Although ACL reconstructions provide satisfactory clinical results nowadays, regardless of the type of graft or the surgical technique used (out-in vs in-out or single- vs double-bundle), the residual rotatory instability which is often detected at clinical follow-ups is still a matter of concern among surgeons. In this paper we try to analyze all the aspects which might contribute to this phenomenon by summarizing the biomechanical functions of the two bundles of the ACL, and by evaluating all the other factors strictly related to the rotatory instability of a reconstructed knee, such as the anatomical positioning of the single- or double-bundle new ACL, or the importance of a valid lateral compartment (LCL, ALTFL). Clinical, biomechanical and cadaver studies are discussed in order to contribute to better understanding of the origin of post-operative residual rotatory instability.
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