Risk of overconstraining femorotibial rotation after anatomical ACL reconstruction using bone patella tendon bone autograft

Introduction Numerous studies have focused on the anteroposterior stability after anterior cruciate ligament (ACL) reconstruction, with less emphasis on rotational stability. It has been hypothesized that bone patella tendon bone (BTB) autograft for ACL reconstruction restores knee rotation closely to normal due to its comparable fiber orientation to the native ACL. Materials and methods Twenty patients with unilateral ACL rupture and an uninjured contralateral knee were included in this study. The ACL was reconstructed using the medial third of the patellar tendon. Tunnel placement was controlled by fluoroscopy. Implant-free press-fit graft fixation was used on both femoral and tibial side. Bone blocks were carefully placed to restore fiber orientation of both the anteromedial and posterolateral bundle, similar to the native ACL. Rotatory laxity of both knees was measured at 0 degrees and 25 degrees of flexion pre- and post-surgery, using an active opto-electronical motion-analysis system (LUKOTRONIC AS 100(R)). All measurements were performed under general anesthesia during surgery. Results Knee rotation was reduced significantly in both 0 degrees and 25 degrees of flexion following ACL reconstruction (p < 0.001). The side to side difference (SSD) of the rotatory laxity in extension was greater in the ACL-deficient knee (14.9 degrees +/- 8.9 degrees), but decreased significantly after ACL reconstruction (- 5.9 degrees +/- 7.7 degrees, minus value means less than in the uninjured knee). There was a similar finding at 25 degrees of knee flexion where greater rotation of the ACL-deficient knee (5.7 degrees +/- 10.3 degrees) prior to surgery changed to lower degree of rotation after surgery (- 11.3 degrees +/- 8.4 degrees) in comparison to the uninjured knee. Conclusions ACL reconstruction with a BTB graft in anatomical position using press-fit implant-free fixation is able to restore rotatory knee stability close to the intact contralateral knee. Despite the fact that the BTB graft offers fiber orientation close to the natural ACL, the surgeon should be aware of the potential risk of over-constraining the knee in terms of rotation.