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A New Algorithm for Extra-Articular Reinforcement in ACL Injury Based on Rotational Instability.

Pedro Jorge¹, Luiz Gabriel Guglielmetti¹, Camilo Helito²

¹Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, Brazil.

Video Journal of Sports Medicine

|May 1, 2025

Summary

Anteromedial rotational instability (AMRI) in anterior cruciate ligament (ACL) injuries can be addressed with specific extra-articular reinforcements. A new algorithm guides the use of anteromedial and anterolateral techniques to improve surgical outcomes.

Keywords:

ACL knee knee injury knee instability rotational instability

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Area of Science:

Orthopedic Surgery
Sports Medicine
Biomechanics

Background:

Anterior cruciate ligament (ACL) reconstructions are improving with extra-articular reinforcements.
Anteromedial rotational instability (AMRI), caused by valgus and external tibial rotation, can occur with ACL injuries.
Reinforcement in the anteromedial quadrant, along the anterior oblique ligament (AOL) topography, can address external rotation instability.

Purpose of the Study:

To propose an algorithm for managing rotational instability in ACL-injured patients undergoing extra-articular reinforcement.
To identify specific indications for anteromedial versus anterolateral reinforcement based on physical examination findings.

Main Methods:

Physical examination under anesthesia, including pivot shift and anterior drawer in external rotation (ADER) tests, is crucial.
An algorithm is proposed to guide the selection of anterolateral, anteromedial, or combined reinforcements.
Patients with positive pivot shift (internal rotation instability) or hyperlaxity may benefit from anterolateral reinforcement.

Main Results:

Isolated positive ADER test indicates a need for anteromedial reinforcement.
Positive ADER and pivot shift suggest the potential benefit of combined medial and lateral extra-articular reinforcement.
AMRI is a risk factor for ACL reconstruction failure and requires treatment.

Conclusions:

Clinical examination under anesthesia should assess both internal and external rotational stability.
Anteromedial reinforcement, specifically in the AOL topography, is a viable option for treating AMRI.
The proposed algorithm aids in optimizing extra-articular reinforcement strategies for ACL reconstructions.