Anterolateral Rotatory Laxity: What is it, When to Address it, and How?

Abstract

The rate of re-injury after anterior cruciate ligament reconstruction (ACLR) in patients under the age of 20 may be as high as 20% with many studies reporting high incidence of persistent rotational laxity as measured by the pivot shift test. It is known that a positive pivot shift test correlates with decreased patient satisfaction and increased functional instability. The anterolateral soft tissues of the knee including the lateral meniscus, iliotibial band and anterolateral ligament contribute to rotational stability in ACL deficient knees. The modified Lemaire extra-articular tenodesis procedure has been shown to restore native kinematics to the knee without over-constraining tibial internal rotation. This technique involves using a strip of iliotibial band tunneled under the fibular collateral ligament and anchored to the lateral femoral condyle to help improve anterolateral rotatory laxity. It should be considered as an adjunct to ACLR in young active patients with grade three pivot shift, generalized ligamentous laxity with the desire to return to a pivoting sport. Current literature demonstrates a pattern suggesting lateral extra-articular tenodesis or anterolateral ligament augmentation can improve rotational stability and result in decreased graft rupture rates following ACLR.