Is notchplasty necessary for anatomic ACL reconstruction?

Abstract

There are controversies on necessity of notchplasty for ACL reconstruction in technical aspects. Preventing graft-notch impingement in ACL reconstruction is of paramount importance for avoiding postoperative graft abrasion and associated symptoms. Historical meanings of notchplasty should be discussed in several aspects. For the nonanatomic “isometric” ACL reconstruction by arthroscopic transtibial approach, notchplasty combined with posterior tibial tunnel placement was a reasonable technique to avoid impingement. The significant associations between narrow notch and ACL injury were another issue. Notch reform and deleterious effect of extensive notchplasty on patellofemoral joint had been recognized. Biomechanical studies indicated that several abnormal knee kinematics occurred after notchplasty. The first clinical study on the effect of notchplasty following anatomic double-bundle ACL reconstruction concluded that anatomic double-bundle ACL reconstruction without notchplasty allowed for physiologic graft-roof impingement without extension deficit. With the paradigm shift in ACL reconstruction from “isometric” to “anatomic” reconstruction in the 2000s, many studies showed that an anatomically placed ACL graft is not destined to impinge in the absence of notchplasty. While surgeons must recognize the risk of graft impingement, restoration of native ACL obliquity and footprint anatomy appears to be the most important factor for achieving favorable biomechanical and clinical outcomes.