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. 2025 Jun 6;10(2):e25.00002. doi: 10.2106/JBJS.OA.25.00002

Approach to Residual Anterolateral Rotatory Knee Instability After Anterior Cruciate Ligament Reconstruction

Mohammad Ayati firoozabadi 1,2, Seyed Mohammad Milad Seyedtabaei 1,2, Hesan Rezaee 1,2, Seyed Mohammad Javad Mortazavi 1,2,a
PMCID: PMC12136665  PMID: 40487140

Abstract

  • » Arthroscopic anterior cruciate ligament (ACL) reconstruction is widely regarded for its excellent results in restoring tibiofemoral anterior laxity to near-normal levels.

  • » However, some operated patients may still experience anterolateral rotatory instability, leading to dissatisfaction and feelings of instability. After ruling out injuries to the posteromedial corner, lateral collateral ligament, and posterolateral corner, the focus should shift to the anterolateral ligament (ALL) and Kaplan fibers.

  • » For ALL injuries causing internal rotatory instability at around 30 degrees knee flexion, a modified deep Lemaire tenodesis is recommended.

  • » Kaplan fiber injuries leading to internal rotatory instability at angles greater than 30 degrees knee flexion can be treated with a modified superficial Lemaire surgery and iliotibial band strap fixation in the distal Kaplan fiber anatomical position.

Introduction

Some patients experience degrees of rotatory instability even after arthroscopic anterior cruciate ligament (ACL) reconstruction. This can lead to a sensation of instability, resulting in dissatisfaction among those individuals1,2. Research shows that the failure rate for primary ACL reconstruction ranges from 3% to 5%. However, this rate rises significantly to between 15% and 20% for revision ACL surgeries3,4. Residual rotary laxity may be a possible cause of the increased failure rate5. In this study, we intend to investigate the causes of residual anterolateral rotatory instability following ACL reconstruction, ruling out other PMC, lateral collateral ligament (LCL), posterior cruciate ligament, and posterior lateral corner (PLC) injuries and finally provide a solution to this problem.

Anterior cruciate ligament

The primary function of the ACL is to prevent the forward movement of the tibia relative to the femur. In addition, the ACL helps limit excessive internal rotation of the tibia on the femur.6,7 The ACL consists of 2 bundles: the anteromedial (AM) and posterolateral (PL) bundles, distinguished by their tibial insertion sites. The AM bundle tightens during knee flexion, while the PL bundle tightens in knee extension, functioning synergistically. Both bundles attach to the medial wall of the lateral femoral condyle, posterior to the resident ridge, with their insertion sites separated by the bifurcate ridge.8,9 Patients with an acute ACL tear typically report knee pain, swelling, and difficulty in bearing full weight on the affected leg. By contrast, those with a chronic ACL tear primarily complain of knee instability and a sensation of the knee giving way. During the physical examination of these patients, the anterior drawer test (ADT), Lachman test, lever sign test, and pivot shift test were helpful. Among these tests, only the pivot shift test evaluates rotatory instability caused by ACL tearing. The sensitivity and specificity of the tests were as follows: ADT (83% sensitivity, 85% specificity), Lachman test (81% sensitivity, 85% specificity), pivot shift test (55% sensitivity, 94% specificity), and Lever sign test (83% sensitivity, 91% specificity). The pivot shift test was best for ruling in an ACL tear, while the Lever sign test was best for ruling it out10.

Anterolateral Rotatory Instability

The primary restraint against the internal rotation of the knee during flexion is the superficial medial collateral ligament, while in extension, it is the posterior oblique ligament. Secondary restraints include the ACL and lateral complex consisting of the anterolateral ligament (ALL), LCL, PFL, and iliotibial band (Kaplan fibers [KFs]). The anterolateral complex (ALC) comprises 2 layers: a superficial layer, which includes the iliotibial band (ITB) and superficial KFs, and a deep layer, consisting of the triangular capsular ligament complex, which features the ALL and the anterolateral capsule (Fig. 1)11. Isolated lesions of the PL bundle of ACL do not significantly increase internal rotation; however, complete ACL tears result in increased internal rotation and altered rotation patterns, with the fulcrum shifting from the joint center to the MCL and leading to anterior translation of the lateral tibial plateau.

Fig. 1.

Fig. 1

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Anterolateral triangular capsular ligament complex11.

In a healthy knee, typical movement involves rolling, gliding, and rotation. In an ACL-deficient knee, the absence of ligament support causes abnormal actions such as excessive tibial translation, internal/external rotation, and lateral shifts. These movements occur around a dynamic helical axis rather than a fixed point, with the tibia moving in a screw-like manner, combining translation and rotation relative to the femur. The helical axis remains stable during motion in a knee with an intact ACL. However, in an ACL-deficient knee, loss of pivot control causes the helical axis to shift, resulting in excessive rotational instability. This instability in the ACL-deficient knee is characterized by complex, three-dimensional translation and rotation around a helical axis12,13. In the context of rotatory knee instability, it is imperative to differentiate between the axial rotation laxity envelope, coupled rotation, and dynamic laxity. This distinction is essential for a comprehensive understanding of the mechanisms and implications associated with knee instability12-15. The axial rotation laxity envelope describes the maximum internal and external tibial rotation under a defined load13. Coupled rotation is the obligatory internal tibial rotation during anterior tibial translation (ATT) when an anterior tibial load is applied15. The pivot shift test assesses the dynamic laxity of the knee, which is the tibial rotation during a giving way symptom.

Following ACL reconstruction, it has been observed that patients may still demonstrate a positive pivot-shift sign and experience internal rotational instability16,17. Numerous factors, such as tunnel positioning, nonanatomic reconstructions, single-bundle reconstructions, concomitant LCL and PLC injuries, and ALC injuries, are emphasized, yet the issue remains unresolved. Tunnel positioning in ACL reconstruction significantly influences rotational stability and surgical outcomes. Increasing the coronal plane angle of the femoral tunnel may enhance the restoration of rotational stability18. Lee et al. found that a vertical orientation of the femoral tunnel in the axial plane correlates with residual pivot shift and rotational instability. They proposed that an oblique graft positioning may improve rotational stability and enhance patient satisfaction19. It should be made clear that for patients who continue to experience significant instability after ACL reconstruction due to technical mistakes (such as misplaced tunnels, insufficient graft tensioning, or improper fixation), a secondary ACL graft revision surgery might be necessary to rectify the instability. It is crucial to note that neither the ALL nor the KF reconstruction can correct these technical faults. However, when conducting revision surgery, addressing the ALL and KFs along with ACL tunnel revision may yield better results than ACL revision alone for rotational instability.

Previous research suggested that double-bundle ACL reconstructions more effectively restore rotational stability, primarily attributed to the PL bundle20. While various clinical and laboratory studies have highlighted the advantages of double-bundle reconstruction, numerous studies have failed to find significant outcome differences21-24. The LCL was identified as the primary stabilizer at 60° under a combined rotational load, effectively limiting ATT. Injury to the LCL significantly increases the risk of anterolateral rotatory instability (ALRI). It is clinically important to distinguish between ALRI with and without involvement of the PLC injuries. In cases of severe rotational instability accompanied by ACL and LCL ruptures, the need for additional extra-articular stabilization procedures should be evaluated25.

Previous studies have reported that injuries to the ALC, such as KFs and ALL injuries, lead to increased internal rotation of the tibia in ACL-deficient knees26-28. Claes et al. demonstrated a significant prevalence of radiological damage associated with ACL injuries, reporting an incidence rate of 78.7% in affected knees29. Farinelli et al. study concluded that ALL and KFs injuries were associated with an increased internal tibial rotation in ACL-deficient knees on high-field magnetic resonance imaging (MRI). The measurement of femorotibial rotation on axial MRI could be useful to detect indirect signs of ALC injuries, which could help in the diagnosis and management of patients with these injuries30.

ALL

The ALL arises from the lateral wall of the femoral lateral condyle and attaches to the proximal and lateral aspects of the tibia. The femoral origin of the ALL varies in reported locations, including the lateral epicondyle and areas proximal and posterior to both the lateral epicondyle and the LCL junction. Conversely, the tibial attachment of the ALL is consistently located midway between the Gerdy tubercle and the anterior edge of the fibular head, approximately 9.5 mm from the joint surface and just proximal to the biceps femoris insertion31. The ALL is a nonisometric ligament, meaning its length increases with knee flexion and internal rotation. In full-knee extension, the average length of the ALL ranges from 33 mm to 37.9 mm, with an average width of 7.4 mm. Its thickness measures approximately 2.7 mm, and the cross-sectional area in the middle is about 1.54 mm2.32 The ALL is connected to the lateral meniscus before attaching to the tibia, situated near this region's lateral inferior genicular artery.

The primary role of the ALL is to prevent the pivot shift phenomenon during early flexion, specifically at flexion less than 30°26. MRI can often assist in diagnosing ALL injuries (Fig. 2).33 The ALL characteristics observed in MRI are comprehensively summarized in Table I. The ALL can be reconstructed anatomically or by doing an ALL tenodesis. Lemaire described the first lateral extra-articular tenodesis (LET) procedure in 1967. This technique involves harvesting a strip of ITB, detaching it proximally, and then passing it deep to the LCL. It is looped through a drilled tunnel at the origin of the lateral gastrocnemius muscle, then passed deep to the LCL and sutured to itself at the Gerdy tubercle. The graft is tensioned with the knee in external rotation and 30 degrees of flexion (Fig. 3)35. Several methods for performing an ALL tenodesis have been proposed since then; the most common is a modified Lemaire procedure using a strip of ITB. In this surgical technique, an incision is made proximal to the Gerdy tubercle to facilitate access to the ITB. A 1 cm wide segment of the ITB is harvested while preserving its distal attachment. The harvest is extended approximately 8 to 12 centimeters and subsequently released at the proximal end. The harvested tendon is then advanced deep to the LCL and secured using an interference screw at the anatomical site corresponding to the ALL on the lateral femoral condyle with appropriate tension36.

Fig. 2.

Fig. 2

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T2-weighted MRI of knee. Arrows represent the corresponding slice levels between axial and coronal images: yellow: ALL; green: FCL; and red: ITB. ALL = anterolateral ligament, FCL = fibular collateral ligament, and ITB = iliotibial band.

Fig. 3.

Fig. 3

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Lemaire technique. FCL = fibular collateral ligament and PFL = popliteofibular ligament34.

TABLE I.

Identification of the ALL on an MRI

• Low-signal band on proton density sequences
• Seen on 2 lines under cross-reference
• Extra-articular structure
• Origin at the posterior-proximal region of the femoral epicondyle
• Running in an anterior-distal direction deep into the ITT
• Crossing the lateral collateral ligament in the proximal third
• Inserting on the anterolateral tibia between Gerdy tubercle and the fibular head
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ALL = anterolateral ligament and MRI = magnetic resonance imaging.

MacIntosh et al. described another surgical technique that involves harvesting a strip of the ITB. The procedure begins by detaching the strip proximally and tunneling it deep to the LCL. An osteoperiosteal flap is then created behind the origin of the LCL, underneath which the strip is passed. The flap is reattached, forming a sling over the iliotibial strip. Next, the strip is tunneled through the lateral intermuscular septum and passed distally, deep to the LCL, where it is sutured to itself at the Gerdy tubercle. The graft is tensioned while the knee is in external rotation at 90 degrees of flexion (Fig. 4)37.

Fig. 4.

Fig. 4

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MacIntosh technique. ACL = anterior cruciate ligament, FCL = fibular collateral ligament, IT = iliotibial, and PCL = posterior cruciate ligament34.

It has gained popularity with advancements in surgical techniques and an improved understanding of knee biomechanics, including LET. However, early studies suggested that LET may overconstrain the knee, potentially leading to suboptimal long-term outcomes38,39. Recent literature presents conflicting findings on the integration of LET with ACL-R. Evidence suggests that including LET in ACL-R enhances procedural efficacy while demonstrating minimal complications at a 2-year follow-up. Furthermore, studies indicate that this combination reduces rotational knee laxity without elevating the risk of osteoarthritis5,12,40-44. Based on previous research, it is advised that ALL reconstruction or ALL tenodesis may be conducted concurrently with ACL reconstruction, as given in Table II.

TABLE II.

Indications for ALL* Reconstruction or Tenodesis

• Patients resume participation in pivot and contact sports
• High-grade rotational laxity (a grade-2 or three pivot shift)
• Existence of knee hyperextension (ligamentous hyperlaxity)
• Genu recurvatum of >10°
• Revision surgery in a patient with failed ACL reconstruction
• Young patients (<25 years old)
• Medial meniscectomy
• Injury in anterolateral structures
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*ALL = anterolateral ligament.

Contraindication in cases of posterolateral corner injury and lateral compartment osteoarthritis.

KFs

In 1958, Kaplan first described that the distal part of the iliotibial band functions as a stabilizing ligament between the lateral femoral condyle and the tibia45. KFs, extensions of the deep iliotibial band, connect to the distal femur and are categorized as proximal Kaplan fibers (PKFs) and distal Kaplan fibers (DKFs) based on their attachment sites. They originate near the tendon of the lateral head of the gastrocnemius and the superior lateral genicular artery (Fig. 5).

Fig. 5.

Fig. 5

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Fig. 5-A Illustration, (Fig. 5-B) sagittal MRI of a right knee viewed from the lateral aspect. Green marks the KF complex; red is the superior lateral geniculate artery; and yellow is the lateral GT46. ALL = anterolateral ligament of the knee, DKF, distal KF, FCL = fibular collateral ligament, GT = gastrocnemius tendon, ITB = iliotibial band, PKF = proximal Kaplan fiber, and PLT = popliteus tendon.

The distance from the lateral epicondyle to the origin of the PKF is 49.20 ± 7.38 mm, while the distance to the origin of the DKF measures 27.54 ± 7.69 mm. In addition, DKF is both thicker and wider than PKF47. Based on MRI findings, the lengths of PKF and DKF were 3.6 ± 17.9 mm and 6.5 ± 12.4 mm, respectively. The distance from the origins of PKF and DKF to the lateral joint surface of the femur was 63.5 ± 7.6 mm and 45.3 ± 3.7 mm, respectively48. Gary et al. studied the anatomy of the KFs in 21 cadavers, with the results depicted in Fig. 649. KFs are vital structures implicated in the biomechanical stability of the knee, especially in controlling rotational movements. Their synergistic action with other anterolateral structures such as the ALL and the robust attachment to the distal femur accentuate their significance in maintaining knee joint integrity and function46.

Fig. 6.

Fig. 6

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Anatomical relationships of DKF (Fig. 6-A), and PKF (Fig. 6-B) with lateral structures and femoral cortical bone. DKF, distal KF, JL = femoral joint line, LFE = lateral femoral epicondyle, LCL = lateral collateral ligament, LGT = lateral gastrocnemius tendon, PKF = proximal Kaplan fiber, and PLT = popliteus tendon.

Kittl et al.28 demonstrated that the ITB was the primary restraint to internal rotation at 30° to 90° of flexion in ACL-intact and ACL-deficient knees. Geeslin et al.50 found that cutting the KF attachment of the ITB increased tibial internal rotation at 30°-90° flexion angles more than cutting the ALL. KFs prevent pivot shift primarily at higher degrees of knee flexion (60-90°), in contrast to the ALL, which mainly prevents pivot shift during the first 30 degrees of knee flexion45,50. KFs can be evaluated using MRI (Fig. 5), and the diagnostic criteria for detecting KFs are given in Table III48,51,52. To accurately diagnose KF injuries through MRI, it is essential to consider both direct and indirect signs outlined in Table IV (Fig. 7)46,51. Gali et al. introduced the KF reconstruction method by removing a strap measuring 1 centimeter in width and 10 centimeters in length from the iliotibial band. This band, connected distally to the Gerdy tubercle, is first freed from its proximal attachment before being repositioned over the LCL. The strap is then secured in place using an interference screw, which is inserted into a tunnel located 31.4 millimeters proximal to the lateral epicondyle of the femur (Fig. 8)47. Modifications to these methods utilize a cortical suspensory button for graft fixation. This technique's advantage is that the tension in the iliotibial band strip can be adjusted, allowing the surgeon to increase the graft's tension as needed to achieve the ideal tension during knee flexion53. The indications for KF reconstruction are presented in Table V.

Fig. 7.

Fig. 7

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Coronal (Fig. 7-A) and sagittal (Fig. 7-B) complete tear of the Kaplan fiber complex (yellow arrow) indicated by the wavy appearance and surrounding edema (green arrow = superficial iliotibial band)46. KF = Kaplan fiber.

Fig. 8.

Fig. 8

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Gali technique. ACL = anterior cruciate ligament, FCL = fibular collateral ligament, IT = iliotibial, and PCL = posterior cruciate ligament.

TABLE III.

Diagnostic Criteria for MRI Identification of the KFs

• Seen on at least 2 consecutive slices
• Connecting the ITB to the femur
• Continuing distally from the intermuscular septum
• Low signal on PD/T2 sequences
• Possible tubercle on the posterolateral femur
• Approximately 68 mm above the lateral joint line for the proximal KFs and 48 mm for the distal KFs)
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KFs = Kaplan fibers, and MRI = magnetic resonance imaging.

TABLE IV.

Diagnostic Criteria for MRI Identification of KF Injury

Signs of Injury Criteria
Direct • Discontinuity of the KFs
• Femoral avulsion of the KFs
Indirect • Thickening or intrasubstance signal change of the KFs
• Focal bone marrow edema at the KF insertion site
• Soft tissue edema in the region of KF
• Wavy appearance
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KFs = Kaplan fibers and MRI = magnetic resonance imaging.

TABLE V.

Indications for KF Reconstruction

• Professional athletes who perform rotational movements
• Pivot shift test grade +2 or +3
• Chronic ACL injuries (more than 12 months)
• ACL revision
• Notch sign of lateral femoral condyle greater than 2 mm
• Existence of Segond fracture
• Young patients (<20 years old)
• Generalized ligamentous laxity
• genu recurvatum of >10°
• Use of allograft in ACL reconstruction
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ACL = anterior cruciate ligament and KFs = Kaplan fibers.

Effects of Common Anterolateral Surgeries Combined with ACL Reconstruction on Knee Kinematics and Stability

The Neri study of 10 cadavers with healthy knee ligaments concluded that ACL reconstruction does not restore normal knee kinematics in concomitant ACL and anterolateral knee damage cases. While anatomic reconstruction of the ALL alongside ACL surgery nearly normalizes internal knee rotation, it requires 2 tunnels—one in the femur and the other in the tibia—along with either an autograft or an allograft. By contrast, ALL tenodesis, which involves only 1 tunnel in the distal femur and eliminates the need for graft harvesting, is becoming the preferred surgical approach54.

In a comparative analysis of the superficial Lemaire, deep Lemaire, and modified MacIntosh techniques for anatomical reconstruction of the ALL, all methods exhibit significant internal rotation restrictions of the knee. The deep Lemaire technique results in greater restriction at lower flexion angles (less than 45°), while the superficial Lemaire technique shows more restriction at higher flexion angles (approximately 60-90°). The MacIntosh technique presents a similar but comparatively lesser restriction than the deep Lemaire method46 (Fig. 9). Internal rotation restrictions from biomechanical changes may cause secondary knee osteoarthritis (OA). This can happen based on several hypothetical situations: (1) Cartilage wear: Compensatory excessive external tibial rotation leads to uneven loading on the tibiofemoral and patellofemoral joints, increasing early osteoarthritis risk. (2) Meniscal stress: Restrictions on internal rotation raise meniscal shear forces, especially affecting the lateral meniscus vital for rotational control. (3) Compensatory joint strain: Limited internal rotation may stress nearby structures, potentially causing PLC overload or MCL strain over time. However, no research exists on the long-term outcomes of ALL and KF reconstruction, emphasizing the need for studies on OA prevalence and risk factors postreconstruction.

Fig. 9.

Fig. 9

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The anatomical scheme of some LET techniques includes ALL reconstruction, KF reconstruction, modified deep/superficial Lemaire, and modified MacIntosh46. ALL = anterolateral ligament of the knee, KF = Kaplan fiber, and LET = lateral extra-articular tenodesis.

Proposing Treatment Algorithm in Patients with Just ACL Tear

After anatomic ACL reconstruction, the degree of internal rotatory instability in the knee should be evaluated at the end of the surgery. The modified deep Lemaire method should be performed if the instability exceeds +1 at 30° of knee flexion. On the other hand, if this instability is observed at knee flexion angles greater than 60°, the modified superficial Lemaire method will be employed for the patient. This method involves fixing the iliotibial band in the anatomical location of the DKF, specifically proximal to the lateral superior genicular artery. Since the simultaneous damage to both the KFs and the ALL is rare, internal rotatory instability typically occurs at either 30° or above 60° of knee flexion. Therefore, one of these methods is generally utilized to address the instability (Fig. 10). ALL and KF reconstruction should take place only after ruling out PMC, PLC, and AMC injuries. Technical errors, such as tunnel malposition, should be corrected through revision surgery. In fact, ALL and KF reconstruction cannot be performed to address failures in other situations. Each issue needs to be handled individually, and this approach is not a one-size-fits-all solution substitute.

Fig. 10.

Fig. 10

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Treatment algorithm for residual rotatory instability of the knee after ACL reconstruction and ruling out other PMC, LCL, PCL, and PLC injuries. ACL = anterior cruciate ligament, LCL = lateral collateral ligament, PCL = posterior cruciate ligament, and PLC = posterior lateral corner.

Conclusion

Although the results of anatomic ACL reconstruction are generally excellent, a significant percentage of patients still experience anterolateral rotatory instability, leading to dissatisfaction and, in some cases, an inability to return to prior activity levels. After ruling out injuries to the PMC, LCL, and PLC, it is important to consider potential injuries to the ALL and KFs in these patients. If internal rotatory instability occurs at lower knee flexion (around 30°), damage to the ALL is likely. In such cases, the modified deep Lemaire tenodesis method is recommended. Conversely, if internal rotatory instability is observed at higher degrees of knee flexion (between 60 and 90°), the KF injury is typically responsible. For these instances, modified superficial Lemaire surgery with iliotibial strap fixation in the anatomical position of the DKF is advised.

Footnotes

The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported. All co-authors have agreed with the final manuscript's contents, and no financial interest remains to be announced.

Investigation performed at the Imam Khomeini Complex Hospital, Tehran University of Medical Sciences, Tehran, Iran

Ethics approval and consent to participate ethical approval is exempt at our institution.

Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSOA/A816).

Contributor Information

Mohammad Ayati firoozabadi, Email: dr.mohammad.ayati@gmail.com.

Seyed Mohammad Milad Seyedtabaei, Email: miladst94@gmail.com.

Hesan Rezaee, Email: hesan.rezaee@gmail.com.

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