Predicting anterior cruciate ligament reconstruction (ACLR) failure remains a challenge, shaped by anatomical, biomechanical, surgical, and rehabilitation factors. The lateral femoral notch sign (LFNS), present in 6-52% of ACL injuries, is linked to lateral meniscal tears (40-67%), steeper posterior tibial slope (PTS, 2.7° higher), and cartilage degradation. However, despite its correlation with injury severity, LFNS has limited value in predicting ACL graft failure or postoperative instability. Recent studies reinforce that LFNS is a marker of past pivot trauma, not a predictor of future ACL failure. While deeper LFNS (>2mm) correlates with more severe initial injury, it does not influence long-term graft survival or knee stability. Research shows that LFNS resolves over time in pediatric patients, fails to correlate with residual tibial laxity or rotational instability, and is associated with non-progressive chondral lesions. In contrast, modifiable factors-such as achieving optimal tunnel positioning and effectively managing rotational instability-play a far more decisive role in determining ACL reconstruction success than static imaging markers like LFNS. Ultimately, LFNS is a historical remnant, not a clinical decision-making tool in ACL failure risk assessment. It reminds us that successful outcomes hinge on a comprehensive approach rather than isolated imaging findings. Such imaging signs show scars of battles lost but often don't predict the outcome of the war.
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