ACL Rupture with Severe Anterolateral Instability - A Case-Based Interactive Live Surgical Demonstration

This case-based surgical demonstration focuses on the management of an ACL rupture with severe anterolateral instability in a young professional female soccer player. The session is introduced by Daniel Guenther and moderated with Christoph Kittl, with Alan Getgood presenting the decision-making framework before moving into the live surgical demonstration. The case includes a complete ACL rupture, generalized ligamentous laxity, high-grade laxity, a positive pivot shift, anterior drawer findings and a medial meniscus ramp lesion.
The first part of the video explores graft choice and indications for lateral extra-articular procedures. Alan Getgood discusses evidence around hamstring, BTB and quadriceps tendon grafts, highlighting concerns about higher failure rates with hamstring grafts in young athletes and the potential benefits of adding a lateral extra-articular tenodesis in high-risk patients. The discussion also covers risk factors such as young age, high activity level, generalized ligamentous laxity, knee hyperextension, high-grade pivot shift, tibial slope and associated meniscal pathology. For the presented patient, the preferred strategy discussed is ACL reconstruction combined with a modified Lemaire lateral tenodesis.
The surgical demonstration begins with assessment and repair of the ramp lesion. The faculty show access to the posteromedial compartment using the Gillquist maneuver and discuss the technical challenges of ramp repair, especially in a small knee. Both a posteromedial portal technique and an anterior approach using a reverse-curve device are demonstrated, with attention to suture placement and repair of the meniscotibial ligament.
The video then proceeds to quadriceps tendon graft harvest with a bone plug. Key technical points include incision placement, centering the harvest on the tendon, reducing the risk of patellar fracture, managing graft thickness and repairing the quadriceps defect when needed. The faculty then demonstrate femoral and tibial tunnel preparation, including anatomical tunnel positioning, management of a tight notch, preservation of useful ACL remnant tissue and avoidance of graft impingement.
In the final section, the modified Lemaire lateral tenodesis is performed using an iliotibial band strip passed deep to the fibular collateral ligament. The demonstration covers landmark identification, graft passage, fixation strategy, avoidance of tunnel conflict and LET tensioning at approximately 60 degrees of flexion in neutral tibial rotation. The ACL graft is then fixed, cycled and checked arthroscopically for full extension and absence of notch impingement. The session concludes with practical rehabilitation considerations, including that the ACL reconstruction dictates the rehabilitation protocol even when a ramp lesion has been repaired.