International Orthopaedics

, Volume 43, Issue 1, pp 223–228 | Cite as

The unhappy triad of the knee re-revisited

  • Andrea Ferretti
  • Edoardo Monaco
  • Antonio PonzoEmail author
  • Matthew Dagget
  • Matteo Guzzini
  • Daniele Mazza
  • Andrea Redler
  • Fabio Conteduca
Original Paper


Aim of the study

To describe the surgical findings of the anterolateral complex in patients with the “unhappy triad” lesion of the knee.


One hundred and twenty-five consecutive patients presenting with acute anterior cruciate ligament (ACL) tears were selected for this study. Only cases, evaluated with a valgus stress test under fluoroscopy, with a medial opening more than 5 mm of the medial collateral ligament (MCL) were included in the study (11 patients). For the included cases, open MCL surgical repair was performed only in cases with a valgus stress test more than 10 mm as revealed by fluoroscopy (3 patients). All included cases (11 patients) underwent ACL reconstruction and exploration of the anterolateral complex that was then assessed, photographed, classified, and eventually repaired.


At clinical evaluation under anaesthesia, all patients presented a positive Lachman test and a pivot shift test graded as ++ in four cases and +++ in five cases, not valuable in two cases. At surgical exploration, the anterolateral complex was involved in all cases (11 patients): one case demonstrated a type I injury, eight cases a type II injury, two cases a type III injury, and no patient with a type IV injury (Segond’s fracture). All anterolateral complex lesions were repaired by direct suture and re-tensioning.


On the basis of a recent analysis performed by other authors, we could speculate that injuries of ACL and anterolateral compartment occur in the very early phase of the injury when the knee is forced into internal rotation. The MRI evidence of bone bruising in the lateral compartment in most cases of the present series support the hypothesis of an internal rotation torque.


The unhappy triad of injuries to the knee is actually a tetrad involving not just the ACL, MCL, and medial/lateral meniscus but also involved the anterolateral complex.


Knee ACL Multiple ligament injuries Anterolateral complex 


Compliance with ethical standards

Conflict of interest

All authors were fully involved in the study and preparation of the manuscript and that the material within has been and will not submitted for publication elsewhere. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.


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Copyright information

© SICOT aisbl 2018

Authors and Affiliations

  1. 1.“La Sapienza” University of Rome, Sant’Andrea Hospital, Traumatology Sports Center “Kilk Kilgour”RomeItaly
  2. 2.Kansas City UniversityKansas CityUSA

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