1 Introduction

The anterior cruciate ligament (ACL) plays a crucial role in maintaining knee stability, serving as the primary passive restraint against the excessive anterior translation of the tibia relative to the femur.^1–3 Most ACL injuries are non-contact in nature and typically occur during sudden pivots, rapid changes in direction, or abrupt deceleration, particularly when the knee is near full extension at footstrike; contact-related ACL injuries usually result from significant valgus stress applied to the knee joint, often from a direct blow or impact.⁴ ACL injury is associated with a significant physical and psychological burden in athletes.⁵ ACL reconstruction is the primary surgical intervention for athletes aiming to return to a high-level of sports.² Recent advancements in orthopedic sports medicine have seen the increasing adoption of augmentation techniques in ACL reconstruction. Particularly, lateral extra-articular procedures like tenodesis (LET) or anterolateral ligament (ALL) reconstruction that aim to enhance knee stability beyond what is achieved with isolated ACL reconstructions.³

The anatomy and function of the anterolateral ligament (ALL) has been a subject of debate within orthopedic sports medicine for more than a century.⁴ In 1879, Paul Segond described a ligamentous structure linking the femur to the tibia on the anterolateral aspect of the knee joint, implicating it in avulsion fractures of the anterolateral margin of the tibia.⁶ Vincent et al. later coined the term 'anterolateral ligament' (ALL) to refer to this structure.⁷ In 2013, Claes et al. confirmed that the ALL is distinct from the anterolateral joint capsule and subsequent radiographic assessments using magnetic resonance imaging (MRI) suggested that Segond fractures are indeed avulsion fractures involving the ALL.^10,11

The femoral origin of the ALL varies between individuals; it typically originates posterior and proximal to the lateral femoral epicondyle and inserts behind Gerdy's tubercle at the proximal tibia.⁷ Cadaveric studies have demonstrated that the simultaneous loss of the ACL and ALL leads to increased anterolateral translation of the tibia relative to the femur, causing significant knee instability during tibial internal rotation.^6,7 As a result, current guidelines recommend the following considerations as indications for combined ACL and ALL reconstructions: high-grade pivot-shift, Segond fractures, participation or return to pivoting sports and/or those with ligamentous laxity (joint hypermobility).⁹ There remains a gap in the literature regarding the value and efficacy of anterolateral procedures in patients undergoing multiple ACL revisions, particularly in those with varying degrees of posterior tibial slope; key areas for further research.

Several surgical techniques for combined ACL and ALL reconstructions have been described in the literature.^8,9,12–14 Sonnery-Cottet et al. described an approach involving the use of a three-stranded semitendinosus graft combined with a gracilis tendon to form a quadruple graft for ACL reconstruction. The remaining, extra-articular portion of the gracilis tendon is then routed and used for the reconstruction of the ALL. This technique remains the most widely supported by clinical data.¹⁵

As the management of ACL injuries involving adjunctive extra-articular anterolateral procedures is rapidly evolving in orthopedic sports medicine, identifying the key studies in this field becomes imperative. Bibliometric analyses offer quantitative insights and qualitative considerations regarding the development and dissemination of knowledge within and across various scientific domains. This article critically evaluates major trends, significant breakthroughs, and areas for further research in the field of combined ACL and ALL reconstructions, based on the top 50 most cited publications.

2 Methodology

3 Results

3.1

3.1 Citation metrics

A total of 10,359 citations were accumulated by the top 50 cited articles on ACL reconstruction combined with anterolateral ligament (ALL) reconstruction. The average number of citations per article was calculated to be 207.18, with a standard deviation of 158.18. It is noteworthy that three articles received more than 500 citations. Detailed citation counts for the top 50 articles are presented in Table 1.

Table 1 The detailed citation counts for the top 50 articles.

Rank	Title	First author	Journal	Total citations	Publication years	Citation Density	Institute, Country	Study Type
1	Anatomy of the anterolateral ligament of the knee	Claes, S	J Anat	1000	2013	90.91	University Hospitals Leuven, Belgium	Anatomic and Biomechanical Analysis
2	Outcome of a Combined Anterior Cruciate Ligament and Anterolateral Ligament Reconstruction Technique With a Minimum 2-Year Follow-up	Sonnery-Cottet	AJSM	506	2015	56.22	Centre Orthopédique Santy, France	Case series
3	The anterolateral ligament: Anatomy, length changes and association with the Segond fracture	Dodds, AL	JBJS Br	447	2014	44.70	Imperial College London, UK	Anatomic and Biomechanical Analysis
4	Anterolateral Ligament Reconstruction Is Associated With Significantly Reduced ACL Graft Rupture Rates at a Minimum Follow-up of 2 Years: A Prospective Comparative Study of 502 Patients From the SANTI Study Group	Sonnery-Cottet, B	AJSM	432	2017	61.57	Centre Orthopédique Santy, France	Prospective Cohort
5	The Anterolateral Ligament: An Anatomic, Radiographic, and Biomechanical Analysis	Kennedy, MI	AJSM	402	2015	44.67	Steadman Philippon Research Institute, USA	Anatomic and Biomechanical Analysis
6	The Biomechanical Function of the Anterolateral Ligament of the Knee	Parsons, EM	AJSM	360	2015	40.00	University of Washington, USA	Anatomic and Biomechanical Analysis
7	A cadaveric study of the anterolateral ligament: re-introducing the lateral capsular ligament	Caterine, S	KSSTA	344	2015	38.22	University of Western Ontario, Canada	Anatomic and Biomechanical Analysis
8	The Role of the Anterolateral Structures and the ACL in Controlling Laxity of the Intact and ACL-Deficient Knee	Kittl, C	AJSM	337	2016	42.13	Imperial College London, UK	Anatomic and Biomechanical Analysis
9	Anatomy and Histology of the Knee Anterolateral Ligament	Helito, CP	OJSM	316	2013	28.73	University of São Paulo, Brazil	Anatomic and Biomechanical Analysis
10	The anterolateral complex of the knee: results from the International ALC Consensus Group Meeting	Getgood, AM	KSSTA	305	2019	61.00	University of Western Ontario, Canada	Consensus Group Meeting
11	Anterolateral Ligament Expert Group consensus paper on the management of internal rotation and instability of the anterior cruciate ligament - deficient knee	Sonnery-Cottet, B	Journal of Orthopaedics and Traumatology	286	2017	40.86	Centre Orthopédique Santy, France	Consensus Group Meeting
12	An In Vitro Robotic Assessment of the Anterolateral Ligament, Part 1: Secondary Role of the Anterolateral Ligament in the Setting of an Anterior Cruciate Ligament Injury	Rasmussen, MT	AJSM	279	2016	34.88	Steadman Philippon Research Institute, USA	Anatomic and Biomechanical Analysis
13	Biomechanical Comparison of Anterolateral Procedures Combined With Anterior Cruciate Ligament Reconstruction	Inderhaug, E	AJSM	263	2017	37.43	Imperial College London, UK	Anatomic and Biomechanical Analysis
14	The Segond Fracture: A Bony Injury of the Anterolateral Ligament of the Knee	Claes, S	Arthroscopy	257	2014	25.70	University Hospitals Leuven, Belgium	Anatomic and Biomechanical Analysis
15	Biomechanical analysis of simulated clinical testing and reconstruction of the anterolateral ligament of the knee	Spencer, Luke	AJSM	253	2015	28.11	University of Western Ontario, Canada	Anatomic and Biomechanical Analysis
16	The involvement of the anterolateral ligament in rotational control of the knee	Sonnery-Cottet, B	AJSM	251	2013	22.82	Centre Orthopédique Santy, France	Anatomic and Biomechanical Analysis
17	An In Vitro Robotic Assessment of the Anterolateral Ligament, Part 2 Anterolateral Ligament Reconstruction Combined With Anterior Cruciate Ligament Reconstruction	Nitri, M	AJSM	211	2016	26.13	Steadman Philippon Research Institute, USA	Anatomic and Biomechanical Analysis
18	Anatomic Anterolateral Ligament Reconstruction of the Knee Leads to Overconstraint at Any Fixation Angle	Schon, J	AJSM	209	2016	26.13	Steadman Philippon Research Institute, USA	Anatomic and Biomechanical Analysis
19	High prevalence of anterolateral ligament abnormalities in magnetic resonance images of anterior cruciate ligament-injured knees	Claes, S	Acta Orthop Belg	204	2014	20.40	University Hospitals Leuven, Belgium	Retrospective Cohort
20	Prevalence and classification of injuries of anterolateral complex in acute anterior cruciate ligament tears	Ferretti, A	Arthroscopy	199	2017	28.29	Sant'Andrea Hospital, Italy	Case series
21	Femoral Origin of the Anterolateral Ligament: An Anatomic Analysis	Daggett, M	Arthroscopy	184	2016	23.00	Kansas City University, USA	Anatomic and Biomechanical Analysis
22	Anterolateral Tenodesis or Anterolateral Ligament Complex Reconstruction Effect of Flexion Angle at Graft Fixation When Combined With ACL Reconstruction	Inderhaug, E	AJSM	166	2017	23.71	Imperial College London, UK	Anatomic and Biomechanical Analysis
23	Biomechanical assessment of the anterolateral ligament of the knee: a secondary restraint in simulated tests of the pivot shift and of anterior stability	Thein, R	JBJS Am	150	2016	18.75	Hospital for Special Surgery, USA	Anatomic and Biomechanical Analysis
24	Assessment of the Anterolateral Ligament of the Knee by Magnetic Resonance Imaging in Acute Injuries of the Anterior Cruciate Ligament	Helito, CP	Arthroscopy	140	2017	20.00	University of São Paulo, Brazil	Anatomic and Biomechanical Analysis
25	The structure and function of the anterolateral ligament of the knee: a systematic review	Van der Watt, L	Arthroscopy	139	2020	34.75	McMaster University, Canada	Review
26	Epidemiological Evaluation of Meniscal Ramp Lesions in 3214 Anterior Cruciate Ligament-Injured Knees From the SANTI Study Group Database: A Risk Factor Analysis and Study of Secondary Meniscectomy Rates Following 769 Ramp Repairs	Sonnery-Cottet, B	AJSM	134	2018	22.33	Centre Orthopédique Santy, France	Case-Control
27	Clinical Outcomes of Isolated Revision Anterior Cruciate Ligament Reconstruction or in Combination With Anatomic Anterolateral Ligament Reconstruction	Lee DW	AJSM	132	2019	26.20	Konkuk University Medical Center, Republic of Korea	Retrospective Cohort
28	Combined reconstruction of the anterolateral ligament in chronic ACL injuries leads to better clinical outcomes than isolated ACL reconstruction	Helito, CP	KSSTA	128	2018	21.17	University of São Paulo, Brazil	Retrospective Cohort
29	Anatomic Reconstruction of the Anterior Cruciate Ligament of the Knee With or Without Reconstruction of the Anterolateral Ligament: A Randomized Clinical Trial	Ibrahim, SA	AJSM	127	2017	18.00	Al-Razi Orthopaedic Hospital, Kuwait	Randomized Controlled Trial
30	Combined Intra- and Extra-articular Reconstruction of the Anterior Cruciate Ligament: The Reconstruction of the Knee Anterolateral Ligament	Helito, CP	Arthroscopy Techniques	122	2015	13.56	University of São Paulo, Brazil	Technical Note
31	Current concepts of the anterolateral ligament of the knee: anatomy, biomechanics, and reconstruction	Kraeutler, MJ	AJSM	119	2018	19.83	Steadman Philippon Research Institute, USA	Anatomic and Biomechanical Analysis
32	Anterolateral Ligament Reconstruction Protects the Repaired Medial Meniscus A Comparative Study of 383 Anterior Cruciate Ligament Reconstructions From the SANTI Study Group With a Minimum Follow-up of 2 Years	Sonnery-Cottet, B	AJSM	117	2018	19.50	Centre Orthopédique Santy, France	Retrospective Cohort
33	Is an Anterolateral Ligament Reconstruction Required in ACL-Reconstructed Knees With Associated Injury to the Anterolateral Structures? A Robotic Analysis of Rotational Knee Stability	Noyes, FR	AJSM	115	2017	16.43	Cincinnati Sportsmedicine and Orthopaedic Center, USA	Anatomic and Biomechanical Analysis
34	Anterolateral ligament abnormalities in patients with acute anterior cruciate ligament rupture are associated with lateral meniscal and osseous injuries	Van Dyck, P	Eur Radiol	112	2016	14.00	University of Antwerp, Belgium	Case series
35	Combined anterolateral ligament and anatomic anterior cruciate ligament reconstruction of the knee	Smith, JO	KSSTA	110	2015	12.22	University of Winchester, UK	Technical Note
36	Anterolateral Ligament Reconstruction Technique: An Anatomic-Based Approach	Chahla, J	Arthroscopy Techniques	110	2016	13.75	Steadman Philippon Research Institute, USA	Anatomic and Biomechanical Analysis
37	Combined Reconstruction of the Anterolateral Ligament in Patients With Anterior Cruciate Ligament Injury and Ligamentous Hyperlaxity Leads to Better Clinical Stability and a Lower Failure Rate Than Isolated Anterior Cruciate Ligament Reconstruction	Helito, CP	Arthroscopy	109	2019	21.80	University of São Paulo, Brazil	Retrospective Cohort
38	Anatomic description of the anterolateral ligament of the knee	Stijak, L	KSSTA	107	2016	13.38	University of Belgrade	Anatomic and Biomechanical Analysis
39	Combined Anterior Cruciate Ligament and Anterolateral Ligament Reconstruction	Sonnery-Cottet, B	Arthroscopy Techniques	105	2016	13.00	Centre Orthopédique Santy, France	Technical Note
40	The role of the anterolateral ligament in ACL insufficient and reconstructed knees on rotatory stability: A biomechanical study on human cadavers	Tavlo, M	Scand J Med Sci Sports	101	2016	12.63	University of Copenhagen, Denmark	Anatomic and Biomechanical Analysis
41	The anterolateral ligament of the knee: A dissection study	Runer, A	The Knee	101	2016	12.63	Medical University of Innsbruck, Austria	Anatomic and Biomechanical Analysis
42	Reoperation Rates After Combined Anterior Cruciate Ligament and Anterolateral Ligament Reconstruction A Series of 548 Patients From the SANTI Study Group With a Minimum Follow-up of 2 Years	Thaunat, M	AJSM	100	2017	14.29	Centre Orthopédique Santy, France	Case series
43	Anterolateral Ligament Reconstruction Techniques, Biomechanics, and Clinical Outcomes: A Systematic Review	DePhillipo, NN	Arthroscopy	100	2017	14.29	Steadman Philippon Research Institute, USA	Review
44	Rotational Knee Instability in ACL-Deficient Knees Role of the Anterolateral Ligament and Iliotibial Band as Defined by Tibiofemoral Compartment Translations and Rotations	Noyes, FR	JBJS Am	100	2017	14.29	Cincinnati Sportsmedicine and Orthopaedic Center, USA	Anatomic and Biomechanical Analysis
45	Behavior of the anterolateral structures of the knee during internal rotation	Lutz, C	Orthop Traumatol Surg Res	100	2015	11.11	Clinique du Diaconat, France	Anatomic and Biomechanical Analysis
46	Isometric Characteristics of the Anterolateral Ligament of the Knee: A Cadaveric Navigation Study	Imbert, P	Arthroscopy	98	2016	12.25	Institute of Saint-Raphaël, France	Anatomic and Biomechanical Analysis
47	Contributions of the anterolateral complex and the anterolateral ligament to rotatory knee stability in the setting of ACL Injury: a roundtable discussion	Musahl, V	KSSTA	97	2017	13.86	University of Pittsburgh, USA	Expert Opinions
48	Structural Properties of the Anterolateral Capsule and Iliotibial Band of the Knee	Rahnemai-Azar, AA	AJSM	94	2016	11.75	University of Pittsburgh, USA	Anatomic and Biomechanical Analysis
49	The anterolateral capsule of the knee behaves like a sheet of fibrous tissue	Guenther, D	AJSM	94	2017	13.43	University of Pittsburgh, USA	Anatomic and Biomechanical Analysis
50	The anterolateral complex of the knee: a pictorial essay	Herbst, E	KSSTA	87	2017	12.43	University of Pittsburgh, USA	Expert Opinions

The distribution of citations across different publication years indicates a significant concentration of influential work in recent years. Specifically, all articles were published between 2013 and 2020. This analysis highlights a consistent trend of citation growth over the years, as depicted in Fig. 1.

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Fig. 1 Citation density of the top 50 articles.

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3.2

3.2 Levels of evidence

The majority of the articles (36) were categorized as level 5 evidence, accumulating a total of 7820 citations, which indicates a predominance of lower-level evidence studies among the top-cited articles. Level 4 evidence was represented by 7 articles, which garnered 1290 citations. Five articles were classified as level 3 evidence, collectively receiving 690 citations. Level 2 evidence included 2 articles, with a total of 559 citations, while no articles were classified under level 1 evidence. Detailed citation counts for each level of evidence are depicted in Fig. 2.

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Fig. 2 The distribution of the top 50 articles based on level of evidence.

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3.3

3.3 Article types

Anatomical and biomechanical analyses were the most common, comprising 29 articles and accounting for the highest total number of citations (6,708). Case series were also frequently observed, with 4 articles accumulating 917 citations. Other types of articles included case-control studies (1 article, 134 citations), consensus group meetings/expert opinions (4 articles, 775 citations), prospective cohort studies (1 article, 432 citations), randomized controlled trials (1 article, 127 citations), retrospective cohort studies (5 articles, 690 citations), reviews (2 articles, 239 citations), and technical notes (3 articles, 337 citations). The distribution and citation impact of these article types are shown in Fig. 3.

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Fig. 3 Article type distribution for the top 50 articles.

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3.5

3.5 Geographic Distribution

The leading role in research on ACL reconstruction combined with anterolateral ligament (ALL) reconstruction is demonstrated by the United States, with 16 publications and 2711 citations. France follows with 10 publications and 2129 citations, while Brazil contributed 5 publications with 815 citations, highlighting strong contributions from these countries. The United Kingdom also made notable contributions, with 5 publications garnering 1323 citations. Canada and Belgium each contributed 4 publications, accumulating 1041 and 1573 citations, respectively. The distribution of citations and articles across different countries is illustrated in Figs. 4 and 5.

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Fig. 4 Geographical distribution of total citations for the top 50 articles.

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Fig. 5 World map illustrating geographic distribution of citations for the top 50 articles.

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3.6

3.6 Institutional distribution

The Centre Orthopédique Santy in France was led with 1931 citations from 8 publications, followed by the Steadman Philippon Research Institute in the United States, which accumulated 1430 citations from 7 articles. The University of São Paulo in Brazil contributed 815 citations from 5 articles, while Imperial College London in the United Kingdom garnered 1213 citations from 4 articles. University Hospitals Leuven in Belgium received 1461 citations from 3 articles. The University of Western Ontario in Canada contributed 902 citations from 3 articles. The distribution of citations by institution is illustrated in Fig. 6.

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Fig. 6 Total citations by institute for the top 50 articles.

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4 Discussion

In this article, various bibliometric measures were employed to evaluate the top 50 most cited articles on combined ACL and ALL reconstruction. This analysis illustrated the influential contributions shaping the current landscape of research in the field. Additionally, it identified key researchers and trends driving advancements in an area of growing clinical relevance. Bibliometric parameters can be used to gauge the evolving trends within a research area enabling analyses like this one to uncover and forecast emerging subjects of future academic exploration. Although the total number of citations alone does not fully capture an article's influence or clinical significance, it remains a reliable benchmark of scientific relevance within specialized fields.

The top 50 articles published on ACL repair with ALL reconstruction have collectively garnered 10,359 citations, with an average of 207 citations per article. The study titled “Anatomy of the anterolateral ligament of the knee” by Claes S et al. holds the highest total citation count at 1000 citations.¹¹ It also achieved the highest citation density, with 90.91 citations per year since its publication in 2013. Claes et al. investigated the presence of the ALL in 41 cadaveric knees and identified it in 97 % of specimens. Their study was among the first to provide a comprehensive description of the ALL's origin, insertion, and relationship with adjacent structures, clarifying aspects of its previously misunderstood anatomy. The authors proposed that the ALL plays a critical role in maintaining knee stability during tibial internal rotation and is therefore integral to the pivot-shift phenomenon.⁷

Another notable contribution is the study by Sonnery-Cottet et al., titled “Anterolateral Ligament Reconstruction Is Associated With Significantly Reduced ACL Graft Rupture Rates at a Minimum Follow-up of 2 Years”¹⁷ which has accumulated 432 citations, with a citation density of 61.57 citations per year since its being published in 2017. It ranks fourth in total citation count and second in citation density. The study is one of only two level 2 evidence studies among the literature included in this analysis. Published in AJSM, the study evaluated ACL reconstruction techniques and reported that graft failure was 3.1 times less frequently observed in cases where hamstring tendon graft ACL reconstruction was performed in combination with an ALL augmentation procedure, compared to cases where isolated hamstring tendon graft ACL reconstruction was performed. Moreover, graft failure was also 2.5 times less frequently observed than in cases where bone-patellar tendon-bone ACL reconstruction was employed.¹⁷

The analysis of the levels of evidence within the included studies revealed a paucity of high quality evidence among the top 50 cited articles on ACL reconstruction with ALL augmentation. Of the 50 articles, 36 were classified as level 5 evidence and were primarily comprised of anatomical and biomechanical analysis studies. While these studies provide foundational insight into the anatomy and functional behaviors of the ALL, they lack the clinical evidence provided by higher-level studies. Only two studies, one randomized controlled trial (RCT) and one prospective cohort study¹⁸, achieved a level 2 evidence grading.¹⁷ The lack of level 1 studies highlights the critical need for more rigorous, higher-quality research to advance evidence-based practices and improve standards of care in ACL and ALL reconstructions.

The only RCT among the top 50 cited articles is by Ibrahim SA,¹⁸ amassing 127 citations since its publication in 2017. The study found that concomitant ALL reconstruction resulted in improved subjective and objective outcomes in ACL reconstruction. With the exception of parameters of instrumented knee laxity, the differences observed were not statistically significant.¹⁸ The limitations highlighted in the aforementioned study provide valuable guidance for the design of future RCTs, which could yield more robust conclusions. Specifically, future research should incorporate larger patient cohorts, extend follow-up periods, and perform rigorous statistical analyses to avoid underpowered findings.

There are several potential reasons for the paucity of high-level studies focused on this subject. For one, study designs such as RCTs pose significant logistical and financial challenges. Additionally, blinding patients and/or investigators in studies investigating invasive procedures may raise ethical concerns. The complexity of coordinating, longitudinal, multi-center studies often deters researchers from pursuing them, a challenge that is often compounded by the risk of attrition bias. Importantly, there is heterogeneity in the surgical techniques employed, particularly regarding ALL reconstruction procedures; future studies should explore comparisons between different techniques of anatomical ALL reconstruction to enhance the generalizability of the results. Lastly, as with any specialized field of research, there is the potential for publication bias.

The American Journal of Sports Medicine (AJSM) holds the largest number of publications among the top 50 cited articles, with 21 articles amassing a total of 4701 citations. Other prominent journals in this analysis included Arthroscopy: The Journal of Arthroscopic & Related Surgery and Knee Surgery, Sports Traumatology, Arthroscopy (KSSTA), which contributed 8 and 7 articles, respectively.

Among the top contributors to research on ALL augmentation, the USA and France are notable for their substantial number of highly-cited publications. The USA contributed 16 articles with a total of 2711 citations. 8 of which were published by the Steadman Philippon Research Institute, with particular emphasis on anatomical and biomechanical analyses of the ALL. France contributed 10 articles with a total of 2129 citations; the Centre Orthopédique Santy was the main institution involved, contributing 8 out of the 10 publications. Their work primarily consisted of observational studies, as well as anatomical and biomechanical analysis articles.

Epidemiological data could play a central role in guiding future research directions in the field. With increasing participation of female athletes in pivoting sports, and the recognition that hormonal and biomechanical factors predispose them to greater joint mobility, ligamentous laxity, and a heightened risk of ACL injury and reconstruction,^19,20 there is a clear need for research into the clinical utility of concomitant anterolateral procedures in female subjects. Additionally, leading research institutions could collaborate with countries or organizations that maintain well-structured ACL injury registries,²¹ opening doors to more comprehensive, data-driven research capable of advancing current knowledge.

The current literature is dominated by anatomical and robotic biomechanical analyses, with a paucity of robust clinical evidence. Advancements in point-of-care knee movement analysis, particularly the KneeKG™ system, have demonstrated its increasing utility as an accurate, reliable, and objective tool for assessing tri-planar knee function, especially with regards to quantifying axial rotation and tibial translation relative to the femur. This makes it particularly suited for evaluating the pivot-shift associated with rotational laxity and instability, a common indication for the concomitant anterolateral procedure in ACL reconstruction.²² These developments highlight gaps in the literature for studies to integrate biomechanical analyses with longitudinal clinical assessments to generate unprecedented evidence on the outcomes of anterolateral procedures in ACL reconstruction.

This article has some limitations. Despite extensive database searches, potential omissions of relevant articles may still exist. To ensure comprehensive coverage, references were manually reviewed to identify any missing articles. Variations in citation counts between databases were resolved by selecting the highest citation count for each article, thus capturing the maximum recognized impact. The “snowball effect” may have biased results toward older, frequently cited articles; however, using citation density helped highlight the influence of more recent studies.

5 Conclusion

This study identified and analyzed the top 50 most cited articles on ACL reconstruction with ALL reconstruction. Highlighting key authors, institutions, journals, countries, study types, levels of evidence, and themes, the analysis reveals a dynamic and evolving field. Notably, all these articles were published between 2013 and 2020, reflecting the recent surge in scientific interest and relevance. The diverse range of study types, primarily anatomical and biomechanical, indicates broad interest in the topic. However, there is a need for more high-quality evidence, as only two articles achieved level 2 evidence, and there were no level 1 studies. The United States and France stand out, contributing significantly to the research.

CRediT authorship contribution statement

Osama Z. Alzobi: All authors contributed to the study conception and design, Material preparation, literature review, and data collection were performed, The first draft of the manuscript was written, All authors read and approved the final manuscript. Hamad Almannai: All authors contributed to the study conception and design, The first draft of the manuscript was written, All authors read and approved the final manuscript. Amgad Mohammed Elshoeibi: All authors read and approved the final manuscript. Ashraf Hantouly: All authors contributed to the study conception and design, Material preparation, literature review, and data collection were performed, all authors commented on the final manuscript, All authors read and approved the final manuscript. Karim Khaled: validation and Supervision. Khalid A. Alkhelaifi: Material preparation, literature review, and data collection were performed, all authors commented on the final manuscript, All authors read and approved the final manuscript. Bashir Zikria: all authors commented on the final manuscript, All authors read and approved the final manuscript, LS: Statistical analysis was performed, The first draft of the manuscript was written.

Consent to participate

Not applicable as this is a review article.

Conflicts of interest

The authors have no relevant financial or non-financial interests to disclose.

Ethical approval

This is a review article. No ethical approval is required.

Availability of data, material and code

Not applicable as this is a review article. However, happy to provide access to any statistical data (coding) upon request.

Consent for publication

Not applicable as this is a review article.

Funding

The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.