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Original Article • Rev. bras. ortop. 60 (1) • 2025 • https://doi.org/10.1055/s-0044-1800939 linkcopy

Open-access The Top 100 Most Cited Articles on Anterolateral Ligament: A Bibliometric Analysis and Review

AuthorshipSCIMAGO INSTITUTIONS RANKINGS

    Abstract

    Objectives  To conduct a bibliometric analysis aimed at evaluating the 100 most frequently cited articles concerning the anterolateral ligament (ALL).

    Methods  A thorough search was executed using the Scopus database with the keyword "Anterolateral Ligament." The analysis incorporated technical notes, systematic reviews focusing on clinical outcomes and/or complications, clinical studies, and foundational scientific articles (both cadaveric and biomechanical). Case reports or personal opinion articles were omitted from the review. The 100 articles with the highest citation counts were examined using the Bibliometrix R-package software, which evaluated total citations, study type, country of origin, journal of publication, affiliated institution, and most prolific authors.

    Results  The 100 articles accumulated 11,192 citations, ranging from 44 to 703 per article. Most articles (69) were published between 2015 and 2017, predominantly focusing on anatomical and biomechanical studies. The United States was the leading country of publication (29%), followed by the United Kingdom (15%), Brazil (14%), France (13%), and Belgium (8%). The top five journals were the American Journal of Sports Medicine (31%), Arthroscopy (17%), Knee Surgery, Sports Traumatology, Arthroscopy (17%), Arthroscopy Techniques (5%), and Skeletal Radiology (4%). The most prolific authors were Sonnery-Cottet (21), Helito (17), with Musahl, Saithna, and Thaunat each contributing 11 articles. Sonnery-Cottet had the highest citation count, with 2,421.

    Conclusion  The analysis reveals that research on the ALL is growing, with significant contributions in anatomy and biomechanics. However, further studies are needed to establish the best indications for reconstruction and optimal surgical techniques.

    Keywords
    bibliometric analysis; knee; ligaments, articular; publications

    Resumo

    Objetivos  Realizar uma análise bibliométrica visando avaliar os 100 artigos mais citados sobre o ligamento anterolateral (LAL).

    Métodos  Uma busca completa foi executada usando o banco de dados Scopus com a palavra-chave anterolateral ligament (ligamento anterolateral). A análise incorporou notas técnicas, revisões sistemáticas com foco em desfechos clínicos e/ou complicações, estudos clínicos e artigos científicos fundamentais (cadavéricos e biomecânicos). Relatos de caso ou opiniões pessoais foram omitidos da revisão. Os 100 artigos com os maiores números de citações foram examinados com o programa Bibliometrix R-package, que avaliou citações totais, tipo de estudo, país de origem, periódico de publicação, instituição afiliada e autores mais prolíficos.

    Resultados  Os 100 artigos acumularam 11.192 citações, variando de 44 a 703 por artigo. A maioria dos artigos (69) foi publicada entre 2015 e 2017, com foco predominante em estudos anatômicos e biomecânicos. Os Estados Unidos foram o principal país de publicação (29%), seguidos pelo Reino Unido (15%), Brasil (14%), França (13%) e Bélgica (8%). Os cinco principais periódicos foram o American Journal of Sports Medicine (31%), Arthroscopy (17%), Knee Surgery, Sports Traumatology, Arthroscopy (17%), Arthroscopy Techniques (5%) e Skeletal Radiology (4%). Os autores mais prolíficos foram Sonnery-Cottet (21), Helito (17) e Musahl, Saithna e Thaunat contribuíram com 11 artigos cada. Sonnery-Cottet teve o maior número de citações, com 2.421.

    Conclusão  A análise revela que a pesquisa sobre o LAL está crescendo, com contribuições significativas em anatomia e biomecânica. No entanto, estudos adicionais são necessários para estabelecer as melhores indicações para a reconstrução e as técnicas cirúrgicas ideais.

    Palavras-chave
    análise bibliométrica; joelho; ligamentos, articulares; publicações

    Introduction

    The anterolateral ligament (ALL) is a structure that has recently garnered significant attention due to its critical role in knee biomechanics, especially concerning anterolateral rotational stability. Positioned in the anterolateral region of the knee (►Fig. 1), the ALL is vital for rotational stability and contributes to limiting anterior tibial translation relative to the femur, albeit to a lesser extent.1 Its importance becomes particularly evident in the context of anterior cruciate ligament (ACL) injuries, where rotational stability may remain compromised even after successful ACL reconstruction.2 An injury to the ALL might contribute to the failure of ACL reconstruction, given its crucial role in maintaining knee rotational stability. Therefore, evaluating its integrity is essential in diagnosing and managing knee injuries, especially in patients who experience persistent rotational instability following ACL reconstruction.3

    Fig. 1
    Anterolateral aspect of the knee, highlighting the relationship between the ALL, Lateral Collateral Ligament, and Popliteus Tendon. Abbreviations: FH, fibular head; GT, Gerdy tubercle; LM, lateral meniscus. Source: Ariel de Lima et al.21

    Since the first detailed descriptions of the ALL by Helito et al.,4 Claes et al.,5 and Vincent et al.6 in 2012 and 2013, there has been a notable increase in publications focusing on the ligament's anatomy, biomechanical characteristics, radiological markers, clinical outcomes, and complications related to its reconstruction.1 Bibliometric analyses have emerged as valuable tools to delineate areas of consensus, identify controversial topics, explore research frontiers, and track current trends across various subjects, thereby providing readers with a comprehensive and up-to-date reference. A review of prior bibliometric studies indexed in the Scopus and PubMed databases revealed several analyses related to the reconstruction of tge anterior cruciate,7 medial patellofemoral (MPFL),8 and posterior cruciate (PCL) ligaments,9 as well as of patellar instability.10 However, to date, no bibliometric analysis has specifically addressed ALL.

    Given the growing acceptance of ALL reconstruction as a standard procedure, this study was conducted to identify the 100 most cited articles published. The aim was to conduct a detailed bibliometric analysis aimed at evaluating the 100 most frequently cited articles concerning the ALL.

    Materials and Methods

    Data Collection and Allocation

    A comprehensive search was performed using the Scopus database, which is recognized for its extensive repository of peer-reviewed scientific articles and detailed citation data, to support this literature review. The search utilized the term "Anterolateral Ligament" across all fields, with the results restricted to English-language publications and no limitations on publication dates. The search included technical notes, systematic reviews focused on clinical outcomes and/or complications, clinical studies, and foundational scientific articles (cadaveric and biomechanical). Case reports and personal opinions were excluded. To enhance accuracy, two of the authors independently selected articles for inclusion. The search was completed in July 2024, yielding 748 articles published since 2000.

    These articles were ranked according to citation count, and after excluding those with fewer than 30 citations, 146 articles were retained for further analysis. Titles and abstracts were thoroughly reviewed, and each article was categorized into one of five study types: cadaveric (anatomical and/or biomechanical), clinical, computational/robotic, radiological, and systematic reviews. After excluding irrelevant articles and resolving any disagreements regarding inclusion, a total of 132 articles were retained. The articles defined as "irrelevant/controversial" were those with more than 30 citations but escaped the first filter of exclusion criteria (non-English language, case reports, and personal opinions). The top 100 most cited articles were then organized by citation count for the final analysis (►Fig. 2).

    Fig. 2
    Flowchart illustrating the article selection procedure for the top 100 most cited articles on ALL.

    Data Extraction

    For data analysis, the Bibliometrix R-package software (https://www.bibliometrix.org) was utilized. In July 2024, a file with the ".bib" extension was extracted from Scopus. The full text of all selected articles was reviewed, and data were extracted, including title, author names, journal, year of publication, total number of citations, geographical origin, primary institution involved, and study type. Statistical analyses and data visualization were conducted using R and RStudio (R Foundation for Statistical Computing, Vienna, Austria), both of which are widely recognized open-source statistical software platforms.

    Results

    The 100 most cited articles on the ALL are detailed in ►Table 1. Research on this topic is relatively recent, as evidenced by the publication dates of the earliest articles in 20126 and 2013,5,11 and the small total number of articles identified in our extensive search (748 results). In comparison, a PubMed search for "ACL" yielded over 38,000 results.

    Thumbnail
    Table 1
    The 100 most cited articles on the ALL

    The majority (69) of the top 100 articles were published between 2015 and 2017, as shown in ►Fig. 3. The total number of citations for these articles was 11,192, with individual citations ranging from 44 to 703. The reduction in the number of top 100 most cited articles after 2017 suggests that citations are concentrated in these earlier publications. Despite an increase in recent ALL research, citations remain predominantly focused on earlier works. Just the first three articles, published in 20126 and 2013,5,11 account for 1,265 citations (11.3%).

    Fig. 3
    Distribution of the top 100 most cited articles on the ALL over the years. (A) All articles were published between 2012 and 2021. (B) Distribution of citations over the years.

    Categorizing the articles by study type (clinical, cadaveric, radiological, reviews, and computational studies), cadaveric studies accounted for 33% of the top 100 most cited articles. Of these, 12 were purely anatomical studies, while the remainder were biomechanical. Clinical studies were the second most common category (22%), followed by radiological studies (21%), literature reviews (18%), and computational studies (6%).

    An analysis of the articles by country revealed that the United States was the most common country of publication (29%), followed by the United Kingdom (15%), Brazil (14%), France (13%), and Belgium (8%), as shown in ►Fig. 4.

    Fig. 4
    Distribution of the top 100 most cited articles on ALL according to the country of origin.

    Institutions with the most cited articles among the top 100 on ALL include:

    • - Centre Orthopedique Paul Santy, Lyon, France;

    • - Institute of Orthopedics and Traumatology, University of São Paulo (IOT-HCFMUSP), São Paulo, Brazil;

    • - Steadman Philippon Research Institute, Vail, Colorado, United States;

    • - Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, USA;

    • - Kansas City University, Kansas City, USA;

    • - Biomechanics Group, Mechanical Engineering Department, Imperial College London, United Kingdom;

    • - Ormskirk Hospital, Ormskirk, Lancashire, United Kingdom;

    • - Department of Orthopedic Surgery & Traumatology, University Hospitals Leuven, Leuven, Belgium;

    • - Orthopaedic Unit and Kirk Kilgour Sports Injury Center, Sant'Andrea University Hospital, "Sapienza" University of Rome, Rome, Italy;

    • - Hospital Sírio Libanês, São Paulo, Brazil.

    Articles and citations per journal were also analyzed. Regarding the number of top 100 most cited articles, the five journals with the most top 100 published were: American Journal of Sports Medicine (31%), Arthroscopy - Journal of Arthroscopic and Related Surgery (17%), Knee Surgery, Sports Traumatology, Arthroscopy (17%), Arthroscopy Techniques (5%), and Skeletal Radiology (4%).

    However, when we analyzed the journals by the number of citations, the order of the journals changed slightly: American Journal of Sports Medicine (4,380 citations), Knee Surgery, Sports Traumatology, Arthroscopy (1,699 citations), Arthroscopy - Journal of Arthroscopic and Related Surgery (1,440 citations), Journal of Anatomy (703 citations), and Skeletal Radiology (471 citations).

    Regarding the authors of the top 100 most cited articles on ALL, in terms of the number of articles, we have Sonnery-Cottet (21), followed by Helito (17), and tied in third place with 11 each, Musahl, Saithna, and Thaunat. When considering the number of citations, we have Sonnery-Cottet with 2,421; Claes with 2,170; Helito with 1,935 citations; Williams with 1,501 citations; and closing the top 5 authors with the most citations, Daggett with 1,410 citations (►Fig. 5).

    Fig. 5
    Distribution of the top 100 most cited articles on ALL. (A) Top 10 authors with the most articles on the list. (B) Top 10 authors with the most citations.

    Discussion

    The research surrounding the ALL has considerable potential, especially in light of the significant advances made since 2012. The top 100 most cited articles on this topic have collectively received 11,192 citations, surpassing the 7,908 citations garnered by the top 50 most cited articles on the PCL since 1975. This count is approximately ⅓ of the 29,629 citations accumulated by the top cited articles on the ACL since 1975, being closely comparable to the 16,358 citations related to the MPFL.8

    The American Journal of Sports Medicine continues to be the leading journal in terms of the number of highly cited articles, consistent with findings from bibliometric studies on the ACL, PCL, and MPFL. The United States remains at the forefront of ALL research, with significant contributions also coming from the United Kingdom, Brazil, France, and Belgium.

    An interesting case is that of the Journal of Anatomy, where its single entry on the list placed this journal among the top 5 most cited, that being Claes et al.5 with 703 citations, which demonstrates how a single article can have a significant impact and relevance.

    Regarding authorship, as depicted in ►Fig. 5, the top 10 authors responsible for the most cited articles on the ALL collectively account for 118 publications. This reflects a high level of collaboration among these researchers, underscoring a strong cooperative environment, which is particularly notable given the relatively recent focus on this topic.

    In reviewing the latest publications, we identified several key areas of controversy within ALL research, including measurements; trajectory and insertions; function and biomechanics; histology; vascularization; innervation; ultrasound; magnetic resonance imaging; combined reconstruction of the ALL and the ACL.

    Measurements of the ALL

    Most studies report that the ALL measures between 33.0 and 42.0 mm in length, with this dimension increasing during knee flexion and internal rotation of the tibia. The ligament's width is typically found to be between 4.0 and 7.0 mm, while its thickness ranges from 1.0 to 2.0 mm.1,4 Daggett et al.,12 in a comprehensive study involving over 160 specimens, observed that the average thickness of the ALL in men is approximately twice that observed in women.

    Trajectory and Insertions of the ALL

    The ALL is characterized by three primary attachment points: femoral, tibial, and meniscal. It originates from the femur, near the lateral epicondyle, and follows an anteroinferior path toward the anterolateral aspect of the tibia.1 The meniscal attachment is positioned between the body and the anterior horn of the lateral meniscus. Before connecting with the meniscus, the ALL fans out, increasing the insertion area.13,14

    The tibial attachment is located midway between the fibular head and the Gerdy tubercle, approximately 4.0 to 7.0 mm distal to the tibial plateau.15

    The femoral origin of the ALL shows the most variability among studies, with anatomical landmarks often including the lateral epicondyle of the femur and the origin of the lateral collateral ligament (LCL). Most studies describe the ALL as originating posterior and proximal to the lateral epicondyle.1

    Function and Biomechanics of the ALL

    The primary function of the ALL is to provide anterolateral stability to the knee, helping to prevent anterior and lateral subluxation of the tibia relative to the distal femur.2 This stabilizing effect is partly attributed to the relatively posterior and proximal insertion of the ALL compared with the LCL.16

    Histology of the ALL

    Histological analysis of the ALL has revealed dense, well-organized collagen fibers, predominantly composed of type I collagen, with an average density of 121 fibroblasts/mm2 in adults and 1,631 in fetuses, along with vascular tissue consistent with typical ligament morphology.1

    Macchi et al.17 described the ALL as being primarily composed of type I collagen (90%), with smaller amounts of III (5%), VI (3%), and minimal elastic fibers (1%). The type I collagen was arranged in parallel, with wavy fibrils surrounded by type VI.

    Vascularization of the ALL

    Situated within the third layer of the anterolateral aspect of the knee, the ALL is closely associated with the lateral inferior genicular vessels, which are separated by a thin layer of adipose tissue.17 These vessels are situated between the ALL and the lateral meniscus, serving as an anatomical landmark for identification.18,19

    Innervation of the ALL

    Caterine et al.20 identified the presence of neurofilament protein within the ALL, suggesting that it is innervated by peripheral nerves. Their research uncovered circular structures that likely correspond to small peripheral nerves or mechanoreceptors. Ariel de Lima et al.,21 through an immunofluorescence study using protein gene product 9.5, determined that this ligament contains peripheral nerve structures, primarily type I and IV mechanoreceptors. These findings imply that the ALL plays a significant role in proprioception and contributes to the anterolateral stabilization of the knee.

    Ultrasonography of the ALL

    Cianca et al.22 and both studies by Cavaignac et al.,23,24 utilizing ultrasonography, reported a 100% success rate in visualizing the ALL. Oshima et al.25 found that most segments could be clearly identified, establishing ultrasonography as a valuable tool for diagnosing related injuries. Conversely, Capo et al.,26 who achieved a 75% visualization rate, noted that ultrasound was not consistently effective in reliably identifying the ligament's tibial and femoral origins.

    Magnetic Resonance Imaging of the ALL

    The ALL can be visualized on conventional 1.5T magnetic resonance imaging (MRI) scans, particularly on coronal sections and T2-weighted images with fat saturation. The visualization rate can reach up to 97.8%, with the meniscal portion being the most frequently observed (94.8%).19 Caterine et al.,20 in a study using 3.0T MRI on cadavers, achieved 100% visualization. However, in many cases, the femoral origin was not distinctly visible on coronal plane images, primarily due to the close association of the ALL with other ligamentous structures. Nevertheless, the tibial and meniscal insertions were identifiable.

    Kosy et al.27 and Helito et al.,28 in 1.5T MRI studies, reported good results in identifying the meniscal portion of the ALL. Taneja et al.,29 in contrast, in studies involving both 1.5 and 3.0T MRI, were unable to identify the meniscal insertion.

    Combined Reconstruction of the Anterolateral and Anterior Cruciate Ligaments

    In a review study, Ariel de Lima et al.,3 concluded that the main surgical indications for combined reconstruction of the ACL and ALL are: revision surgery, a physical examination with pivot shift grade 2 or 3, participation in sports with a pivot mechanism and/or high levels of activity, ligamentous laxity, and presence of a Segond fracture. Secondary indications may include those aged under 25 years, chronic ACL injury, and radiological signs of lateral femoral condyle depression.

    Limitations

    Our research included only articles published in English, which means that high-quality studies in other languages may have been overlooked. Furthermore, data collection was limited to the Scopus database, as it is known for its accuracy and extensive coverage, and it allowed us to export citation data; other databases, such as PubMed or the Cochrane Library, were not included in our search. Additionally, our research was restricted to the ligament specifically described as "Anterolateral," potentially excluding relevant studies that refer to it by other names, such as the "Lateral Capsular Ligament" or the "Anterior Oblique Band."

    Another limitation arises from the nature of bibliometric research itself, as the articles included may not fully represent the current standard of care and evidence. Despite this, the bibliometric analysis of the top 100 most cited articles on ALL offers a valuable foundation for identifying research trends and highlighting key research centers. It also provides a curated list of influential articles, serving as essential reading material for researchers and new residents aiming to build upon the existing body of literature on this subject.

    Conclusion

    This analysis reveals that research on ALL is growing, with significant contributions in anatomy and biomechanics. However, further studies are needed to establish the best indications for ALL reconstruction and optimal surgical techniques.

    • Financial Support
      The authors declare that they did not receive financial support from agencies in the public, private, or non-profit sectors to conduct the present study.
    • Work carried out at the Universidade Federal Rural do Semiárido (UFERSA), Mossoró, RN, Brazil.

    References

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    Publication Dates

    • Publication in this collection
      24 Mar 2025
    • Date of issue
      2025

    History

    • Received
      19 Aug 2024
    • Accepted
      02 Oct 2024
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