Editorial Commentary: Lateral Femoral Notch Sign Is a Marker of Past Pivot Trauma Rather Than a Predictor of Future Anterior Cruciate Ligament Failure.

Abstract

Predicting anterior cruciate ligament (ACL) reconstruction failure remains a challenge, shaped by anatomic, biomechanical, surgical, and rehabilitation factors. The lateral femoral notch sign (LFNS), present in 6% to 52% of ACL injuries, is linked to lateral meniscal tears (40%-67%), steeper posterior tibial slope (2.7° higher), and cartilage degradation. However, despite its correlation with injury severity, the LFNS has limited value in predicting ACL graft failure or postoperative instability. Recent studies reinforce that the LFNS is a marker of past pivot trauma, not a predictor of future ACL failure. While a deeper LFNS (>2 mm) correlates with more severe initial injury, it does not influence long-term graft survival or knee stability. Research shows that the LFNS resolves over time in pediatric patients, fails to correlate with residual tibial laxity or rotational instability, and is associated with nonprogressive chondral lesions. In contrast, modifiable factors-such as achieving optimal tunnel positioning and effectively managing rotational instability-play a far more decisive role in determining ACL reconstruction success than static imaging markers such as LFNS. Ultimately, the LFNS is a historical remnant, not a clinical decision-making tool in ACL failure risk assessment. It reminds us that successful outcomes hinge on a comprehensive approach rather than isolated imaging findings. Such imaging signs show scars of battles lost but often do not predict the outcome of the war.