Optimizing Anterior Cruciate Ligament (ACL) Outcomes: What Else Needs Fixing Besides the ACL?

This review focuses on the management of anterior cruciate ligament (ACL) reconstruction patients when other concomitant pathology may need to be addressed at the time of surgery. Given the role of the posterior horn of the medial meniscus in preventing osteoarthritis progression and contributing to knee stability, medial meniscus repair should always be considered when performing ACL reconstruction. Meniscal transplant may also be appropriate in select patients with normal knee alignment and absent of cartilage abnormalities in the compartment. Varus alignment with a varus thrust or increased posterior tibial slope will increase stress on the ACL graft and may predispose to early failure. Alignment should be assessed with appropriate radiographs and corrective osteotomy in isolation or in conjunction with ACL reconstruction should be considered for certain patients. Low-grade medial collateral ligament (MCL) and lateral collateral ligament (LCL) injuries can be treated nonsurgically prior to ACL reconstruction. These are frequently missed with either physical examination or radiographic imaging. High-grade LCL injuries are often treated with repair versus reconstruction in conjunction with ACL reconstruction depending on the timing of the injury. When chronic MCL injuries show opening in extension, MCL reconstruction may be needed in addition to the ACL reconstruction to improve outcome. The role of extra-articular reconstruction or anterolateral ligament (ALL) reconstruction remains controversial but may have a role in protecting rotatory stability in primary ACL reconstruction for high-risk patients, and in the revision setting. Cartilage lesions noted in the setting of ACL injury should be considered. Small, asymptomatic lesions in locations unrelated to the ACL injury may not necessitate additional intervention. Large symptomatic lesions may require additional cartilage restoration procedures at the time of ACL reconstruction or in a staged fashion. In this ICL, we will address the diagnosis, management, and surgical indications of other concomitant pathology associated with ACL ruptures.