isolated Anterolateral ligament injuries (2%). Kaplan Fibre injuries are associated with the presence of lateral femoral condyle bone oedema, and injuries to the superficial MCL, deep MCL, and ramp lesions. High grade pivot shift test was not associated with the presence of Kaplan Fibre or Anterolateral ligament injuries. Patients with an intact Anterolateral complex sustained injury to other knee structures (13% to medial ligament complex, 14% to medial meniscus, and 16% to lateral meniscus). Conclusion There is a high incidence of concomitant Anterolateral complex injuries in combination with ACL ruptures, with Kaplan Fibre (and therefore the deep capsulo‐osseous layer of the iliotibial band) being the most commonly injured structure. Anterolateral ligament injuries occur much less frequently. These findings reinforce the importance of considering the presence of, and if necessary, treating injuries to structures other than the ACL, as a truly isolated ACL injury is rare.