ACL reconstruction success requires additional correction of tibial slope, rotational instability, and meniscus pathology: Meniscal repair failure increases knee rotational laxity.

The anterior cruciate ligament (ACL) and medial and lateral menisci are essential contributors of both anteroposterior (AP) and rotational knee stability. Multiple studies have shown both ACL-deficient knees lead to increased risk of meniscal injury, as well as multiple types of meniscal tears or deficiency leading to increased risk of ACL tear or ACL reconstruction (ACLR) failures. All amenable meniscal tears, such as red-red peripheral tears, radial tears, root tears, lateral meniscal oblique radial tears (LMORTs), and ramp lesions should be attempted to be repaired at time of ACLR. In addition, other contributors to rotational stability, such as collateral, posterolateral/posteromedial corner, anterolateral injuries, and excessive posterior tibial slope (PTS) should be identified and addressed. Rotational stability should be part of every ACL surgeon's algorithm; in my practice, my preference for patients that will place high rotational stress on their knee is for bone-patellar tendon-bone autograft ACLR, aggressively repairing aforementioned meniscal pathology, and adding anterolateral extraarticular reconstructions when recurvatum/ligamentous laxity, increased PTS, high risk patients (e.g., young females in pivoting sports), or high-grade pivot shift is present.