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

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
Affiliations
Review

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

Mohammad Ayati Firoozabadi et al. JB JS Open Access. .

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.

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Conflict of interest statement

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

Figures

Fig. 1
Fig. 1
Anterolateral triangular capsular ligament complex.
Fig. 2
Fig. 2
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
Lemaire technique. FCL = fibular collateral ligament and PFL = popliteofibular ligament.
Fig. 4
Fig. 4
MacIntosh technique. ACL = anterior cruciate ligament, FCL = fibular collateral ligament, IT = iliotibial, and PCL = posterior cruciate ligament.
Fig. 5
Fig. 5
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 GT. 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.
Fig. 6
Fig. 6
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.
Fig. 7
Fig. 7
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). KF = Kaplan fiber.
Fig. 8
Fig. 8
Gali technique. ACL = anterior cruciate ligament, FCL = fibular collateral ligament, IT = iliotibial, and PCL = posterior cruciate ligament.
Fig. 9
Fig. 9
The anatomical scheme of some LET techniques includes ALL reconstruction, KF reconstruction, modified deep/superficial Lemaire, and modified MacIntosh. ALL = anterolateral ligament of the knee, KF = Kaplan fiber, and LET = lateral extra-articular tenodesis.
Fig. 10
Fig. 10
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.
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