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The natural history of the isolated ACL deficient knee with or without reconstruction remains unclear. Although multifactorial in nature, evidence demonstrates these knees gradually deteriorate over time. Mechanical overload from knee malalignment has been identified to contribute not only to early failure of ACL reconstruction, but also to more rapid deterioration of the joint. However, assessing limb alignment as a contributing factor still remains largely overlooked in the ligamentously unstable knee, and reconstruction has generally focused on the soft tissue constraints. Therefore, the emphasis of this paper is that mechanical axis deviation in the chronic ACL deficient knee needs to be addressed as a means of treating the instability and protecting the joint. Over time, untreated malalignment can worsen ligamentous laxity and lead to symptomatic chronic instability. On reviewing the literature regarding the ACL deficient knee, some emphasis has been placed on the varus knee in the coronal plane, however little exists on the effect of malalingment, particularly in the sagittal plane. Previous authors have identified the varus component and advocate early intervention for the varus, anterior cruciate deficient knee. Most of these studies examined the effect of a closing wedge osteotomy in the chronically ACL deficient knee. In this review, the authors discuss the indications for realignment and the surgical technique utilizing an opening wedge technique at the time of ACL reconstruction. In addition, the importance of this paper is to discuss coronal and sagittal plane alignment and the need to assess and correct alignment in the unstable ACL deficient knee.