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Decision-making in the ACL-deficient malaligned knee: An algorithm-based current concepts review.

Horacio Rivarola1, Cristian Collazo1, Marcos Palanconi1

  • 1Hospital Universitario Austral, Buenos Aires, Argentina.

Journal of Clinical Orthopaedics and Trauma
|May 11, 2026
PubMed
Summary

Managing knees with chronic anterior cruciate ligament (ACL) deficiency and malalignment requires a unified approach. This review presents an algorithm to guide surgical decisions based on pain, instability, and alignment for better outcomes.

Keywords:
Algorithm-based approachAnterior cruciate ligament deficiencyCoronal malalignmentHigh tibial osteotomyJoint-preserving surgeryKnee instabilitySurgical decision-making

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Area of Science:

  • Orthopedic Surgery
  • Biomechanics
  • Sports Medicine

Background:

  • Chronic anterior cruciate ligament (ACL) deficiency often coexists with coronal plane malalignment, leading to abnormal joint loading and degeneration.
  • Current management strategies for ACL-deficient malaligned knees frequently treat instability and alignment separately, resulting in inconsistent decision-making and suboptimal outcomes.
  • A unified biomechanical framework integrating instability, pain, and alignment is lacking for these complex cases.

Purpose of the Study:

  • To propose an algorithm-based decision-making framework for managing the ACL-deficient malaligned knee.
  • To integrate clinical presentation, coronal alignment, cartilage status, and activity level to guide joint-preserving surgical strategies.
  • To synthesize biomechanical principles and clinical evidence for improved patient management.

Main Methods:

  • A comprehensive review of biomechanical principles and contemporary clinical evidence regarding ACL deficiency and malalignment.
  • Categorization of clinical presentations into dominant syndromes: pain-dominant, instability-dominant, or mixed.
  • Development of a stepwise algorithm to guide surgical indications based on a hierarchical assessment.

Main Results:

  • The proposed algorithm prioritizes the dominant clinical syndrome, followed by evaluation of alignment severity, cartilage status, and functional demand.
  • The framework clarifies indications for isolated ACL reconstruction, isolated corrective osteotomy, combined one-stage procedures, or staged interventions.
  • Evidence supports both one-stage and two-stage approaches in appropriately selected patients, emphasizing matching treatment to the mechanical environment.

Conclusions:

  • An algorithm-based approach offers a structured method for decision-making in ACL-deficient malaligned knees.
  • This framework aims to improve consistency in surgical indications and reduce inappropriate isolated procedures.
  • Individualized, biomechanically coherent management is crucial for successful outcomes in this complex patient population.