Management of Rotational Instability After Anterior Cruciate Ligament Reconstruction.

Background: Femoral tunnel malposition is a leading cause of anterior cruciate ligament (ACL) graft failure, accounting for 63% of cases. Accurate tunnel placement and proper alignment of the reconstructed ACL are essential for restoring knee stability. Vertical femoral tunnels can cause persistent rotational instability despite an intact ACL graft. The transtibial technique, commonly used for tunnel creation, often results in suboptimal graft positioning, contributing to instability. Extra-articular procedures, such as lateral extra-articular tenodesis (LET), have been shown to improve rotational stability. Indications: This case-based technique paper illustrates the management of rotational instability in the setting of vertical ACL grafts, tailored to patients' symptoms and activity levels. Technique Description: We discuss 2 cases of patients with vertical femoral tunnels who sustained bucket-handle tears of the medial meniscus despite having intact ACL grafts. The aim is to highlight surgical decision-making between revision ACL reconstruction (ACLR) + LET and isolated LET in patients with vertical ACL grafts and medial meniscal bucket-handle tears. Results: The first case involves a low-demand patient who presented with a single episode of knee instability and locking 13 years after ACLR. The management was a medial meniscal repair using a hybrid technique and a LET to improve rotational stability.The second case features a highly active patient involved in pivoting sports who reported multiple episodes of knee instability 9 years after ACLR. The management was revision ACLR with a quadriceps tendon autograft, medial meniscal repair using a hybrid technique, and LET. Discussion/Conclusion: Studies have shown that vertical ACL grafts can restore anteroposterior stability but may lead to long-term rotational instability. The combination of ACL revision and LET is beneficial for patients with persistent instability and high activity levels. Isolated LET can be effective in patients with low functional demands and intact grafts. By carefully selecting patients and planning surgery appropriately, knee stability can be effectively restored through a targeted treatment approach, leading to enhanced patient-reported function, increased physical activity, and improved psychological readiness to return to sports. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.