Abstract
Background:
Femoral tunnel malposition is a leading cause of anterior cruciate ligament (ACL) graft failure, accounting for 63% of cases. Accurate tunnel placement and proper alignment of the reconstructed ACL are essential for restoring knee stability. Vertical femoral tunnels can cause persistent rotational instability despite an intact ACL graft. The transtibial technique, commonly used for tunnel creation, often results in suboptimal graft positioning, contributing to instability. Extra-articular procedures, such as lateral extra-articular tenodesis (LET), have been shown to improve rotational stability.
Indications:
This case-based technique paper illustrates the management of rotational instability in the setting of vertical ACL grafts, tailored to patients’ symptoms and activity levels.
Technique Description:
We discuss 2 cases of patients with vertical femoral tunnels who sustained bucket-handle tears of the medial meniscus despite having intact ACL grafts. The aim is to highlight surgical decision-making between revision ACL reconstruction (ACLR) + LET and isolated LET in patients with vertical ACL grafts and medial meniscal bucket-handle tears.
Results:
The first case involves a low-demand patient who presented with a single episode of knee instability and locking 13 years after ACLR. The management was a medial meniscal repair using a hybrid technique and a LET to improve rotational stability.
The second case features a highly active patient involved in pivoting sports who reported multiple episodes of knee instability 9 years after ACLR. The management was revision ACLR with a quadriceps tendon autograft, medial meniscal repair using a hybrid technique, and LET.
Discussion/Conclusion:
Studies have shown that vertical ACL grafts can restore anteroposterior stability but may lead to long-term rotational instability. The combination of ACL revision and LET is beneficial for patients with persistent instability and high activity levels. Isolated LET can be effective in patients with low functional demands and intact grafts. By carefully selecting patients and planning surgery appropriately, knee stability can be effectively restored through a targeted treatment approach, leading to enhanced patient-reported function, increased physical activity, and improved psychological readiness to return to sports.
Patient Consent Disclosure Statement:
The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.
This is a visual representation of the abstract.
Keywords
Video Transcript
This video journal discusses management options for patients with vertical anterior cruciate ligament (ACL) femoral grafts presenting with bucket-handle medial meniscal tears, using 2 case examples, along with surgical tips and relevant literature.
Background
Nonanatomic positioning of the ACL tunnel increases the risk of revision anterior cruciate ligament reconstruction (ACLR). 3 Approximately 63% of tunnel malpositions occur in the femur. 8 Femoral tunnel angles >75° to a line perpendicular to the long axis of the tibia are considered vertical, 1 which can lead to rotational instability. 18
Vertical ACL grafts, often resulting from transtibial femoral drilling, are less effective in controlling rotational instability compared with anteromedial (AM) techniques.6,14 Chronic ACL insufficiency and instability increase the risk of medial meniscal tears.4,19 Anterolateral soft tissue structures contribute to rotational stability,15,21 and Modified Lemaire extra-articular tenodesis (LET) has been shown to restore native kinematics without overconstraining the knee. 12 Anterolateral reinforcement has been shown to play a role in improving rotational stability after ACLR.9,10
Indications and Technique Description
We present 2 patients with vertical femoral tunnels who sustained bucket-handle medial meniscal tears. Despite intact ACL grafts, both patients had rotational instability, leading to medial meniscal tears. We discuss their management and provide surgical tips.
Case 1
The first patient was a 30-year-old female office worker who had undergone ACLR 13 years prior for right knee instability. After surgery, there was no recurrence, and she engaged in occasional jogging and hiking.
On examination, she had a 10° extension lag. Anterior drawer, Lachman, and pivot shift tests were negative. Magnetic resonance imaging (MRI) revealed an intact ACL and a bucket-handle tear of the medial meniscus. The ACL graft formed a 76° angle relative to a line perpendicular to the tibial long axis, indicating a vertically oriented graft.
The surgical plan was to repair the medial meniscus and improve rotational stability through a hybrid meniscal repair and LET, with intraoperative ACL evaluation.
The patient was positioned supine with the right knee flexed to 90°. Standard arthroscopy portals were established. A bucket-handle tear was confirmed, and the vertically oriented ACL graft was intact with good tension.
The medial meniscal scar tissue in the gutter between the rim and displaced fragment was debrided with a shaver. Both sides were rasped. A hybrid repair was performed using the following implants: 8 inside-out 2-0 FiberWire sutures (Arthrex) across the body and anterior horn; 3 curved Fast-Fix 360 all-inside sutures; and 2 reverse-curved flexible Fast-Fix sutures (Smith & Nephew) in the posterior horn.
For the LET, a longitudinal incision was made along the lateral aspect of the knee. An 11-cm by 8-mm iliotibial band (ITB) strip was harvested and passed under the lateral collateral ligament. A femoral tunnel was created 10° cephalad and 30° anterior, and the graft was fixed using a suture anchor with the knee at 30° of flexion and the foot in neutral. The ITB donor site was closed routinely.
Postoperatively, the patient followed a phased rehabilitation protocol: touchdown weightbearing and 0° to 90° bracing for 3 weeks, partial weightbearing until 6 weeks, and then full weightbearing with gradual return to motion and closed-chain exercises.
Case 2
The second patient was a 40-year-old man who underwent left ACLR 9 years ago. He reported multiple episodes of instability over the past 5 years, with the most recent involving a locked knee. He remained active in pivoting sports, such as soccer and rugby.
The examination showed restricted extension. The anterior drawer and pivot shift tests were negative, but the Lachman test was positive. The MRI revealed an intact ACL graft and a medial meniscal bucket-handle tear. The ACL graft had a vertical orientation of 76°, similar to that in the previous case.
Surgical goals included restoring ACL and meniscus function to allow return to pivoting sports. A revision ACLR using a quadriceps tendon autograft, hybrid meniscal repair, and LET was planned.
The arthroscopy confirmed the bucket-handle tear and vertical ACL graft. A robust hybrid repair was performed using 6 curved Fast-Fix 360 all-inside sutures, 2 reverse-curved flexible Fast-Fix all-inside sutures (Smith & Nephew) in the posterior horn, and 8 inside-out 2-0 FiberWire sutures (Arthrex) across the body of the meniscus.
A new femoral tunnel was drilled via the AM portal, located distal and deeper to the old tunnel. The prior tibial tunnel was reused. The quadriceps tendon autograft was fixed with suspensory cortical fixation on the femur and interference screw fixation on the tibia, supplemented with a suture anchor.
The LET was performed identically to the first case. The same rehabilitation protocol was followed.
Results
At the 1-year follow-up, both patients reported no pain, swelling, or instability. Clinical examinations were negative for anterior drawer, Lachman, and pivot shift tests. The second patient had resumed light ball training.
Discussion
Rotational instability after ACLR may present as persistent instability despite a clinically intact graft, vertical tunnel orientation on imaging, and bucket-handle medial meniscal tears.
Medial meniscal bucket-handle tears require a robust repair using a hybrid combination of inside-out and all-inside sutures. Given the poor vascularity of the medial meniscus, 17 especially in the red-white zone, healing is less predictable, and repair must be optimized to reduce the risk of retears.2,20
In the management of persistent rotational instability after ACLR, a decision must be made whether to revise the vertically oriented ACL graft.
Loh et al 13 demonstrated that grafts placed at the 10 o'clock position better resist rotational loads than those at the 11 o'clock position. Our patients had 76° graft angles, well beyond the 11 o'clock equivalent (60°), which predisposed them to instability.
Lee et al 11 reported lower Lysholm scores and residual pivot shift in patients with vertical grafts, despite minimal anteroposterior laxity. This matches our findings—both patients had negative anterior drawer tests but demonstrated rotational instability and medial meniscal injury.
Anterolateral reinforcement improves rotational stability. A comparative biomechanical study showed that combined ACL and anterolateral ligament (ALL) reconstruction (ALLR) restored knee kinematics more effectively than isolated ACLR. Both LET and ALLR provided similar biomechanical outcomes. 7
In older, low-demand patients, Perelli et al 16 demonstrated that isolated LET can restore stability without ACL revision surgery. Recent studies support LET in patients with intact but nonanatomic grafts and moderate instability, especially when return to sport demands are low. The LET significantly improved subjective function and psychological readiness to return to sport. 5
Recommendations
We recommend robust hybrid repair of all medial meniscal bucket-handle tears. For patients with vertical ACL grafts and rotational instability, surgical decision-making should be guided by the patient’s activity level and the condition of the graft. In active patients, ACL revision with LET may be a suitable option. In patients with lower demand and intact but vertical grafts, isolated LET may be sufficient.
When revising ACLR, prioritize proper visualization of the prior femoral tunnel to position a new, anatomical femoral tunnel accurately. Tibial tunnels can often be reused. LET or ALLR should be added to address rotational control.
Limitations
Management should be individualized. Accurate assessment of a patient’s activity level is essential, and expectations must be carefully managed, particularly when opting against ACL revision.
Conclusion
Medial meniscal bucket-handle tears should be repaired robustly. Consider ACL revision with LET in high-demand patients with instability. For low-demand patients with intact grafts, isolated LET may restore rotational stability.
Footnotes
Submitted March 8, 2025; accepted August 14, 2025.
The authors declared that they have no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.
