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ACL reconstruction

219 citationsUpdated Sep 2026

Overview¶

Anterior cruciate ligament reconstruction (ACLR) is the standard of care and preferred treatment for young, highly active patients [11]. An evidence-based approach integrates the best available research with clinical expertise and patient values, emphasizing appropriately powered expertise-based trials and best-practice rehabilitation protocols to optimize outcomes [5]. While primary ACL repair remains a valuable asset in the surgeon's armamentarium [11], it is currently indicated for a limited subset of patients, such as older or less active individuals who prefer or are unable to undergo reconstruction [54, 56]. For young, active athletes, traditional autograft reconstruction remains the standard because repair failure rates of 20% to 30% are unacceptable for this group [54]. Current evidence supports the feasibility of ACL repair under favorable conditions but does not justify an expansion of its indications [49].

Graft selection is critical to surgical success, with hamstring tendon and bone-patellar tendon-bone autografts remaining viable options for ACLR plus lateral extra-articular procedure (LEP) [162, 188]. Quadriceps tendon autografts, with or without bone block, are also safe and viable options with comparable clinical outcomes, complications, and revision rates [142]. Allograft is an acceptable option for patients older than 16 years [191], and patients aged 60 years or older and those aged 40 to 59 years demonstrate similar outcomes after undergoing ACL reconstruction with allograft [37]. In patients with an isolated rupture, hamstring tendon autograft reconstruction is associated with good long-term outcomes and does not appear to cause osteoarthritis regardless of age [50].

Early ACL reconstruction is associated with superior overall knee function and a greater proportion of patients reporting acceptable knee function compared with those who cross over from nonreconstructive treatment [165]. Combined ACL and ALLR procedures result in significantly better long-term ACL graft survivorship and lower overall rates of reoperation compared with isolated ACLR, without an increase in complications [21]. Recommendations for new criteria are provided for the sports medicine community to consider before allowing an athlete to return to sports after ACL reconstruction [1]. Larger-scale studies with long-term follow-ups are needed to better understand the outcomes of modern ACLR techniques [186], and the benefit of LEP in ACLR requires further validation [188].

Anatomy & Pathophysiology¶

Epidemiology and Risk Factors¶

ACL injury accounts for between 40% and 50% of all knee ligament injuries [226]. Female athletes face a two to eight times higher risk of ACL tear than male athletes [226]. This disparity is attributed to biomechanical differences, including greater total valgus knee loading during landing and a more erect landing posture in women [226]. Additionally, women exhibit increased quadriceps-to-hamstring strength ratios, which generate greater anterior shear forces [226]. Proposed anatomical and physiological factors contributing to higher injury risk in women include smaller intercondylar notches, smaller ligaments with reduced cross-sectional area, greater generalized ligament laxity, increased knee laxity, and the absence of the COL5A1 gene [226]. Skiing, soccer, basketball, and football represent the highest-risk sports for ACL injury [226].

Injury Mechanism and Ligament Function¶

The typical mechanism of ACL injury involves a valgus load combined with internal tibial rotation and anterior tibial translation while the knee is in almost full extension [226]. The ligament functions through two distinct bundles with specific biomechanical roles: * Anteromedial bundle: Provides anterior restraint and is evaluated clinically by Lachman and anterior drawer tests [226]. * Posterolateral bundle: Provides rotatory restraint and is evaluated by the pivot shift test [226].

The in situ force of the ACL is highest at 30 degrees of flexion in response to anterior tibial load [226].

Associated Injuries¶

Acute lateral meniscal tears are more common than acute medial tears, whereas medial tears occur more frequently with chronic ACL deficiency [226]. MCL injuries occur in approximately 25% of cases of ACL injury and are typically treated nonoperatively [226]. PLC injuries occur in approximately 10% of cases of ACL injury [226]. Lack of recognition of a PLC injury has been cited as a common cause of ACL reconstruction failure [226]. Chronic ACL deficiency is associated with higher incidences of complex meniscal tears not amenable to repair and chondral injury [226].

Biological Response and Healing¶

Myofibroblasts coat the ends of the ACL stumps, making primary healing unlikely [2]. Consequently, primary repair of ACL tears is not currently recommended [2]. The weakest link after ACL reconstruction is the fixation points on the tibial and femoral side until the graft has adequately healed in the bone tunnel [48]. The two main sites of biological incorporation after ACL reconstruction are the gradual healing at the enthesis and the intra-articular ligamentization process [48].

In the very early post-operative phase, a consistent increased release of monocyte-driven, non-specific, IL-1 and IL-6 was found in host production of key cytokines [272]. Very early high concentrations of secondary growth factors PDGF and TGF-b, suggestive of an anabolic response, were also found after ACL reconstruction [272]. Excessive physical activity may delay or prevent resolution of the post-injury inflammatory process in the setting of delayed ACL reconstruction [278]. Unresolved or excessive inflammation may impair graft healing due to stimulation of fibrosis and may contribute to the development of post-traumatic osteoarthritis [278].

Biomechanics and Kinematics¶

The position of an ACL graft is the most critical surgical variable because it has a direct effect on knee biomechanics and, ultimately, on clinical outcome [113]. The position of the tibia during graft fixation is an important consideration for the biomechanical performance of an anterior cruciate ligament-reconstructed knee [55].

Single- vs. Double-Bundle Reconstruction: * Neither anatomic single-bundle nor double-bundle ACL reconstruction fully restores normal knee kinematics, but both are similarly effective for restoring near-normal dynamic knee function [77]. * The single-bundle ACL reconstruction does not reproduce the biomechanics of the native ACL and increases stresses in most knee joint elements [120]. * Joint kinematics are better restored with double-bundle reconstruction but still did not completely recreate the native ACL [163]. * The DB technique more consistently reproduced the biomechanical profile of the uninjured limb than did the SB technique without increasing the risk of over-constraining the knee [128]. * Both anatomic single- and double-bundle ACL reconstruction adequately restore tibial rotational excursion in a human, in vivo kinematic model [181].

Graft Position and Tensioning: * The MID-MID position provided the best stability among all anatomic SB reconstructions and more closely restored normal knee kinematics in a porcine model [141]. * A total of 50 N of tension force was assumed to be excessive for normalizing knee kinematics at a low flexion angle even if double bundle reconstruction was used [131]. * The combined ACL and ALL procedure restored intact knee kinematics when tensioned in full extension [152].

Meniscal Repair and Kinematic Restoration: * Anatomic ACL reconstruction with medial meniscal repair restored knee kinematics compared to the intact knee [136]. * Anatomic ACL reconstruction with medial meniscal repair did not reveal significant differences in knee kinematics compared with the intact knee [151].

Post-Reconstruction Kinematic Alterations: * Knee biomechanics in the leg with ACLR were altered mainly in the sagittal plane during side-cutting compared with the contralateral leg [82]. * The ACLR group demonstrated a consistent transverse plane kinematic pattern suggestive of greater knee internal rotation during the early landing phase across all tasks [130]. * Persistent biomechanical alterations after ACL reconstruction are related to significant changes in cartilage T1r and T2 at 1 year postreconstruction [190]. * Abnormal rotational kinematics is a potential risk factor for the pathogenesis and onset of posttraumatic articular cartilage degeneration after ACLR [187]. * The continued reduction in range of tibial rotation one year after ACL reconstruction may be a combination of neuromuscular adaptation and the biomechanical impact of the reconstruction [180].

Functional and Neuromuscular Factors: * Static (anatomic) lower limb alignment did not influence knee abduction moments once dynamic factors were considered in adolescents following ACL reconstruction [91]. * Poor knee function after ACL reconstruction is associated with attenuated landing force and knee flexion moment during running [76]. * Knee self-efficacy was consistently associated with asymmetries in quadriceps neuromuscular function and jump-landing biomechanics following ACLR [115]. * Patients after ACLR immersed in a virtual reality environment demonstrated knee joint biomechanics that approximate those of healthy controls [126].

Laxity Assessment: * The dynamic evaluation of pivot shift is able to better describe knee laxity, in particular rotational laxities, and has no correlation with static laxity [179]. * The pivot-shift test remains the most representative dynamic test for knee dysfunction [169].

Long-term Outcomes and Arthritis¶

Currently there is no high-level evidence to suggest that ACL reconstruction reduces the risk of development of arthritis [226]. Chondral and meniscal injuries that occur at the time of initial ACL rupture have been demonstrated to be the main predictors of arthritic change [226]. Several studies have demonstrated a higher incidence of arthritis associated with the use of BPTB autograft than with hamstring autograft 5 to 7 years after ACL reconstruction [2].

Classification¶

Gächter: The Gächter classification system stages septic knee arthritis following ACL reconstruction [18]. Stage 1 presents with synovitis, no cartilage damage, and no visible radiographic changes [18]. Stage 2 involves thickened synovium with no cartilage damage and no visible radiographic changes [18]. Stage 3 features markedly thickened synovium transformed into a sponge-like structure with beginning cartilage damage but no visible radiologic changes to bony structures [18]. Stage 4 involves a destroyed synovial structure with radiologic signs of subchondral bone involvement [18].

Howell: The Howell classification determines graft maturity based on signal intensity within the knee joint [224]. Grade 1 is defined as a homogeneous, low-intensity signal indistinguishable from the posterior cruciate ligament and patellar tendon [224]. Grade 2 is defined as normal ligament signal over at least 50% of its volume intermingled with portions of increased signal intensity [224]. Grade 3 is defined as increased signal intensity over at least 50% of its volume intermingled with portions of normal ligament signal [224]. Grade 4 is defined as a diffuse increase in signal intensity without strands with a normal ligament appearance [224].

Ge et al.: The protocol by Ge et al. measures graft healing at the bone-graft interface in the tibial tunnel [224]. Grade 1 is defined as low intensity with no fibrosis at the bone-graft interface and full attachment [224]. Grade 2 is defined as high intensity over a portion of the interface [224]. Grade 3 is defined as high intensity over the entire bone-graft interface with poor attachment [224].

Modified Sherman: The modified Sherman classification by van der List et al. classifies ACL tear location on preoperative MRI [233]. Type I is a proximal avulsion tear with a distal remnant length >90% [233]. Type II is a proximal tear with a distal remnant length of 75–90% [233]. Type III is a mid-substance tear located in the middle 25–75% of the ligament [233].

Sherman et al.: The Sherman et al. classification grades ACL tissue quality [233]. "Good" tissue quality is defined as (nearly) all fibres running in the same direction with a homogenous signal [233]. "Fair" tissue quality is defined as part of the fibres running in the same direction with a mildly heterogeneous signal [233]. "Poor" tissue quality is defined as most fibres running in different directions [233].

Henle et al.: The Henle et al. classification reports the ACL state and location of rupture intraoperatively [247].

ICRS: The International Cartilage Repair Society (ICRS) Classification System grades cartilage injuries [254].

Kellgren & Lawrence: The Kellgren & Lawrence radiographic osteoarthritis classification assesses the presence of osteoarthritis, with Grade I considered as the presence of osteoarthritis [229].

Other Considerations: Postoperative knee infections following ACL reconstruction are classified as acute (≤2 weeks), subacute (between 2 weeks and 2 months), or late (>2 months) [18]. The ACLISS (Anterior Cruciate Ligament Injury Severity Scale) predicts short-term reoperation and functional outcomes after ACL reconstruction [12]. The ACL Methodology Score (AMS) is a scoring system developed to evaluate the methodological quality of data in ACL reconstruction studies [40].

Clinical Presentation¶

History and Initial Symptoms¶

Young athletes with ACL tears frequently report the sudden onset of knee pain, often accompanied by a popping sensation following a noncontact, twisting-type injury [23]. Difficulty bearing weight and hemarthrosis are commonly present in these patients [23]. Patients with ACLISS grades 2 and 3 experienced earlier reoperations after ACL reconstruction, with 69% occurring between 5 and 15 months compared to 22% for grade 1 [12].

Physical Examination¶

The initial evaluation includes inspecting the soft tissues, performing passive motion of the ipsilateral hip, knee, and ankle, carefully palpating the entire affected limb, and assessing neurovascular status [23]. Clinical tests for ACL deficiency include the Lachman, anterior drawer, and pivot shift tests [23]. Because clinical tests for ACL deficiency may be difficult to perform and/or interpret in a young, anxious patient, results should be compared with similar tests performed on the contralateral, unaffected knee and may need to be repeated [23]. The presence of associated meniscal injuries may be established by evaluating for tenderness of the joint line [23]. Decreased passive knee motion may indicate a meniscal injury with displacement [23]. Injuries of the collateral ligaments may be evaluated by varus and valgus stress testing of the knee performed at 0° and 30° of flexion [23]. Specialized maneuvers such as the dial test and posterior drawer test can be performed to evaluate other structures of the knee, including the posterolateral corner and posterior cruciate ligament, respectively [23]. If ACL injury in a skeletally immature patient is suspected, limb alignment and lengths are assessed clinically [23]. The patient’s degree of physiologic maturity may be gauged by use of Tanner staging of sexual maturation in skeletally immature patients [23].

Imaging and Diagnostic Confirmation¶

MRI of the knee is helpful for confirming an ACL tear with 95% sensitivity and 88% specificity [23]. MRI of the knee is helpful for elucidating additional injuries and assessing physeal patency [23]. An ACL tear suspected on the basis of clinical findings or MRI should have the diagnosis confirmed arthroscopically, especially when ligament reconstruction is envisaged [9]. Orthogonal radiographs of the affected knee should be obtained, with additional radiographs obtained as suggested by the physical examination findings [23]. Before surgical treatment, a bone age study (a PA radiograph of the left hand compared with the Greulich and Pyle atlas) is generally performed for skeletally immature patients to estimate the amount of remaining skeletal growth [23]. Standing hip-to-ankle alignment radiographs may be obtained to evaluate for preexisting angular deformity or limb-length discrepancy of the lower limbs before surgical intervention [23]. Knee radiographs are valid for determining skeletal age and provide early evidence to simplify the diagnostic workup and operative management of pediatric knee injuries, including ACL tears [30]. Both MRI and SPECT/CT play an important role in postoperative diagnostics of patients with problems after ACL reconstruction [25].

Preoperative Assessment and Decision Making¶

The subjective instability of the patient is appraised as the most important criterion for the determination of performing surgery, followed by the Lachman test [33]. The Pivot shift test, anterior drawer test, and MRI are evaluated as equally important diagnostic tools for determining surgical indication [33]. Knee function at the time of surgery has been shown to be of greater importance for the expected outcome after ACL reconstruction than the time since injury [86]. Knee function at the time of surgery affects the final outcome after ACL reconstruction [86]. Less than a quarter of patients with a diagnosed ACL injury underwent ACL reconstruction in the 3 years after diagnosis [24]. Preoperative knee hyperextension is the most relevant predictor for ACL reconstruction objective failure [14]. Machine learning algorithms demonstrated good performance to predict ACL reconstruction objective failure [14].

Investigations¶

Clinical Examination¶

In young, anxious patients, clinical test results should be compared with similar tests performed on the contralateral, unaffected knee and may need to be repeated [23]. The patient’s degree of physiologic maturity may be gauged by use of Tanner staging of sexual maturation [23].

Imaging¶

MRI: MRI of the knee has 95% sensitivity and 88% specificity for confirming an ACL tear [23]. It is helpful for elucidating additional injuries and assessing physeal patency in skeletally immature patients [23]. MRI can be used as a valuable tool in anatomic ACL reconstruction [157]. It was excellent at distinguishing damage to the cartilage and can be useful in early follow-up evaluation of patients with septic arthritis after ACL reconstruction [185]. Quantitative T2 and T1rho relaxation times of the ACL graft may offer a non-invasive method for monitoring graft maturation that correlates with patient-reported knee function after ACL reconstruction [262].

High-resolution 3T MRI scans taken 12 months after transphyseal ACL reconstruction in a pediatric population demonstrated two tibial physeal bar formations (6.6% incidence) and no femoral physeal bars [239]. ACL grafts in skeletally immature patients with all-epiphyseal reconstructions maintain stable intensity signaling at long-term MRI follow-up with no significant signal reduction over time [194]. Development of new cartilage lesions was evident after 2-year follow-up in patients with arthroscopic ACL reconstruction as detected by MR imaging [264]. For younger patients who underwent both ACL reconstruction and lateral meniscal repair, higher MRI signal intensity of the repaired lateral meniscus was associated with a higher prevalence of residual anterolateral knee laxity [267].

Plain radiography: Knee radiographs are valid for determining skeletal age in pediatric patients undergoing ACL reconstruction [30]. Patients who underwent bilateral ACL reconstruction had a significantly greater posterior tibial slope on radiography and a significantly greater lateral posterior tibial slope on MRI compared with those who underwent unilateral ACL reconstruction [215, 218]. Radiographic evaluations demonstrated a consistent increase in posterior tibial slope over an average of 9 years among patients undergoing revision ACL reconstruction, with posterior medial meniscus resection significantly linked to these increases [251]. Even young, active patients begin to develop radiographic changes by 2 years after ACL reconstruction; however, these changes are not associated with increased pain up to 6 years postoperatively [263].

CT: CT imaging is recommended for precise evaluation of femoral tunnel position, particularly in failed reconstructions requiring revision, comparative studies, or second opinions [268].

Other Considerations: The AI-driven segmentation of CT-MRI fusion images and automatic preoperative ACL reconstruction planning demonstrated the capability to automatically, precisely, and reproducibly generate plans for nearly ideal tunnel entry and exit points with isometric, anatomical, and individualization characteristics [260]. The KOOS is considered a valid, reliable, and responsive self-administered questionnaire for patients with several types of knee injury and knee OA [4]. The KOOS consists of 42 questions distributed between 5 subscales: pain, other symptoms, activities in daily living, function in sport and recreation, and knee-related quality of life [4]. A difference or change of 10 points or more in either of the KOOS subscales was considered as clinically relevant [4].

Treatment¶

Non-Operative Management and Preoperative Preparation¶

Initial management of ACL injury consists of physical therapy to restore motion, with immobilization avoided [2]. Full range of motion and good quadriceps control should be achieved prior to surgery [2]. Treatment should be individualized based on age, activity level, instability, associated injuries, and other medical factors [2]. An ACL tear suspected on clinical findings or MRI should have the diagnosis confirmed arthroscopically, especially when ligament reconstruction is envisaged [9]. Acute reconstruction for ACL tears appears to be associated with fewer medial meniscal injuries and articular cartilage lesions compared with delayed or non-operative management [182]. ACL reconstruction in youth athletes results in an improved rate of return to athletic activity when compared with non-operative treatment [175]. A greater proportion of patients report an acceptable symptom state after ACL reconstruction compared with non-surgical treatment [62]. The ACL-reconstructed group reported statistically greater KOOS scores at all follow-ups compared to the non-surgical group [62].

Surgical Technique: Reconstruction¶

Primary repair of ACL tears is not currently recommended because myofibroblasts coat the ends of the ACL stumps, making primary healing unlikely [2]. Single-bundle reconstruction is the most commonly performed reconstruction technique [2]. There is currently no difference in patient-reported outcomes between single-bundle and double-bundle ACL reconstruction techniques [2]. Placement of a more horizontal femoral tunnel (10- or 2-o’clock position) to center the graft in the middle of the femoral ACL footprint is the focus of independent femoral tunnel drilling techniques [2]. A more horizontal graft position may reduce rotational instability [2]. The most common technical error in ACL reconstruction is tunnel malposition [2]. Vertical graft placement results in decreased rotational stability [2]. Anterior placement of the femoral tunnel results in flexion loss [2]. Aberrant hardware placement, defined as interference screw divergence of >30 degrees for femoral tunnels or >15 degrees for tibial tunnels, can result in complications [2]. Fixation of the ACL graft at 30° of knee flexion followed by fixation of the PCL graft best restores the tibiofemoral position of the intact knee in combined reconstruction [221]. The surgical outcomes of anatomical ACL reconstruction in patients with non-isometric ACL graft was not inferior in terms of clinical scores and knee laxity compared to those with nearly-isometric ACL graft [202]. The arthroscopic single-incision technique has no advantage over a mini-open two-incision technique for ACL reconstruction with patellar tendon graft in terms of subjective or objective parameters [117]. The posterior horn of the lateral meniscus is a reliable novel landmark for femoral tunnel placement in ACL reconstruction [114]. Non-experienced ACL surgeons will benefit from using the posterior horn of the lateral meniscus as a landmark for femoral tunnel placement [114]. The central anteromedial portal allows a straightforward view of the femoral ACL bundles insertion sites that are unlikely visualized with the standard anterolateral portal [304]. Use of the central anteromedial portal allows preservation of native bony anatomy and soft tissue remnants, which can be used as landmarks to guide anatomical positioning of the femoral tunnel [304]. The outside-in femoral tunnel drilling technique aims to avoid injury of the lateral collateral ligament or the popliteus tendon and to best match the created femoral tunnel with the ACL femoral footprint [276]. In the outside-in technique, a guide pin entrance angle of 60° to a line perpendicular to the femoral anatomic axis, combined with a guide pin entrance angle of 20° to the transepicondylar axis, results in the closest approximation of normal anatomic morphology of the human knee ACL femoral footprint [276]. The TLS system allows for ACL reconstruction using a single hamstring tendon with a short graft length and novel fixation [61]. The TLS system potentially reduces morbidity and addresses fixation challenges in ACL reconstruction [61]. The press-fit femoral fixation technique can be a good alternative in ACL surgery due to its implant-free nature [81]. The outcome studies of implant-free ACL reconstruction report clinical results similar to ACL reconstruction with conventional implants [240]. Graft fixation with double biodegradable pin fixation appears to be a reliable technique for ACL reconstruction providing a stable close-to-joint graft fixation [155]. Longer and wider interference screws provide better fixation in tibial ACL graft fixation [206]. In ACL reconstruction with hamstrings graft, similar clinical results are obtained for the use of bioabsorbable cross pins when compared to bioabsorbable interference screws for femoral fixation [213]. The choice of fixation after ACL reconstruction with a hamstring tendon has a significant effect on a patient's risk of revision [257]. Registry data highlight increased revision rates for Endobutton/Biosure HA in ACL reconstruction with hamstring tendon autograft [257]. The tendon-bone healing after ACL reconstruction was affected by the method of graft fixation [237]. The weakest link after ACL reconstruction is not the graft but the fixation points on the tibial and femoral side until the graft has adequately healed in the bone tunnel [48]. The gradual healing at the enthesis and the intra-articular ligamentization process together make up the 2 main sites of biological incorporation after ACL reconstruction [48]. Adult non-cultivated bone marrow stem cells do not seem to accelerate graft-to-bone healing in ACL reconstruction [199]. The over-the-top approach provides a versatile method for the surgical treatment of recurrent ACL tears [116]. The over-the-top double-bundle technique is a valid treatment option for complex ACL revision scenarios, offering biomechanical strengths while reducing surgical morbidity and tunnel requirements [103]. Both continuous and separate graft techniques are equivalent and can be used for an anterolateral augmentation procedure in combination with ACL reconstruction [105]. The evidence suggests that it should be appropriate to add a lateral extra-articular procedure to an ACL reconstruction in selected cases, but further data are required before definitive guidelines on the use of a lateral tenodesis can be established [161]. Intact cartilage and severely abnormal preoperative knee laxity represent indications for lateral extra-articular tenodesis in revision ACL reconstruction [57]. Quadriceps tendon autograft is becoming increasingly popular in revision ACL reconstruction [57]. The presence of knee hyperextension alone should not be considered a contraindication per se for the use of hamstring tendon autografts in ACL reconstruction [168]. ACL reconstruction using a Single Hamstring Tendon with Tibial Adjustable Button Fixation results in significantly lower graft signal on MRI at both 6 month and 12 month time points, indicating radiologically improved healing and integration [72]. No detectable changes in dynamic knee kinematics during downhill running were observed 10+ years after anatomic ACL reconstruction [174]. Early surgical reconstruction of the ACL and nonoperative treatment of the MCL in combined injuries is acceptable and results in excellent clinical and functional outcomes [195]. Despite conservative weight-bearing and range of motion restrictions, repair of the meniscus in combination with ACL reconstruction in pediatric patients does not appear to induce a meaningful strength deficit at the return-to-activity evaluation phase [208]. Meniscus repair in combination with ACL reconstruction in pediatric patients is not expected to influence return to activity in comparison with non-meniscus repair patients [208].

Graft Selection¶

Graft selection depends on patient factors and surgeon’s preference, and choices usually include bone–patellar tendon–bone (BPTB) autograft, four-strand hamstring autograft, quadriceps tendon autograft, and allograft [2]. BPTB demonstrates faster incorporation into the bone tunnels than hamstring autograft [2]. BPTB is often the graft of choice in patients who desire an early return to sports activity [2]. BPTB autograft harvest carries the risk of anterior knee pain, pain with kneeling, loss of extension, and poorer recovery of quadriceps strength [2]. Hamstring autograft is similar in strength to the native ACL but is less stiff [2]. Hamstring autograft harvest carries the risk of weakness of knee flexion and internal rotation, along with injury to branches of the saphenous nerve [2]. Both BPTB and quadriceps tendon with bone block grafts carry the risk of patellar fracture [2]. Use of allograft with ACL reconstruction in younger, more active patients is associated with a higher rate of rerupture [2]. Chemically processed and irradiated allografts have demonstrated higher rates of failure than fresh frozen allografts [2]. Allografts have been demonstrated to incorporate into bone tunnels more slowly [2]. Use of allograft includes infection risk with Clostridium species, hepatitis, and human immunodeficiency virus (HIV), although rates are low at 1:1.6 million [2]. Preimplantation culture of allografts is not widely recommended [2]. Allograft remodeling is delayed in ACL reconstruction and resulted in reduced long-term stability and mechanical function compared to autologous ACL reconstruction [265]. Using non-irradiated tibialis or Achilles tendon allografts for ACL reconstructions in active patients under 25 years of age can have good outcomes with a low rate of failure [210]. ACL reconstructive surgery in patients with an 'isolated' rupture using hamstring tendon autograft was associated with good long term outcomes and does not appear to cause osteoarthritis, regardless of age [50]. ACL reconstruction using a quadriceps-tendon-bone autograft with anteromedial portal technique has equally good functional, clinical and radiological long-term results compared to hardware-free methods [74]. ACL reconstruction with an all soft tissue quadriceps tendon autograft using a minimally invasive harvest technique and suspensory fixation has acceptable short and intermediate-term clinical outcomes [238]. Primary ACL-R using quadriceps tendon grafts appears to have successful short-term outcomes with a short-term graft failure rate of 3% independent of fixation method [75]. Aperture and suspensory fixation are equally efficacious for quadriceps tendon graft fixation in primary ACL reconstruction [75]. Graft choice for ACL reconstruction should be tailored to the individual patient and their sport or activity level rather than being a debate about the 'best' graft type [183]. The double-incision mini-invasive technique for BPTB harvesting is superior in reducing anterior knee pain following ACL reconstruction compared to the single-incision technique [284]. Nonoperative treatment of a partial patellar tendon rupture after ACL graft harvest may result in an excellent outcome in patients without patella alta, abnormal patellar tracking, or inability to actively extend the knee [204].

Surgical Technique: Primary Repair¶

ACL primary repair should not replace ACL reconstruction but is one of several treatment options within a multifaceted algorithm tailored to specific patient cohorts based on factors such as tear type, tissue quality, age, and activity level [20]. Modern ACL repair is less invasive than reconstruction, avoids autograft harvest comorbidities, and leads to improved early rehabilitation and forgotten knee scores [38]. Current evidence may support the feasibility of anterior cruciate ligament repair under favorable conditions, but does not justify expansion of its indications [49]. Based on survey results, ACL repair remains a procedure with limited indications [56]. The short-term results of bridge-enhanced ACL repair are promising, showing noninferiority to traditional ACL reconstruction at 2 years postoperatively and a higher rate of return to sport at 6 months [60]. Bridge-enhanced ACL repair has demonstrated noninferiority to ACL reconstruction with autograft at 2-year follow-up [234]. Combined ACL repair and ALL internal brace augmentation resulted in significant improvements in patient-reported outcome measures at 2 years [258]. Internal braced knotless adjustable fixation for ACL repair with preconditioning of the suture repaired ligament increased the overall stabilization with higher load share on the ACL and restricted gap formation compared with fixed suture repair [220]. With studies showing noninferiority at worst and an evolving body of evidence realizing the advantages of the internal bracing technique, authors argue for its use to protect ACL reconstructions [198]. The primary aim of the described technical note is to describe step-by-step the ACL repair technique with and without suture augmentation [109]. The surgery for arthroscopic primary ACL repair with polyester suture tape augmentation takes place in the operating room adapted to arthroscopic procedures with the patient in a supine position [285]. Standard anterolateral and anteromedial arthroscopic portals are used for arthroscopic primary ACL repair with polyester suture tape augmentation [285]. During tibial canal preparation for arthroscopic primary ACL repair with polyester suture tape augmentation, the cortex is accessed approximately 1 cm proximal to the pes anserinus and about 1.5 cm medial to the tibial tuberosity [285]. Careful surgical tissue preparation during tibial canal preparation for arthroscopic primary ACL repair focuses on avoiding damage to a branch of the saphenous nerve [285]. Advantages of arthroscopic primary ACL repair with polyester suture tape augmentation include relatively short surgery time, preservation of native anatomy and biology of the distal attachment, proprioception preservation, and minimally invasive procedure [285]. Limitations of arthroscopic primary ACL repair with polyester suture tape augmentation include potential failure if the stump does not heal properly, indications limited to a small group of ACL patients, and lack of long-term results or strong evidence in the literature [285]. The final construct for arthroscopic all-epiphyseal button and anchor technique ACL repair includes a button positioned on the proximal-anterior tibial epiphysis and an extra-articular knotless anchor on the lateral femoral epiphysis [286]. For ACL restoration with the BEAR implant, at least 1 cm of tibial ACL stump must be preserved for adequate suturing [286]. The surgical technique for primary ACL repair at arthrotomy involved meticulous attention to detail and was based on the work of Marshall et al [287]. A prearthrotomy arthroscopy was not routinely performed in the described primary ACL repair technique [287]. An anteromedial, straight parapatellar incision was used in cases of isolated ACL injury in the described primary ACL repair technique [287]. The incision was slanted more obliquely medially if the MCL was also torn in the described primary ACL repair technique [287]. In a typical two-way repair, 8 to 10 sutures are placed in both portions of the ligament [287]. Several methods that are simple and reproducible have been published lately to address potential events when performing an ACL reconstruction [80].

Pediatric and Adolescent Considerations¶

The meta-analysis found overall similar results with the three ACL reconstruction approaches (physeal-sparing, partial transphyseal, and complete transphyseal) in the pediatric population [16]. ACL reconstruction is recommended for treating patients older than 50 years with ACL insufficiency, especially for those with high functional demand [170]. Patients older than 50 years had similar results of knee strength and anteroposterior stability after ACL reconstruction compared to younger patients [170]. There is a lack of evidence regarding return to activity in middle-aged patients with an ACL injury and conservative treatment [193]. High rate of return to activity after ACL reconstruction has been observed in patients over 40 years of age [193]. Significant variability exists in pain management practices in pediatric ACL reconstruction [156]. Total doses of postoperative opioids prescribed for pain management in pediatric ACLR have declined in recent years, which appears related to preoperative counseling through mandated opioid consenting and paralleled by greater utilization of non-opioid medications [244]. Pediatric and adolescent patients treated with a femoral nerve block for postoperative pain control

Complications¶

Graft Failure and Revision¶

Tunnel malposition is the most common technical error leading to graft failure [2]. While graft failure is uncommon, it is functionally devastating, with an estimated 91% graft survival rate at 25 years following primary reconstruction [69]. In a cohort of 1,497 patients, 140 (9.4%) experienced graft failure and 128 (8.6%) sustained a contralateral ACL injury at a median follow-up of 140.7 months [19]. Over a 7-year period, the ipsilateral graft tear rate was 5.86% and the contralateral ACL tear rate was 6.66%, with no significant difference between the two [112]. Combined ACL and anterolateral ligament reconstruction yields significantly better long-term graft survivorship and lower reoperation rates compared with isolated ACL reconstruction, without increasing complications [21].

Revision surgery is associated with worse short-term outcomes, including unplanned readmission, reoperation, return to the operating room, and surgical complications [15]. Patients report slightly inferior 1-year outcomes after revision compared to their primary procedure [66], and experience lower rates of return to preinjury activity and less favorable patient-reported outcomes between 12 and 24 months [68]. Long-term data indicate a 22% reoperation rate at 10 years after index revision [332]. In a young cohort, recurrent ACL failure occurred in 6% of patients, and subsequent total knee arthroplasty occurred in 5% at 6 years following revision [323]. Multiple revision surgeries carry a relatively high failure rate [335], and overall results following revision are less favorable than primary reconstruction [349]. Allograft use in revision settings is associated with higher re-tear rates [338].

Risk factors for revision include young age, female gender, Caucasian race, workers’ compensation claims, and elevated BMI [314, 328, 341]. Patients under 16 years have higher rates of contralateral and ipsilateral ACL surgeries and secondary surgeries compared to older patients [70], and adolescents have twice the revision rate of young adults after hamstring autograft reconstruction [102]. Increased posterior tibial slope and lateral extra-articular tenodesis are independently associated with revision in young high-risk populations, where increased posterior tibial slope was present in nearly 30% of patients [318]. Age, time from injury to surgery, and quadriceps strength also affect revision risk [346]. Specific risk factors for unplanned subsequent knee surgery include revision status, contralateral ACL reconstruction, meniscus injury surgery, and procedures for loss of motion [108]. Oral contraceptive use at the time of initial reconstruction may provide a protective effect against subsequent ipsilateral reconstruction within five years in female patients [317].

Different combinations of femoral and tibial fixation devices result in different early revision rates within 2 years of primary hamstring autograft reconstruction [351]. Patients with ACLISS grades 2 and 3 experience earlier reoperations, with 69% occurring between 5 and 15 months compared to 22% for grade 1 [12]. An ipsilateral reoperation rate of 10.7% at an average of 25.9 months and an overall revision rate of 3.1% have been demonstrated [328].

Arthrofibrosis and Stiffness¶

Arthrofibrosis is the most common complication following ACL reconstruction, often occurring with reconstruction for acute tears [2]. The risk is minimized by achieving full range of motion prior to surgery [2]. It remains a rare but potentially devastating complication, with roughly 2% of patients requiring intervention [32]. In a cohort of 902 young patients, the overall incidence was 8.3% [22]. Female sex, older age, the use of bone–patellar tendon–bone autograft, and concomitant meniscal repair are additional risk factors in young patients [22]. In a systematic review of all-epiphyseal ACL reconstruction in pediatric patients, arthrofibrosis accounted for 3.8% of reported complications [297].

Infection¶

Infection occurs in less than 1% of cases following ACL reconstruction [2]. The overall surgical site infection rate is 0.48%, with deep surgical site infections identified in 0.32% of cases [319]. The incidence of septic arthritis varies across studies, ranging from 0.92% in a single-center analysis [321] to 1.1% in a nationwide cohort of 26,014 patients [354], and 1.8% in a specific series [342]. Rates in pediatric patients are relatively low at 0.52%, similar to rates in young adults [296].

Risk factors for infection include diabetes, which confers 18.8-times higher odds of postoperative infection compared with patients without diabetes [345], as well as increased BMI and increased operative time [337]. The ACL graft serves as a nidus for infection because it is nonviable tissue that can harbor bacteria until replaced by host tissue [18]. Both autografts and allografts respond as foreign bodies with initially absent blood supply [18]. Infection is often from natural skin flora and associated with concomitant extraarticular sites such as the graft, femoral, or tibial sites [18]. Use of allograft carries a low risk (1:1.6 million) of Clostridium species, hepatitis, and human immunodeficiency virus [2]. Graft choice may affect septic arthritis rates, but patient characteristics, technique, revision status, and accompanying intra-articular procedures were not associated with postoperative septic arthritis in available analyses [350].

Postoperative infections are classified as acute (less than 2 weeks), subacute (between 2 weeks and 2 months), or late (greater than 2 months) [18]. Most patients present with acute or subacute intra-articular knee infections [18]. Irrigation and débridement with graft retention are successful in up to 85% of cases [2]. Patients undergoing irrigation and debridement have a high rate of additional surgery but attain reasonable clinical outcomes 6 years after reconstruction [301]. Septic arthritis results in the same objective knee function as uncomplicated cases [344]. The incidence of septic arthritis can be reduced by vancomycin-soaking the grafts intra-operatively [353], and graft preparation with intraoperative vancomycin decreases infection overall [337].

Donor Site and Hardware Complications¶

Bone–patellar tendon–bone autograft harvest carries the risk of anterior knee pain, pain with kneeling, loss of extension, and poorer recovery of quadriceps strength [2]. Both bone–patellar tendon–bone and quadriceps tendon with bone block grafts carry the risk of patellar fracture [2]. Within 6 months after a first ACL reconstruction, the risk of complication, including infection or device removal, was 5% in the entire cohort [271].

Six patients (0.2%) underwent reoperation within 30 days of surgery, including 4 for irrigation and debridement for infection, 1 for repair of a traumatic infrapatellar tendon rupture, and 1 for removal of a broken intra-articular nitinol guide pin [269]. Fifteen patients (0.6%) underwent reoperation within 90 days, including 5 for lysis of adhesions for arthrofibrosis, 1 for removal of hardware, 1 for loose body removal, 1 for irrigation and debridement for septic arthritis, and 1 for wound exploration for saphenous neuritis [269]. ACL reconstructions performed without a tourniquet resulted in a significantly lower incidence of deep venous thrombosis and significantly less bleeding from drains [347].

Pediatric-Specific Complications¶

The most common complications in skeletally immature patients include arthrofibrosis, growth disturbance, and secondary injury of the same or contralateral ACL [22]. Growth arrest can occur despite efforts to avoid this complication [22]. Clinically important growth disturbances, including tibial recurvatum and genu valgum, have developed after transphyseal ACL reconstruction using physeal-respecting techniques [22]. Focal physeal bone bridges were noted in five knees of 43 patients who underwent transphyseal ACL reconstruction using soft-tissue graft, although no patient had resultant limb deformity [22]. Growth disturbance has been reported with physeal-sparing techniques, with one patient in a series of all-epiphyseal ACL reconstructions developing clinically significant growth arrest [22].

In a systematic review of all-epiphyseal ACL reconstruction, the overall complication rate was 9.8%, with 49.5% being ACL re-ruptures, 15.1% limb overgrowths, 5.7% limb length discrepancies, 3.8% arthrofibrosis, 1.9% knee stiffness, and 1.9% soft-tissue infection [297]. Only 1.5% of patients treated with all-epiphyseal ACL reconstruction demonstrated growth disturbances such as limb-length discrepancy [297].

Secondary Injury and Contralateral Injury¶

Secondary ACL injury in either the ipsilateral or contralateral knee occurs with alarming frequency in young athletes [22]. In a cohort of young athletes (average age 17 years), nearly 30% sustained a second ACL injury within 24 months of return to sports, with approximately one-third occurring in the ipsilateral knee and two-thirds in the contralateral knee [22]. Patients younger than 20 years at the time of reconstruction had a 29% chance of sustaining a second ACL injury within 5 years of the index surgery [22]. In a cohort of 85 patients younger than 18 years, 32% sustained a second ACL injury, with later return to sport being protective against new ACL injury [22]. Athletes younger than 25 years who return to sports had a secondary rate of ACL injury of 23% [22].

The pooled incidence of second ACL injury in football players after index reconstruction was 21.6%, with contralateral (10.6%) and ipsilateral (10.4%) injuries of similar magnitude [316]. In a 7-year study, the mean time to ipsilateral graft tear was 2.64 years and the mean time to contralateral ACL tear was 2.78 years [112]. Younger age is a risk factor for both ipsilateral graft tear and contralateral ACL tear [112]. Contralateral ACL injury rates at a minimum 5 years were not significantly different between 2-year and 5-year time points in a primary ACL repair cohort [111]. In a 2-year follow-up of the NACOX prospective cohort, 36 (21%) patients in the ACL reconstruction group had a surgery, with the most common being debridement (27%) and three (8%) ACL reconstruction revisions [119]. More knee reinjuries occurred after ACL reconstruction compared to nonsurgical treatment of the ACL in a 2-year follow-up [119].

Recovery¶

Light activity (weeks): The provided evidence does not specify a typical week range for light activities such as desk work, driving, or light ADLs. However, patients can be informed that they will benefit from ACL reconstruction in terms of improved knee function and satisfaction with health, though heavy physical workload is a risk factor for prolonged time lost to return to work [223].

Full activity (months): The majority of patients undergoing ACL reconstruction return to sport, with a return rate of 78.6% when excluding those who did not intend to return [212]. High recovery rates were seen after arthroscopic ACLR, regardless of leg dominance [320]. LEAT resulted in improved clinical scores and earlier overall return to sport compared to ACL reconstruction alone [295]. The short-term results of bridge-enhanced ACL repair are promising, showing noninferiority to traditional ACL reconstruction at 2 years postoperatively and a higher rate of return to sport at 6 months [60].

Complete recovery / outcome plateau (months): Success of ACL reconstruction is a complex issue requiring comprehensive subjective and objective evaluation beyond simply returning to activity [29]. Achieving an acceptable symptom state after ACL reconstruction is more dependent on the ability to participate in sports than on the absence of symptoms or participation in ADL [43]. Test results from an ACL-reconstructed patient should be at least classified as a functionally average outcome to support a safe return to sports [232].

Rehabilitation protocol: An evidence-based approach to anterior cruciate ligament reconstruction integrates best available research with clinical expertise and patient values, emphasizing appropriately powered expertise-based trials and best-practice rehabilitation protocols to optimize outcomes [5]. Rehabilitation-related factors that the physician can control at the time of an ACL reconstruction have the ability to influence clinical outcomes at 2 years [135]. There are rehabilitation-related factors that the physician can control at the time of an ACL revision which have the ability to modify clinical outcomes at 2 years [153]. Cross-education should be integrated into ACL reconstruction rehabilitation, especially in the early rehabilitative phases to restore quadriceps strength [140]. Cross-education exercise used as an adjunct to the ACL traditional rehabilitation program at the weekly frequencies of 3 and 5 times at the early stage of reconstruction significantly improved quadriceps deficit [154]. However, cross-education does not further accelerate ACL recovery when added to 26 weeks of standard care, which improved self-reported knee function and maximal leg strength relative to pre-surgery [143]. Supplementing primary ACL reconstruction and standard physical therapy with a return to sports bridge program prior to release to unrestricted sports performance was effective at improving patient outcomes and decreasing ipsilateral knee re-injury and contralateral knee injury rates [149, 150]. Completion of a specific return to sports program, in addition to standard rehabilitation, was the most important factor influencing the K-STARTS composite functional and psychological return to sports test score at 6 months after ACL reconstruction [289]. Graft maturity should not be used as an objective test to determine the appropriate time to return to sports during the first year after ACL reconstruction [281]. Modifying the individual rehabilitation according to the extent of graft maturity may be necessary to optimize patient function and prevent re-injury of the ACL graft [138]. These findings may help refine strategies to enhance early graft incorporation and support the development of rehabilitation protocols that optimize postoperative outcomes for patients undergoing ACLR [129]. Surgeons should consider utilizing similar rehabilitation timelines and functional performance goals for patients following ACL reconstruction with QT and PT graft options [158].

Functional milestones: At 2 years after ACL reconstruction with tibialis anterior allografts, this subject group displayed satisfactory functional outcomes [36]. The children had good objective physical function 1 and 3 years after ACL reconstruction [39]. Patients with increased posterolateral tibial plateau bone loss showed lower Tegner activity scores 12 months after ACL reconstruction [283].

Other Considerations: Among all patients receiving primary ACLR, graft failure remains an uncommon but functionally devastating outcome with an estimated graft survival rate of 91% at 25 years following surgery [69]. At a minimum of 10 years following ACL reconstruction in a young athletic population, over 80% of all grafts were intact and had maintained stability [306]. Preserving the remnant tissue of the ACL may facilitate recovery of function and decrease graft rupture after primary reconstruction [294]. Patients who underwent combined ACL + ALLR experienced significantly better long-term ACL graft survivorship, lower overall rates of reoperation, and no increase in complications compared with patients who underwent isolated ACLR [21]. In select patients with steep posterior tibial slope (PTS ≥12°) and elevated static anterior tibial translation, slope-correcting osteotomy may be warranted even in primary ACL reconstruction, as soft tissue augmentation alone may be insufficient [324]. The study suggests that SRO in the setting of ACL reconstruction for large posterior tibial slope deformities is effective at correcting malalignment, restoring objective and self-reported function, and avoiding graft failure out to 2 years [331]. Increasing slopes in the coronal and sagittal planes with decreasing concavity of the medial tibial plateau lead to less favorable outcomes 7 years after surgery [327].

ACL reconstruction performed in patients with an isolated concomitant full-thickness cartilage lesion restored patient-reported knee function to the same level as ACL reconstruction performed in patients without concomitant cartilage lesions, 5–9 years after surgery [13]. Patients receiving a concomitant MAT exhibit lower return to sport rates, delayed time to release to activity, and lower subjective function compared to those undergoing an isolated ACL reconstruction [230]. Patients undergoing ACL reconstruction with OCA demonstrate similar self-reported function and return-to-sport rates, along with a delayed time to return to sport, to those undergoing isolated ACL reconstruction [307]. Steep tibial plateau slope ≥ 12° is associated with a higher risk of contralateral ACL injury within 2 years after ACL reconstruction in patients less than 18 years of age [291]. ACL reconstruction using a living related donor allograft is associated with high rates of return to sport and good subjective outcomes [205]. This work adds to the growing mass of literature supporting the safety and efficacy of this procedure in the setting of ACL reconstruction [209].

Relative to primary ACL reconstruction, revision ACL procedures are associated with worse short-term outcomes including unplanned readmission, reoperation, return to the OR, and surgical complications [15]. Revision and contralateral ACLR were associated with lower rates of return to preinjury physical activity levels and less favorable PROs between 12 and 24 months after reconstruction compared with primary ACLR [68]. Only a small percentage of patients returned to the same level of sport after single-revision and multiple-revision ACL reconstruction, yet significantly more in the former [311]. Good mid-term clinical results can be obtained after repeated ACL revision with allograft in patients that experienced multiple failures, however, who need additional procedure due to malalignment or post-meniscectomy syndrome reported lower objective and subjective results [308]. Slope-reducing high tibial osteotomy significantly improves midterm functional outcomes and reduces graft failure risk in patients with increased tibial slope undergoing revision ACL reconstruction without altering patellar height [300]. In patients with ACL graft failure and increased tibial slope, anterior closing wedge high tibial osteotomy provides a safe and reliable technique to control ACL graft re-tear and offer good functional outcome on the midterm [325].

Primary ACL repair has potential advantages over reconstruction, such as decreased surgical morbidity, faster return of range of motion, and minimally invasive surgery, with promising results documented in a clearly defined subset of patients [7]. Based on cumulative findings across 2,401 patients from 28 included studies, ACL reconstruction (ACLR) results in better survivorship and patient-perceived postoperative improvement when compared with ACL repair [65]. Early results suggest the knees are stable and recover motion after bridge-enhanced ACL repair [310]. The healing response procedure is an effective treatment technique for a select group of mature patients with acute proximal ACL tears, allowing them to return to high levels of recreational activity and restore knee function to normal levels [159]. Further work is clearly needed but there is renewed interest and focus for primary ACL repair that may yet prove the new frontier in ligament repair [207].

In active adults with an anterior cruciate ligament tear, at the time of the 5-year follow-up, a strategy of rehabilitation plus early reconstruction did not provide better patient-reported or radiographic outcomes than did rehabilitation with an option of delayed reconstruction [133].

Key Evidence¶

[L4] Recommendations for new criteria are given for the sports medicine community to consider, before allowing an athlete to return to sports after an ACL reconstruction. [1] (10.1007/s00167-011-1669-8)
[L1] [4] (10.1007/s00167-011-1739-y)
[L5] An evidence-based approach to anterior cruciate ligament reconstruction integrates best available research with clinical expertise and patient values, emphasizing appropriately powered expertise-based trials and best-practice rehabilitation protocols to optimize outcomes. [5] (10.1016/j.csm.2012.08.008)
[L5] Primary ACL repair has a future for some indications and will be established next to the gold standard of ACL reconstruction and nonsurgical therapy. [6] (10.1016/j.arthro.2019.05.003)
[L5] Primary ACL repair has potential advantages over reconstruction, such as decreased surgical morbidity, faster return of range of motion, and minimally invasive surgery, with promising results documented in a clearly defined subset of patients. [7] (10.1177/2325967121s00863)
[L2] An ACL tear suspected on the basis of clinical findings or MRI should have the diagnosis confirmed arthroscopically, especially when ligament reconstruction is envisaged. [9] (10.1186/1471-2474-5-21)
[L5] ACLR is the standard of care and preferred treatment for young and highly active patients; ACL repair should be considered a valuable asset in the surgeon's armamentarium. [11] (10.1002/ksa.70254)
[L3] Survival analysis revealed that patients with ACLISS grades 2 and 3 experienced earlier reoperations, with 69% occurring between 5 and 15 months compared to 22% for grade 1. [12] (10.1177/03635465261443315)
[L1] ACL reconstruction performed in patients with an isolated concomitant full-thickness cartilage lesion restored patient-reported knee function to the same level as ACL reconstruction performed in patients without concomitant cartilage lesions, 5–9 years after surgery. [13] (10.1007/s00167-016-4163-5)
[L3] Machine learning algorithms demonstrated good performance to predict ACL reconstruction objective failure. [14] (10.1177/2325967124s00466)
[L3] Relative to primary ACL reconstruction, revision ACL procedures are associated with worse short-term outcomes including unplanned readmission, reoperation, return to the OR, and surgical complications. [15] (10.1007/s00167-021-06646-0)
[L1] The meta-analysis found overall similar results with the three ACL reconstruction approaches. [16] (10.1007/s00167-022-07032-0)
[L4] [18] (10.1007/s00167-009-0793-1)
[L3] [19] (10.1177/23259671241282316)
[L5] ACL primary repair should not replace ACL reconstruction but is one of several treatment options within a multifaceted algorithm tailored to specific patient cohorts based on factors such as tear type, tissue quality, age, and activity level. [20] (10.1016/j.arthro.2025.04.006)
[L3] Patients who underwent combined ACL + ALLR experienced significantly better long-term ACL graft survivorship, lower overall rates of reoperation, and no increase in complications compared with patients who underwent isolated ACLR. [21] (10.1177/03635465211028990)
[L3] Less than a quarter of patients with a diagnosed ACL injury underwent ACL reconstruction in the 3 years after diagnosis. [24] (10.1177/0363546512472042)
[L4] Both imaging modalities play an important role in postoperative diagnostics of patients with problems after ACL reconstruction. [25] (10.1177/2325967116s00047)
[L4] ACL repair has demonstrated significant clinical improvement in an appropriately selected patient cohort. [28] (10.1177/2325967126s00016)
[L5] Success of ACL reconstruction is a complex issue requiring comprehensive subjective and objective evaluation beyond simply returning to activity. [29] (10.1007/s00167-017-4559-x)
[L2] This study supports the validity of knee radiographs in determining skeletal age and provides early evidence in certain clinical presentations to simplify the diagnostic workup and operative management of pediatric knee injuries, including ACL tears. [30] (10.1177/23259671211036897)
[L3] Arthrofibrosis remains a rare but potentially devastating complication after ACL reconstruction, with roughly 2% of patients requiring intervention. [32] (10.1007/s00167-015-3799-x)
[L4] [33] (10.1007/s00402-016-2426-8)
[L4] At 2 years after ACL reconstruction with tibialis anterior allografts, this subject group displayed satisfactory functional outcomes. [36] (10.1007/s00167-003-0371-x)
[L3] Patients 60 years or older and 40- to 59-year-old patients demonstrated similar outcomes after undergoing ACL reconstruction with allograft. [37] (10.1002/ksa.12491)
[L5] Modern ACL repair is less invasive than reconstruction, avoids autograft harvest comorbidities, and leads to improved early rehabilitation and forgotten knee scores. [38] (10.1016/j.jisako.2023.08.008)
[L2] The children had good objective physical function 1 and 3 years after ACL reconstruction. [39] (10.1002/ksa.12211)
[L1] [40] (10.1177/0363546513481947)
[L4] Achieving an acceptable symptom state after ACL reconstruction is more dependent on the ability to participate in sports than on the absence of symptoms or participation in ADL. [43] (10.1177/2325967113s00069)
[L4] ACL repair in young children using this technique negates the requirement and potential morbidity of graft harvest and demonstrates the potential for excellent outcome as an attractive alternative to ACL reconstruction, where an adequate ACL remnant permits direct repair. [46] (10.1007/s00167-016-4150-x)
[Letter] The authors apologize for mischaracterizing the patient's outcome and emphasize the need for more individualized approaches to graft size selection in ACL repairs to prevent similar complications. [47] (10.1016/j.arthro.2014.05.018)
[L5] [48] (10.1016/j.csm.2012.08.010)
[L5] Current evidence may support the feasibility of anterior cruciate ligament repair under favorable conditions, but does not justify expansion of its indications. [49] (10.1002/arj.70340)
[L2] ACL reconstructive surgery in patients with an 'isolated' rupture using this technique was associated with good long term outcomes and does not appear to cause osteoarthritis, regardless of age. [50] (10.1177/2325967117s00175)
[L3] Revision ACLR practices vary widely, with no uniform consensus on graft choice and indications for ALC augmentation. [53] (10.1177/23259671251386878)
[L5] ACL repair may offer a viable alternative for older or less active patients who prefer or are unable to undergo reconstruction, though young, active athletes should still be treated with traditional autograft reconstruction as repair failure rates of 20% to 30% remain unacceptable for this group. [54] (10.1016/j.arthro.2024.11.085)
[L5] The position of the tibia during graft fixation is an important consideration for the biomechanical performance of an anterior cruciate ligament-reconstructed knee. [55] (10.1177/03635465010290061601)
[L4] Based on the survey results, ACL repair remains a procedure with limited indications. [56] (10.1002/ksa.12788)
[L3] Intact cartilage and severely abnormal preoperative knee laxity represent indications for LET in revision ACL reconstruction. [57] (10.1007/s00167-021-06478-y)
[L2] However, comparative studies are lacking and upcoming studies should compare the technique to ACL reconstruction with failure as an endpoint. [59] (10.1007/s00167-018-5301-z)
[Paper] The short-term results of this procedure are promising, showing noninferiority to traditional ACL reconstruction at 2 years postoperatively and a higher rate of return to sport at 6 months. [60] (10.1016/j.eats.2024.103034)
[L4] The TLS system allows for ACL reconstruction using a single hamstring tendon with a short graft length and novel fixation, potentially reducing morbidity and addressing fixation challenges. [61] (10.1016/j.otsr.2011.03.016)
[L3] The ACL-reconstructed group also reported statistically greater KOOS at all follow-ups. [62] (10.1136/bjsports-2021-105115)
[L4] Based on cumulative findings across 2,401 patients from 28 included studies, ACL reconstruction (ACLR) results in better survivorship and patient-perceived postoperative improvement when compared with ACL repair. [65] (10.1016/j.arthro.2019.04.005)
[L3] Patients undergoing ACL revision reported a 1-year outcome that was slightly inferior to the 1-year outcome after their primary ACL reconstruction. [66] (10.1186/s13018-019-1532-z)
[L3] Revision and contralateral ACLR were associated with lower rates of return to preinjury physical activity levels and less favorable PROs between 12 and 24 months after reconstruction compared with primary ACLR. [68] (10.1177/23259671261470914)
[L4] Among all patients receiving primary ACLR, graft failure remains an uncommon but functionally devastating outcome with an estimated graft survival rate of 91% at 25 years following surgery. [69] (10.1007/s00167-016-4275-y)
[L3] Patients under 16 years undergoing ACL reconstruction had higher rates of both contralateral and ipsilateral ACL surgeries, as well as secondary surgeries, compared to older patients. [70] (10.1186/s13018-025-05935-5)
[L1] ACL reconstruction using a Single Hamstring Tendon with Tibial Adjustable Button Fixation results in significantly lower graft signal on MRI at both 6 month and 12 month time points, indicating radiologically improved healing and integration. [72] (10.1016/j.jisako.2025.100535)
[L2] This study shows equally good functional, clinical and radiological long-term results for both hardware-free methods of ACL reconstruction. [74] (10.1007/s00402-020-03508-1)
[L4] Primary ACL-R using QT grafts appears to have successful short-term outcomes with a short-term graft failure rate of 3% independent of fixation method. [75] (10.1055/s-0039-1685160)
[L3] These findings provide greater understanding of the relationship between knee biomechanics during running and clinical assessments of knee function. [76] (10.1007/s00167-017-4810-5)
[L1] While neither procedure fully restored normal knee kinematics, both anatomic reconstructions were similarly effective for restoring near-normal dynamic knee function. [77] (10.1007/s00167-021-06479-x)
[L2] Several methods that are simple and reproducible have been published lately to address this potential event when performing an ACL reconstruction. [80] (10.1302/2058-5241.3.170038)
[L5] The technique can be a good alternative in ACL surgery due to its implant-free nature. [81] (10.1007/s00167-003-0452-x)
[L3] Knee biomechanics in the leg with ACLR were altered mainly in the sagittal plane during side-cutting compared with the contralateral leg. [82] (10.1177/03635465221112940)
[L2] [86] (10.1007/s00167-010-1113-5)
[L3] Static (anatomic) lower limb alignment did not influence knee abduction moments once these dynamic factors were considered. [91] (10.1177/2325967120s00144)
[L3] [102] (10.1177/23259671211038893)
[L4] This novel non-anatomic double-bundle technique is a valid treatment option for complex ACL revision scenarios, offering biomechanical strengths while reducing surgical morbidity and tunnel requirements. [103] (10.1007/s00167-011-1753-0)
[L3] Both techniques are equivalent and can be used for an anterolateral augmentation procedure in combination with ACL reconstruction. [105] (10.1177/03635465231197353)
[L3] The study identified specific risk factors for unplanned subsequent knee surgery following primary ACL reconstruction, including revision, contralateral ACLR, meniscus injury surgery, and procedures for loss of motion. [108] (10.1186/s12891-026-09925-4)
[L5] The primary aim of this technical note is to describe step-by-step the ACL repair technique with and without suture augmentation. [109] (10.1136/jisakos-2020-000508)
[L4] [111] (10.1177/03635465251340087)
[L3] [112] (10.1055/s-0040-1713861)
[L4] The position of an ACL graft is the most critical surgical variable because it has a direct effect on knee biomechanics and, ultimately, on clinical outcome. [113] (10.1177/0363546505279922)
[L4] In particular, non-experienced ACL surgeons will benefit from this apparent landmark and the corresponding easy-to-use ACL reconstruction method. [114] (10.1007/s00167-017-4759-4)
[L3] Knee self‐efficacy was consistently associated with asymmetries in quadriceps neuromuscular function and jump‐landing biomechanics following ACLR. [115] (10.1002/ksa.70192)
[L5] The over-the-top approach provides a versatile method for the surgical treatment of recurrent ACL tears. [116] (10.1016/j.eats.2022.05.010)
[L1] The arthroscopic single-incision technique has no advantage over a mini-open two-incision technique for ACL reconstruction with patellar tendon graft in terms of subjective or objective parameters. [117] (10.1007/s001670050052)
[L2] [119] (10.1002/ksa.12473)
[L5] The single-bundle ACL reconstruction does not reproduce the biomechanics of the native ACL and increases stresses in most knee joint elements. [120] (10.1002/ksa.12263)
[L3] Patients after ACLR immersed in a virtual reality environment demonstrated knee joint biomechanics that approximate those of healthy controls. [126] (10.1007/s00167-014-3374-x)
[L3] The DB technique more consistently reproduced the biomechanical profile of the uninjured limb than did the SB technique without increasing the risk of over-constraining the knee. [128] (10.1007/s00167-010-1247-5)
[L3] These findings may help refine strategies to enhance early graft incorporation and support the development of rehabilitation protocols that optimize postoperative outcomes for patients undergoing ACLR. [129] (10.1177/23259671251413600)
[L4] The ACLR group demonstrated a consistent transverse plane kinematic pattern suggestive of greater knee internal rotation during the early landing phase across all tasks. [130] (10.1186/s12891-026-09967-8)
[L5] A total of 50 N of tension force was assumed to be excessive for normalizing knee kinematics at a low flexion angle even if double bundle reconstruction was used. [131] (10.1007/s00167-006-0242-3)
[L1] In active adults with an anterior cruciate ligament tear, at the time of the 5-year follow-up, a strategy of rehabilitation plus early reconstruction did not provide better patient-reported or radiographic outcomes than did rehabilitation with an option of delayed reconstruction. [133] (10.2106/jbjs.9516.ebo781)
[L1] Rehabilitation-related factors that the physician can control at the time of an ACL reconstruction have the ability to influence clinical outcomes at 2 years. [135] (10.2106/jbjs.18.00397)
[L5] Anatomic ACL reconstruction with medial meniscal repair restored knee kinematics compared to the intact knee. [136] (10.1177/2325967113s00073)
[L4] Modifying the individual rehabilitation according to the extent of graft maturity may be necessary to optimize patient function and prevent re-injury of the ACL graft. [138] (10.1007/s00167-014-3302-0)
[L1] CE should be integrated into ACL reconstruction rehabilitation, especially in the early rehabilitative phases to restore quadriceps strength. [140] (10.1007/s00167-018-5040-1)
[L5] The MID-MID position provided the best stability among all anatomic SB reconstructions and more closely restored normal knee kinematics. [141] (10.1007/s00167-009-0916-8)
[L4] Both grafts are safe and viable options for ACL reconstruction with comparable clinical outcomes, complications and revision rates. [142] (10.1007/s00167-022-07281-z)
[L1] 26 weeks of standard care improved self-reported knee function and maximal leg strength relative to pre-surgery, and adding cross-education did not further accelerate ACL recovery. [143] (10.1007/s00167-018-5116-y)
[L2] Supplementing primary ACL reconstruction and standard physical therapy with a return to sports bridge program prior to release to unrestricted sports performance was effective at improving patient outcomes and decreasing ipsilateral knee re-injury and contralateral knee injury rates. [149] (10.1007/s00167-020-06162-7)
[L3] Supplementing primary ACL reconstruction and standard physical therapy with a return to sports bridge program prior to release to unrestricted sports performance was effective at improving patient outcomes and decreasing ipsilateral knee re-injury and contralateral knee injury rates. [150] (10.1016/j.jisako.2023.03.136)
[L5] Anatomic ACL reconstruction with medial meniscal repair did not reveal significant differences in knee kinematics compared with the intact knee. [151] (10.1007/s00167-014-3071-9)
[L5] The combined ACL and ALL procedure restored intact knee kinematics when tensioned in full extension. [152] (10.1177/0363546517724422)
[L3] There are rehabilitation-related factors that the physician can control at the time of an ACL revision which have the ability to modify clinical outcomes at 2 years. [153] (10.1177/2325967116s00165)
[L1] CEE used as an adjunct to the ACL traditional rehabilitation program at the weekly frequencies of 3 and 5 times at the early stage of reconstruction significantly improved quadriceps deficit. [154] (10.1055/s-0032-1313744)
[L4] The graft fixation with double biodegradable pin fixation appears to be a reliable technique for ACL reconstruction providing a stable close-to-joint graft fixation. [155] (10.1007/s00167-008-0585-z)
[L4] Significant variability exists in pain management practices in pediatric ACL reconstruction. [156] (10.1177/2325967121s00449)
[L5] MRI can be used in different ways, serving as a very valuable tool in anatomic ACL reconstruction. [157] (10.1007/s00167-012-2153-9)
[L3] Surgeons should consider utilizing similar rehabilitation timelines and functional performance goals for patients following ACL reconstruction with QT and PT graft options. [158] (10.1177/2325967121s00539)
[L4] The healing response procedure is an effective treatment technique for a select group of mature patients with acute proximal ACL tears, allowing them to return to high levels of recreational activity and restore knee function to normal levels. [159] (10.1055/s-0032-1313742)
[L3] The evidence suggests that it should be appropriate to add a lateral extra-articular procedure to an ACL reconstruction in selected cases, but further data are required before definitive guidelines on the use of a lateral tenodesis can be established. [161] (10.1007/s00167-017-4537-3)
[L5] Selection of the appropriate graft for ACL reconstruction is very important as the right choice determines surgical success. [162] (10.1177/2325967121s00839)
[L5] Joint kinematics are better restored with double-bundle reconstruction but still did not completely recreate the native ACL. [163] (10.1016/j.arthro.2009.04.041)
[L2] A greater proportion of patients treated with early ACL reconstruction reported acceptable knee function and superior overall knee function as compared with patients who decided to cross over from nonreconstructive treatment to ACL reconstruction. [165] (10.1177/03635465211069995)
[L3] Therefore, the presence of knee hyperextension alone should not be considered a contraindication per se for the use of HT autografts in ACLR. [168] (10.1177/03635465241288238)
[L4] The review concludes that knee rotational laxity is an extensive field requiring precise definition before comparison or assessment, and that the pivot-shift test remains the most representative dynamic test for knee dysfunction, with new technologies like accelerometers showing promise for objective quantification. [169] (10.1016/j.otsr.2012.10.005)
[L3] ACL reconstruction is recommended for treating patients older than 50 years with ACL insufficiency, especially for those with high functional demand. [170] (10.1007/s00167-018-5342-3)
[L1] Preoperative adductor canal block improves immediate postoperative pain in ACL reconstruction patients but offers no long-term benefit for pain control or opioid consumption beyond 24 hours. [174] (10.1016/j.jisako.2025.100566)
[L1] Based on available literature, there appears to be an improved rate of return to athletic activity after ACLR when compared with non-operative treatment. [175] (10.1136/jisakos-2015-000013)
[L4] The dynamic evaluation of pivot shift is able to better describe knee laxity, in particular rotational laxities and has no correlation with static laxity. [179] (10.1007/s00167-009-0853-6)
[L2] The continued reduction in range of tibial rotation one year after ACL reconstruction may be a combination of this neuromuscular adaptation and the biomechanical impact of the reconstruction. [180] (10.1186/s13018-023-03639-2)
[L2] Both anatomic single- and double-bundle ACL reconstruction adequately restore tibial rotational excursion in a human, in vivo kinematic model. [181] (10.1007/s00167-011-1568-z)
[L4] On the basis of the available published literature which is largely retrospective, acute reconstruction for ACL tears appears to be associated with fewer medial meniscal injuries and articular cartilage lesions when compared with delayed or non-operative management. [182] (10.1136/jisakos-2015-000012)
[L5] Graft choice for ACL reconstruction should be tailored to the individual patient and their sport or activity level rather than being a debate about the 'best' graft type. [183] (10.1016/j.arthro.2024.09.018)
[L2] In contrast to radiograph analyses, MRI was excellent at distinguishing damage to the cartilage and can be useful in early follow-up evaluation of patients with septic arthritis after ACL reconstruction. [185] (10.1177/23259671211052519)
[L5] Larger-scale studies with long-term follow-ups are needed to better understand the outcomes of modern ACLR techniques. [186] (10.1136/jisakos-2020-000456)
[L4] These findings suggest that abnormal rotational kinematics is a potential risk factor for the pathogenesis and onset of posttraumatic articular cartilage degeneration after ACLR. [187] (10.1007/s00167-020-06387-6)
[L1] Both grafts remain viable options for ACLR plus LEP, with the benefit of LEP requiring further validation. [188] (10.2106/jbjs.25.00068)
[L2] Persistent biomechanical alterations after ACL reconstruction are related to significant changes in cartilage T1r and T2 at 1 year postreconstruction. [190] (10.1177/2325967116644421)
[L3] Allograft is an acceptable option for ACLR in patients >16 years of age. [191] (10.1016/j.arthro.2016.03.044)
[L3] However, there is a lack of evidence regarding return to activity in middle-aged patients with an ACL injury and conservative treatment. [193] (10.1136/jisakos-2016-000085)
[L3] ACL grafts in skeletally immature patients with all-epiphyseal reconstructions maintain stable intensity signaling at long-term MRI follow-up with no significant signal reduction over time. [194] (10.1177/2325967117s00431)
[L4] Early surgical reconstruction of the ACL and nonoperative treatment of the MCL in combined injuries is acceptable and results in excellent clinical and functional outcomes. [195] (10.1055/s-0030-1248204)
[L5] With studies showing noninferiority at worst and an evolving body of evidence realizing the advantages of the internal bracing technique, the authors argue for its use to protect ACL reconstructions. [198] (10.1016/j.arthro.2024.03.014)
[L2] Adult non-cultivated bone marrow stem cells do not seem to accelerate graft-to-bone healing in ACL reconstruction. [199] (10.1007/s00167-012-2279-9)
[L4] The surgical outcomes of anatomical ACL reconstruction in patients with non-isometric ACL graft were not inferior in terms of clinical scores and knee laxity compared to those with nearly-isometric ACL graft. [202] (10.1007/s00167-021-06654-0)
[L4] Nonoperative treatment of a partial patellar tendon rupture after ACL graft harvest may result in an excellent outcome in patients without patella alta, abnormal patellar tracking, or inability to actively extend the knee. [204] (10.1055/s-0032-1324810)
[L3] ACL reconstruction using a living related donor allograft is associated with high rates of return to sport and good subjective outcomes. [205] (10.1177/2325967117s00184)
[L5] Longer and wider interference screws provide better fixation in tibial ACL graft fixation. [206] (10.1186/1471-2474-11-139)
[L5] Further work is clearly needed but there is renewed interest and focus for primary ACL repair that may yet prove the new frontier in ligament repair. [207] (10.1186/s40634-018-0136-6)
[L3] Despite conservative weight-bearing and range of motion restrictions, repair of the meniscus in combination with ACL reconstruction in pediatric patients does not appear to induce a meaningful strength deficit at the return-to-activity evaluation phase, and is therefore not expected to influence return to activity in comparison with non-meniscus repair patients. [208] (10.1177/2325967121s00456)
[L3] This work adds to the growing mass of literature supporting the safety and efficacy of this procedure in the setting of ACL reconstruction. [209] (10.1177/2325967126s00252)
[L4] Using non-irradiated tibialis or Achilles tendon allografts for ACL reconstructions in active patients under 25 years of age can have good outcomes with a low rate of failure. [210] (10.1016/j.arthro.2014.04.024)
[L3] The majority of patients undergoing ACL reconstruction return to sport, with a return rate of 78.6% when excluding those who did not intend to return. [212] (10.1016/j.jisako.2025.100532)
[L3] In ACL reconstruction with hamstrings graft, similar clinical results are obtained for the use of bioabsorbable cross pins when compared to bioabsorbable interference screws for femoral fixation. [213] (10.1007/s00167-011-1875-4)
[L3] Patients who underwent bilateral ACLR had a significantly greater PTS on radiography and a significantly greater LPTS on MRI compared with those who underwent unilateral ACLR. [215] (10.1177/03635465231177086)
[L3] Patients who underwent bilateral ACLR had significantly greater PTS on radiographs and LPTS on MRI compared to those with unilateral ACLR. [218] (10.1177/2325967124s00006)
[L5] Internal braced knotless adjustable fixation for ACL repair with preconditioning of the suture repaired ligament increased the overall stabilization with higher load share on the ACL and restricted gap formation compared with fixed suture repair. [220] (10.1177/23259671231201462)
[L5] Fixation of the ACL graft at 30° of knee flexion followed by fixation of the PCL graft can best restore the tibiofemoral position of the intact knee. [221] (10.1007/s00167-017-4615-6)
[L2] Patients can be informed that they will benefit from ACL reconstruction in terms of improved knee function and satisfaction with health, though heavy physical workload is a risk factor for prolonged time lost to return to work. [223] (10.1007/s00167-017-4623-6)
[L3] [224] (10.1177/23259671221125493)
[L4] [229] (10.1177/2325967124s00509)
[L3] Patients receiving a concomitant MAT exhibit lower return to sport rates, delayed time to release to activity, and lower subjective function compared to those undergoing an isolated ACL reconstruction. [230] (10.1177/2325967123s00314)
[L4] Test results from an ACL-reconstructed patient should be at least classified as a functionally average outcome to support a safe return to sports. [232] (10.1007/s00167-015-3529-4)
[L4] [233] (10.1007/s00167-017-4646-z)
[L5] This implant has demonstrated noninferiority to ACL reconstruction with autograft at 2-year follow-up. [234] (10.1016/j.eats.2022.07.014)
[L5] The tendon-bone healing after ACL reconstruction was affected by the method of graft fixation. [237] (10.1007/s00402-013-1790-x)
[L2] ACL reconstruction with an all soft tissue QT autograft using a minimally invasive harvest technique and suspensory fixation has acceptable short and intermediate-term clinical outcomes. [238] (10.1177/2325967117s00310)
[L3] High resolution 3T MRI scan taken 12 months after transphyseal ACL reconstruction in a genuine paediatric population demonstrated two tibial physeal bar formations (6.6% incidence) and no femoral physeal bars. [239] (10.1016/j.jisako.2023.03.294)
[L4] The outcome studies of implant-free ACL reconstruction also report clinical results similar to ACL reconstruction with conventional implants. [240] (10.1007/s00402-013-1913-4)
[L3] Total doses of postoperative opioids prescribed for pain management in pediatric ACLR have declined in recent years, which appears related to preoperative counseling through mandated opioid consenting and paralleled by greater utilization of non-opioid medications. [244] (10.1177/2325967121s00066)
[L4] [247] (10.1002/ksa.12417)
[L3] Radiographic evaluations demonstrated a consistent increase in posterior tibial slope over an average of 9 years among patients undergoing revision ACL reconstruction, with posterior medial meniscus resection significantly linked to these increases. [251] (10.1002/ksa.12719)
[L3] [254] (10.1177/23259671251399817)
[L2] The choice of fixation after ACLR with an HT has a significant effect on a patient's risk of revision. [257] (10.1177/0363546515584757)
[L4] Combined ACL repair and ALL internal brace augmentation resulted in significant improvements in patient-reported outcome measures at 2 years. [258] (10.1177/2325967120968557)
[L4] The AI-driven segmentation of CT-MRI fusion images and automatic preoperative ACL reconstruction planning demonstrated the capability to automatically, precisely, and reproducibly generate plans for nearly ideal tunnel entry and exit points with isometric, anatomical, and individualization characteristics. [260] (10.2106/jbjs.25.00485)
[L2] Quantitative T2 and T1rho relaxation times of ACL graft may offer a non-invasive method for monitoring graft maturation that correlates with patient-reported knee function after ACL reconstruction. [262] (10.1177/2325967119s00352)
[L2] Even young, active patients begin to develop radiographic changes by 2 years after ACLR; however, these changes are not associated with increased pain up to 6 years postoperatively. [263] (10.1177/2325967124s00316)
[L2] Development of new cartilage lesions was evident after 2-year follow-up in patients with arthroscopic ACLR as detected by MR imaging. [264] (10.1007/s00167-016-4153-7)
[L5] Allograft remodeling is delayed in ACL reconstruction and resulted in reduced long-term stability and mechanical function compared to autologous ACL reconstruction. [265] (10.1016/j.arthro.2007.10.011)
[L3] For younger patients who underwent both ACLR and lateral meniscal repair, higher MRI signal intensity of the repaired lateral meniscus was associated with a higher prevalence of residual anterolateral knee laxity. [267] (10.1177/23259671241241821)
[L3] CT imaging is recommended for precise evaluation, particularly in failed reconstructions requiring revision, comparative studies, or second opinions. [268] (10.1007/s00167-004-0548-y)
[L4] [269] (10.1177/2325967117724345)
[L3] Within 6 months after a first ACL reconstruction surgery, the risk of complication, including infection or device removal, was 5% in the entire cohort. [271] (10.1016/j.arthro.2011.03.070)
[L4] [272] (10.1007/s00167-011-1486-0)
[L4] [276] (10.1007/s00402-015-2160-7)
[L5] [278] (10.1177/2325967124s00293)
[L3] Graft maturity should not be used as an objective test to determine the appropriate time to return to sports during the first year after ACL reconstruction. [281] (10.1007/s00167-016-4252-5)
[L3] Patients with increased posterolateral tibial plateau bone loss showed lower Tegner activity scores 12 months after ACL reconstruction. [283] (10.1007/s00167-022-07282-y)
[L2] [284] (10.1016/j.otsr.2008.09.006)
[L5] [285] (10.1016/j.eats.2024.103241)
[L5] [286] (10.1002/atn2.70141)
[L3] [287] (10.1177/036354659101900307)
[L3] Completion of a specific return to sports program, in addition to standard rehabilitation, was the most important factor influencing the K-STARTS composite functional and psychological return to sports test score at 6 months after ACL reconstruction. [289] (10.1177/2325967121s00301)
[L3] Steep tibial plateau slope ≥ 12° is associated with a higher risk of contralateral ACL injury within 2 years after ACL reconstruction in patients less than 18 years of age. [291] (10.1007/s00167-020-06195-y)
[L3] These findings confirmed that preserving the remnant tissue of the ACL may facilitate recovery of function and decrease graft rupture after primary reconstruction. [294] (10.1177/2325967113505076)
[L3] LEAT resulted in improved clinical scores and earlier overall return to sport compared to ACL reconstruction alone. [295] (10.1007/s00402-019-03218-3)
[L3] Rates of infection after ACL reconstruction in pediatric patients are relatively low (0.52%) and similar to rates in young adults. [296] (10.1177/2325967121s00393)
[L4] [297] (10.1007/s00167-020-06085-3)
[L2] Slope-reducing high tibial osteotomy significantly improves midterm functional outcomes and reduces graft failure risk in patients with increased tibial slope undergoing revision ACL reconstruction without altering patellar height. [300] (10.1016/j.jisako.2025.100689)
[L4] Patients who undergo I&D for an infection following ACLR have a high rate of additional surgery but still attain reasonable clinical outcomes 6 years after ACLR. [301] (10.1136/jisakos-2018-000264)
[L4] [304] (10.1007/s00167-011-1426-z)
[L1] At a minimum of 10 years following ACL reconstruction in a young athletic population, over 80% of all grafts were intact and had maintained stability. [306] (10.1177/2325967114s00043)
[L3] Patients undergoing ACL reconstruction with OCA demonstrate similar self-reported function and return-to-sport rates, along with a delayed time to return to sport, to those undergoing isolated ACL reconstruction. [307] (10.1177/23259671261463928)
[L3] Good mid-term clinical results can be obtained after repeated ACL revision with allograft in patients that experienced multiple failures, however, who need additional procedure due to malalignment or post-meniscectomy syndrome reported lower objective and subjective results. [308] (10.1016/j.jisako.2023.03.108)
[L2] Early results suggest the knees are stable and recover motion after bridge-enhanced ACL repair. [310] (10.1177/2325967117s00305)
[L3] Only a small percentage of patients returned to the same level of sport after single-revision and multiple-revision ACL reconstruction, yet significantly more in the former. [311] (10.1177/23259671221133762)
[L3] The revision rate of primary ACL repair with SA at a 2-year follow-up was 10%. [312] (10.1177/23259671241244734)
[L4] Arthroscopic primary ACL repair led to high RTS rates, 10% failure rate, and satisfactory patient-reported outcome measures at a minimum 2-year follow-up. [313] (10.1002/arj.70218)
[L4] A greater revision rate was observed among younger patients, female patients, and those receiving allografts during primary surgery, while contralateral ACLR was more common than revision surgery. [314] (10.1177/23259671241265074)
[L1] The pooled incidence of second ACL injury in football players after index ACL reconstruction was 21.6%, with contralateral (10.6%) and ipsilateral (10.4%) injuries of similar magnitude. [316] (10.1002/ksa.70471)
[L3] Our findings suggest that OCP use at the time of initial ACL reconstruction in female patients may provide a protective effect against subsequent ipsilateral ACL reconstruction within five years, with the most significant protective effect observed in younger and more active individuals, without significantly increasing the risk of developing a VTE. [317] (10.1177/2325967126s00333)
[L3] In a young high-risk primary ACLR population, increased PTS was present in nearly 30% of patients. [318] (10.1177/03635465261473931)
[L2] The overall SSI rate after ACLR was 0.48%, with deep SSIs identified in 0.32% of cases. [319] (10.1177/0363546513490665)
[L3] High recovery rates were seen after arthroscopic ACLR, regardless of leg dominance. [320] (10.1177/2325967121995808)
[L4] ACL reconstruction is a safe procedure with an incidence of septic arthritis of 0.92%. [321] (10.1016/j.arthro.2009.04.048)
[L3] Of particular interest is that there was a 6% rate of recurrent ACL failure and 5% rate of subsequent TKA in this young cohort 6 years following a revision ACL reconstruction. [323] (10.1177/2325967119s00292)
[L4] In select patients with steep posterior tibial slope (PTS ≥12°) and elevated static anterior tibial translation, slope-correcting osteotomy may be warranted even in primary ACL reconstruction, as soft tissue augmentation alone may be insufficient. [324] (10.1177/03635465251387704)
[L2] In patients with ACL graft failure and increased tibial slope, anterior closing wedge high tibial osteotomy provides a safe and reliable technique to control ACL graft re-tear and offer good functional outcome on the midterm. [325] (10.1016/j.jisako.2023.03.220)
[L3] Increasing slopes in the coronal and sagittal planes with decreasing concavity of the medial tibial plateau lead to less favorable outcomes 7 years after surgery. [327] (10.1177/0363546518823556)
[L3] A 10.7% ipsilateral reoperation rate at an average of 25.9 months after ACLR and an overall ACLR revision rate of 3.1% were demonstrated. [328] (10.1007/s00167-019-05798-4)
[L3] The study suggests that SRO in the setting of ACL reconstruction for large posterior tibial slope deformities is effective at correcting malalignment, restoring objective and self-reported function, and avoiding graft failure out to 2 years. [331] (10.1177/2325967124s00014)
[L3] A reoperation rate of 22% was noted 10 years after index ACL revision reconstruction, which is an important point of discussion between surgeons and their patients. [332] (10.1177/2325967126s00354)
[L4] Multiple revision ACL reconstruction surgery appears to have reasonable functional outcomes but is associated with a relatively high failure rate. [335] (10.1016/j.asmr.2020.06.013)
[L3] Other risk factors for infection after ACL reconstruction included increased BMI and increased operative time. [337] (10.2106/jbjs.19.00270)
[L3] Overall re-tear rates were higher in patients who underwent revision ACL reconstruction with allograft. [338] (10.1177/2325967124s00296)
[L3] This nationally-representative, population-based study demonstrates that patients with elevated BMI are much more likely to require additional surgery in the setting of primary ACL reconstruction. [341] (10.1007/s00167-018-5267-x)
[L4] The prevalence of septic arthritis after an ACL reconstruction in this series was 1.8%. [342] (10.1007/s00167-012-2264-3)
[L3] Septic arthritis after ACL reconstruction results in the same objective knee function as uncomplicated cases. [344] (10.1016/j.arthro.2013.07.242)
[L2] Patients with diabetes undergoing ACL reconstruction have a significantly elevated risk of postoperative infection (18.8-times higher odds) compared with that for patients without diabetes. [345] (10.2106/jbjs.n.00694)
[L3] Understanding these risk factors has important implications for appropriate counseling for primary ACLR. [346] (10.1007/s00167-021-06517-8)
[L3] ACLRs performed without tourniquet resulted in a significantly lower incidence of DVT after ACLR and significantly less bleeding from drains. [347] (10.1177/23259671211056677)
[L3] The rates of LARS ACL construct failure (33.3%) in this cohort are high and based on these results the LARS should not be considered as a graft option for primary ACL reconstruction. [348] (10.1007/s00167-019-05478-3)
[L3] Results following revision anterior cruciate ligament reconstruction (ACLR) are less favourable than primary ACLR. [349] (10.1177/2325967120s00305)
[L3] While graft choice may affect rates of septic arthritis after ACLR, patient characteristics, ACLR technique, revision ACLR, and accompanying intra-articular procedures during ACLR were not associated with postoperative septic arthritis with the numbers available for analysis. [350] (10.1177/03635465231165509)
[L4] Different early ACL revision rates were found across different combinations of femoral and tibial fixation devices within 2 years of primary hamstring tendon autograft ACLR. [351] (10.1186/s12891-023-07109-y)
[L1] The incidence of septic arthritis following ACLR can be reduced dramatically by vancomycin-soaking the grafts intra-operatively. [353] (10.1007/s00167-019-05353-1)
[L3] The incidence of septic arthritis after ACLR in this nationwide cohort was 1.1%. [354] (10.1177/0363546521993812)

References¶

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[57] Quadriceps tendon autograft is becoming increasingly popular in revision ACL reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy. 2021. DOI: 10.1007/s00167-021-06478-y

[59] Dynamic intraligamentary stabilization for ACL repair: a systematic review. Knee Surgery, Sports Traumatology, Arthroscopy. 2018. DOI: 10.1007/s00167-018-5301-z

[60] Modified Bridge‐Enhanced Anterior Cruciate Ligament Repair. Arthroscopy Techniques. 2024. DOI: 10.1016/j.eats.2024.103034

[61] The Tape Locking Screw technique (TLS): A new ACL reconstruction method using a short hamstring graft. Orthopaedics & Traumatology: Surgery & Research. 2011. DOI: 10.1016/j.otsr.2011.03.016

[62] Greater proportion of patients report an acceptable symptom state after ACL reconstruction compared with non-surgical treatment: a 10-year follow-up from the Swedish National Knee Ligament Registry. British Journal of Sports Medicine. 2022. DOI: 10.1136/bjsports-2021-105115

[65] Anterior Cruciate Ligament Repair Outcomes: An Updated Systematic Review of Recent Literature. Arthroscopy. 2019. DOI: 10.1016/j.arthro.2019.04.005

[66] Comparison of concomitant injuries and patient-reported outcome in patients that have undergone both primary and revision ACL reconstruction—a national registry study. Journal of Orthopaedic Surgery and Research. 2020. DOI: 10.1186/s13018-019-1532-z

[68] Inferior Outcomes after Subsequent Revision or Contralateral ACL Reconstruction: A Cross-Sectional Study. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/23259671261470914

[69] Long-term rate of graft failure after ACL reconstruction: a geographic population cohort analysis. Knee Surgery, Sports Traumatology, Arthroscopy. 2016. DOI: 10.1007/s00167-016-4275-y

[70] Higher revision and secondary surgery rates after ACL reconstruction in athletes under 16 compared to those over 16: a case-control study. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-05935-5

[72] Knee Hyperextension is not Associated with Revision ACL Reconstruction or Anterior Knee Laxity in Children and Adolescents. Journal of ISAKOS. 2025. DOI: 10.1016/j.jisako.2025.100535

[74] Quadriceps tendon vs. patellar tendon autograft for ACL reconstruction using a hardware-free press-fit fixation technique: comparable stability, function and return-to-sport level but less donor site morbidity in athletes after 10 years. Archives of Orthopaedic and Trauma Surgery. 2020. DOI: 10.1007/s00402-020-03508-1

[75] Aperture and Suspensory Fixation Equally Efficacious for Quadriceps Tendon Graft Fixation in Primary ACL Reconstruction: A Systematic Review. The Journal of Knee Surgery. 2019. DOI: 10.1055/s-0039-1685160

[76] Poor knee function after ACL reconstruction is associated with attenuated landing force and knee flexion moment during running. Knee Surgery, Sports Traumatology, Arthroscopy. 2017. DOI: 10.1007/s00167-017-4810-5

[77] Anatomic single‐ and double‐bundle ACL reconstruction both restore dynamic knee function: a randomized clinical trial—part II: knee kinematics. Knee Surgery, Sports Traumatology, Arthroscopy. 2021. DOI: 10.1007/s00167-021-06479-x

[80] Hamstring autograft size importance in anterior cruciate ligament repair surgery. EFORT Open Reviews. 2018. DOI: 10.1302/2058-5241.3.170038

[81] Biomechanical evaluation of press‐fit femoral fixation technique in ACL reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy. 2003. DOI: 10.1007/s00167-003-0452-x

[82] Bilateral Alterations in Isokinetic Strength and Knee Biomechanics During Side-Cutting 1 Year After Unilateral ACL Reconstruction. The American Journal of Sports Medicine. 2022. DOI: 10.1177/03635465221112940

[86] Functional tests should be accentuated more in the decision for ACL reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy. 2010. DOI: 10.1007/s00167-010-1113-5

[91] INFLUENCE OF LOWER EXTREMITY STATIC ALIGNMENT ON DYNAMIC KNEE VALGUS IN ADOLESCENTS FOLLOWING ACL RECONSTRUCTION. Orthopaedic Journal of Sports Medicine. 2020. DOI: 10.1177/2325967120s00144

[102] Adolescents Have Twice the Revision Rate of Young Adults After ACL Reconstruction With Hamstring Tendon Autograft: A Study From the Swedish National Knee Ligament Registry. Orthopaedic Journal of Sports Medicine. 2021. DOI: 10.1177/23259671211038893

[103] Over‐the‐top double‐bundle revision ACL reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy. 2011. DOI: 10.1007/s00167-011-1753-0

[105] Comparison Between Continuous and Separate Grafts for ALL Reconstruction When Combined With ACL Reconstruction: A Retrospective Cohort Study From the SANTI Study Group. The American Journal of Sports Medicine. 2023. DOI: 10.1177/03635465231197353

[108] Predicting risk of unplanned subsequent knee surgery following ACL reconstruction. BMC Musculoskeletal Disorders. 2026. DOI: 10.1186/s12891-026-09925-4

[109] Arthroscopic anterior cruciate ligament repair with and without suture augmentation: technical note. Journal of ISAKOS. 2021. DOI: 10.1136/jisakos-2020-000508

[111] Sustained Clinical and Functional Outcomes After Primary Anterior Cruciate Ligament Repair: A Minimum 5-Year Follow-up Study. The American Journal of Sports Medicine. 2025. DOI: 10.1177/03635465251340087

[112] Tear Rates of the Ipsilateral ACL Graft and the Contralateral Native ACL Are Similar following ACL Reconstruction. The Journal of Knee Surgery. 2020. DOI: 10.1055/s-0040-1713861

[113] Treatment of Anterior Cruciate Ligament Injuries, Part 2. The American Journal of Sports Medicine. 2005. DOI: 10.1177/0363546505279922

[114] The posterior horn of the lateral meniscus is a reliable novel landmark for femoral tunnel placement in ACL reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy. 2017. DOI: 10.1007/s00167-017-4759-4

[115] Lower knee self‐efficacy is associated with greater asymmetries in quadriceps neuromuscular function and jump‐landing biomechanics post‐ACL reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy. 2025. DOI: 10.1002/ksa.70192

[116] Over‐The‐Top Technique for Revision ACL Reconstruction with Achilles Allograft and Associated Lateral Extra‐articular Tenodesis. Arthroscopy Techniques. 2022. DOI: 10.1016/j.eats.2022.05.010

[117] One‐ versus two‐incision technique for anterior cruciate ligament reconstruction with patellar tendon graft. Knee Surgery, Sports Traumatology, Arthroscopy. 1997. DOI: 10.1007/s001670050052

[119] More knee reinjuries after ACL reconstruction compared to nonsurgical treatment of the ACL. A 2‐year follow‐up of the NACOX prospective cohort study. Knee Surgery, Sports Traumatology, Arthroscopy. 2024. DOI: 10.1002/ksa.12473

[120] Smith machine squats pose high risk to ACL graft integrity after the ACL reconstruction and conventional squats are a safer alternative. Knee Surgery, Sports Traumatology, Arthroscopy. 2024. DOI: 10.1002/ksa.12263

[126] Immersive virtual reality improves movement patterns in patients after ACL reconstruction: implications for enhanced criteria‐based return‐to‐sport rehabilitation. Knee Surgery, Sports Traumatology, Arthroscopy. 2014. DOI: 10.1007/s00167-014-3374-x

[128] Double‐bundle ACL reconstruction demonstrated superior clinical stability to single‐bundle ACL reconstruction: a matched‐pairs analysis of instrumented tests of tibial anterior translation and internal rotation laxity. Knee Surgery, Sports Traumatology, Arthroscopy. 2010. DOI: 10.1007/s00167-010-1247-5

[129] Effect of Hyperbaric Oxygen Therapy on Early MRI-Based Graft Healing Following ACL Reconstruction With Hamstring Autografts. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/23259671251413600

[130] Task dependent early landing kinematics after return to sport in individuals with ACL reconstruction: a secondary analysis. BMC Musculoskeletal Disorders. 2026. DOI: 10.1186/s12891-026-09967-8

[131] The effect of graft tensioning in anatomic 2‐bundle ACL reconstruction on knee joint kinematics. Knee Surgery, Sports Traumatology, Arthroscopy. 2006. DOI: 10.1007/s00167-006-0242-3

[133] Rehabilitation Plus Early ACL Reconstruction and Rehabilitation Plus Delayed Reconstruction Were Similar at 5 Years. The Journal of Bone & Joint Surgery. 2013. DOI: 10.2106/jbjs.9516.ebo781

[135] Rehabilitation Predictors of Clinical Outcome Following Revision ACL Reconstruction in the MARS Cohort. Journal of Bone and Joint Surgery. 2019. DOI: 10.2106/jbjs.18.00397

[136] Biomechanical Evaluation of Knee Kinematics after ACL Reconstructions in Anatomic SB and DB - Technique with Additional Medial Meniscus Suture. Orthopaedic Journal of Sports Medicine. 2013. DOI: 10.1177/2325967113s00073

[138] Graft maturity of the reconstructed anterior cruciate ligament 6 months postoperatively: a magnetic resonance imaging evaluation of quadriceps tendon with bone block and hamstring tendon autografts. Knee Surgery, Sports Traumatology, Arthroscopy. 2014. DOI: 10.1007/s00167-014-3302-0

[140] Cross‐education improves quadriceps strength recovery after ACL reconstruction: a randomized controlled trial. Knee Surgery, Sports Traumatology, Arthroscopy. 2018. DOI: 10.1007/s00167-018-5040-1

[141] Effect of tunnel position for anatomic single‐bundle ACL reconstruction on knee biomechanics in a porcine model. Knee Surgery, Sports Traumatology, Arthroscopy. 2009. DOI: 10.1007/s00167-009-0916-8

[142] Quadriceps tendon autograft with or without bone block have comparable clinical outcomes, complications and revision rate for ACL reconstruction: a systematic review. Knee Surgery, Sports Traumatology, Arthroscopy. 2022. DOI: 10.1007/s00167-022-07281-z

[143] Cross-education does not improve early and late-phase rehabilitation outcomes after ACL reconstruction: a randomized controlled clinical trial. Knee Surgery, Sports Traumatology, Arthroscopy. 2018. DOI: 10.1007/s00167-018-5116-y

[149] Return to sports bridge program improves outcomes, decreases ipsilateral knee re-injury and contralateral knee injury rates post-ACL reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy. 2020. DOI: 10.1007/s00167-020-06162-7

[150] Return to Sports Bridge Program Improves Outcomes, Decreases Ipsilateral Knee Re-injury and Contralateral Knee Injury Rates Post-ACL Reconstruction: 2022 Update. Journal of ISAKOS. 2023. DOI: 10.1016/j.jisako.2023.03.136

[151] Biomechanical evaluation of knee kinematics after anatomic single‐ and anatomic double‐bundle ACL reconstructions with medial meniscal repair. Knee Surgery, Sports Traumatology, Arthroscopy. 2014. DOI: 10.1007/s00167-014-3071-9

[152] Anterolateral Tenodesis or Anterolateral Ligament Complex Reconstruction: Effect of Flexion Angle at Graft Fixation When Combined With ACL Reconstruction. The American Journal of Sports Medicine. 2017. DOI: 10.1177/0363546517724422

[153] Rehabilitation Predictors of Clinical Outcome following Revision ACL Reconstruction. Orthopaedic Journal of Sports Medicine. 2016. DOI: 10.1177/2325967116s00165

[154] Cross-Exercise on Quadriceps Deficit after ACL Reconstruction. Journal of Knee Surgery. 2012. DOI: 10.1055/s-0032-1313744

[155] Anterior cruciate ligament reconstruction using autografts and double biodegradable femoral cross‐pin fixation: functional, radiographic and MRI outcome after 2‐year minimum follow‐up. Knee Surgery, Sports Traumatology, Arthroscopy. 2008. DOI: 10.1007/s00167-008-0585-z

[156] Variability Exists in Pain Management Practices for Pediatric ACL Reconstruction. Orthopaedic Journal of Sports Medicine. 2022. DOI: 10.1177/2325967121s00449

[157] How to optimize the use of MRI in anatomic ACL reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy. 2012. DOI: 10.1007/s00167-012-2153-9

[158] Paper 01: Quadriceps Tendon Autograft Exhibits Similar Outcomes at Return-to-Sport & Two-Years When Compared to Patellar Tendon Autograft for Primary ACL Reconstruction. Orthopaedic Journal of Sports Medicine. 2022. DOI: 10.1177/2325967121s00539

[159] Outcomes Following Healing Response in Older, Active Patients: A Primary Anterior Cruciate Ligament Repair Technique. Journal of Knee Surgery. 2012. DOI: 10.1055/s-0032-1313742

[161] The scientific rationale for lateral tenodesis augmentation of intra-articular ACL reconstruction using a modified ‘Lemaire’ procedure. Knee Surgery, Sports Traumatology, Arthroscopy. 2017. DOI: 10.1007/s00167-017-4537-3

[162] Holy Grail of ACL Reconstruction Grafts. Orthopaedic Journal of Sports Medicine. 2023. DOI: 10.1177/2325967121s00839

[163] Effects of Single‐Bundle and Double‐Bundle ACL Reconstruction on Tibiofemoral Forces and Joint Kinematics Under Dynamic Loading (SS‐42). Arthroscopy. 2009. DOI: 10.1016/j.arthro.2009.04.041

[165] Superior Outcome of Early ACL Reconstruction versus Initial Non-reconstructive Treatment With Late Crossover to Surgery: A Study From the Swedish National Knee Ligament Registry. The American Journal of Sports Medicine. 2022. DOI: 10.1177/03635465211069995

[168] Physiologic Preoperative Knee Hyperextension Is Not Associated With Postoperative Laxity, Subjective Knee Function, or Revision Surgery After ACL Reconstruction With Hamstring Tendon Autografts. The American Journal of Sports Medicine. 2024. DOI: 10.1177/03635465241288238

[169] Current concept in rotational laxity control and evaluation in ACL reconstruction. Orthopaedics & Traumatology: Surgery & Research. 2012. DOI: 10.1016/j.otsr.2012.10.005

[170] Patients older than 50 years had similar results of knee strength and anteroposterior stability after ACL reconstruction compared to younger patients. Knee Surgery, Sports Traumatology, Arthroscopy. 2019. DOI: 10.1007/s00167-018-5342-3

[174] No Detectable Changes in Dynamic Knee Kinematics During Downhill Running 10+ Years After Anatomic ACL Reconstruction. Journal of ISAKOS. 2025. DOI: 10.1016/j.jisako.2025.100566

[175] ACL reconstruction in youth athletes results in an improved rate of return to athletic activity when compared with non-operative treatment: a systematic review of the literature. Journal of ISAKOS. 2016. DOI: 10.1136/jisakos-2015-000013

[179] Clinical relevance of static and dynamic tests after anatomical double‐bundle ACL reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy. 2009. DOI: 10.1007/s00167-009-0853-6

[180] High-demand tasks show that ACL reconstruction is not the only factor in controlling range of tibial rotation: a preliminary investigation. Journal of Orthopaedic Surgery and Research. 2023. DOI: 10.1186/s13018-023-03639-2

[181] Tibial rotation in single‐ and double‐bundle ACL reconstruction: a kinematic 3‐D in vivo analysis. Knee Surgery, Sports Traumatology, Arthroscopy. 2011. DOI: 10.1007/s00167-011-1568-z

[182] Early ACL reconstruction in children leads to less meniscal and articular cartilage damage when compared with conservative or delayed treatment. Journal of ISAKOS. 2016. DOI: 10.1136/jisakos-2015-000012

[183] Editorial Commentary: Anterior Cruciate Ligament Graft Selection Is Best Tailored to Individual Patient Sport and Activity Level. Arthroscopy. 2024. DOI: 10.1016/j.arthro.2024.09.018

[185] MRI Findings of Early Osteoarthritis in Patients Who Sustained Septic Arthritis of the Knee After ACL Reconstruction. Orthopaedic Journal of Sports Medicine. 2021. DOI: 10.1177/23259671211052519

[186] ACL reconstruction in the professional or elite athlete: state of the art. Journal of ISAKOS. 2021. DOI: 10.1136/jisakos-2020-000456

[187] Development of new cartilage lesions after ACL reconstruction is associated with abnormal knee rotation. Knee Surgery, Sports Traumatology, Arthroscopy. 2021. DOI: 10.1007/s00167-020-06387-6

[188] Hamstring Tendon Versus Bone-Patellar Tendon-Bone Autograft for ACL Reconstruction with Concurrent Lateral Extra-Articular Procedure. Journal of Bone and Joint Surgery. 2025. DOI: 10.2106/jbjs.25.00068

[190] Persistent Biomechanical Alterations After ACL Reconstruction Are Associated With Early Cartilage Matrix Changes Detected by Quantitative MR. Orthopaedic Journal of Sports Medicine. 2016. DOI: 10.1177/2325967116644421

[191] A Matched‐pair Comparison of Patient‐reported Outcomes following Primary ACL Reconstruction with Hamstring Autograft vs Hybrid Graft. Arthroscopy. 2016. DOI: 10.1016/j.arthro.2016.03.044

[193] High rate of return to activity after ACL reconstruction in patients over 40 years of age: a systematic review. Journal of ISAKOS. 2017. DOI: 10.1136/jisakos-2016-000085

[194] Sequential MRI Study of Graft Integrity and Signal Following Pediatric All-epiphyseal ACL Reconstruction: Does the “Sharp Turn” at the Socket of the Distal Femoral Aperture Matter?. Orthopaedic Journal of Sports Medicine. 2017. DOI: 10.1177/2325967117s00431

[195] Early ACL Reconstruction in Combined ACL—MCL Injuries. The Journal of Knee Surgery. 2010. DOI: 10.1055/s-0030-1248204

[198] Editorial Commentary: Anterior Cruciate Ligament Repair or Reconstruction With Internal Bracing, for Properly Indicated Patients, Is Safe, Biocompatible, and Biomimetic. Arthroscopy. 2024. DOI: 10.1016/j.arthro.2024.03.014

[199] Is there a role for adult non‐cultivated bone marrow stem cells in ACL reconstruction?. Knee Surgery, Sports Traumatology, Arthroscopy. 2012. DOI: 10.1007/s00167-012-2279-9

[202] Graft isometry during anatomical ACL reconstruction has little effect on surgical outcomes. Knee Surgery, Sports Traumatology, Arthroscopy. 2021. DOI: 10.1007/s00167-021-06654-0

[204] Nonoperative Management of a Partial Patellar Tendon Rupture after Bone-Patellar Tendon-Bone Graft Harvest for ACL Reconstruction. Journal of Knee Surgery. 2012. DOI: 10.1055/s-0032-1324810

[205] 5 Year Survival of Endoscopic ACL Reconstruction with Live Donor Hamstring Tendon Allograft in Juveniles and Adolescents. Orthopaedic Journal of Sports Medicine. 2017. DOI: 10.1177/2325967117s00184

[206] Fixation strength of biocomposite wedge interference screw in ACL reconstruction: effect of screw length and tunnel/screw ratio. A controlled laboratory study. BMC Musculoskeletal Disorders. 2010. DOI: 10.1186/1471-2474-11-139

[207] Anterior cruciate ligament repair – past, present and future. Journal of Experimental Orthopaedics. 2018. DOI: 10.1186/s40634-018-0136-6

[208] The Impact of Concomitant Meniscus Repair on Functional and Patient Reported Outcomes at Return to Activity in Paediatric Patients Undergoing ACL Reconstruction. Orthopaedic Journal of Sports Medicine. 2022. DOI: 10.1177/2325967121s00456

[209] ACL Reconstruction Using Hamstring Autograft in Adolescent Patients is Associated with Low Rates of Arthrofibrosis with or without Lateral Extra-Articular Tenodesis. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/2325967126s00252

[210] Allograft ACL Reconstruction in Patients Under 25 Years of Age. Arthroscopy. 2014. DOI: 10.1016/j.arthro.2014.04.024

[212] Predictors of Return to Sport After ACL Reconstruction: A New Zealand ACL Registry Study. Journal of ISAKOS. 2025. DOI: 10.1016/j.jisako.2025.100532

[213] Bioabsorbable interference screw versus bioabsorbable cross pins: influence of femoral graft fixation on the clinical outcome after ACL reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy. 2012. DOI: 10.1007/s00167-011-1875-4

[215] Posterior Tibial Slope in Patients Undergoing Bilateral Versus Unilateral ACL Reconstruction: MRI and Radiographic Analyses. The American Journal of Sports Medicine. 2023. DOI: 10.1177/03635465231177086

[218] Patients with Bilateral ACL Reconstruction (ACLR) have 3x the Rate of Posterior Tibial Slope Greater than 12-Degrees Compared to Unilateral ACLR: MRI and Radiographic Evaluation. Orthopaedic Journal of Sports Medicine. 2024. DOI: 10.1177/2325967124s00006

[220] Stabilization and Gap Formation of Adjustable Versus Fixed Primary ACL Repair With Internal Brace: An in Vitro Full-Construct Biomechanical Cadaveric Study. Orthopaedic Journal of Sports Medicine. 2023. DOI: 10.1177/23259671231201462

[221] Anterior cruciate ligament graft fixation first in anterior and posterior cruciate ligament reconstruction best restores knee kinematics. Knee Surgery, Sports Traumatology, Arthroscopy. 2017. DOI: 10.1007/s00167-017-4615-6

[223] Patient satisfaction with health is substantially improved following ACL reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy. 2017. DOI: 10.1007/s00167-017-4623-6

[224] Effect of Joint Infection After Arthroscopic Single-Bundle ACL Reconstruction With Autologous Hamstring Tendon: A Retrospective Matched MRI Study. Orthopaedic Journal of Sports Medicine. 2022. DOI: 10.1177/23259671221125493

[226] Miller S Review Of Orthopaedics. SECTION 16 PATELLAR TRACKING IN TOTAL KNEE ARTHROPLASTY > 1. ACL injury > Introduction.

[229] Transtibial Femoral Tunnel Technique in ACL Reconstruction and Osteoarthritis Incidence. Orthopaedic Journal of Sports Medicine. 2024. DOI: 10.1177/2325967124s00509

[230] Poster 349: Outcomes Following ACL Reconstruction with Concomitant Meniscus Allograft Transplantation Versus Isolated ACL Reconstruction. Orthopaedic Journal of Sports Medicine. 2023. DOI: 10.1177/2325967123s00314

[232] Functional assessments for decision‐making regarding return to sports following ACL reconstruction. Part I: development of a new test battery. Knee Surgery, Sports Traumatology, Arthroscopy. 2015. DOI: 10.1007/s00167-015-3529-4

[233] Preoperative magnetic resonance imaging predicts eligibility for arthroscopic primary anterior cruciate ligament repair. Knee Surgery, Sports Traumatology, Arthroscopy. 2017. DOI: 10.1007/s00167-017-4646-z

[234] Bridge‐Enhanced Anterior Cruciate Ligament Repair for Mid‐Substance Tear With Concomitant Lateral Meniscus Radial Repair. Arthroscopy Techniques. 2022. DOI: 10.1016/j.eats.2022.07.014

[237] Graft failure versus graft fixation in ACL reconstruction: histological and immunohistochemical studies in rabbits. Archives of Orthopaedic and Trauma Surgery. 2013. DOI: 10.1007/s00402-013-1790-x

[238] Clinical Outcomes of All Soft Tissue Quadriceps Tendon Autograft in ACL Reconstruction. Orthopaedic Journal of Sports Medicine. 2017. DOI: 10.1177/2325967117s00310

[239] Incidence of Iatrogenic Physeal Bar Formation in a Paediatric Population Undergoing Transphyseal ACL Reconstruction Using A Validated High-Resolution MRI Protocol at 12 Months Post Surgery. Journal of ISAKOS. 2023. DOI: 10.1016/j.jisako.2023.03.294

[240] Implant-free ACL reconstruction: a review. Archives of Orthopaedic and Trauma Surgery. 2013. DOI: 10.1007/s00402-013-1913-4

[244] DECREASE PRESCRIBING OF POSTOPERATIVE OPIOIDS IN PEDIATRIC ACL RECONSTRUCTION- TREATMENT TRENDS AT A SINGLE CENTER. Orthopaedic Journal of Sports Medicine. 2021. DOI: 10.1177/2325967121s00066

[247] Anterior cruciate ligament repair using dynamic intraligamentary stabilization grants 88.5% survival at minimum follow‐up of 5 years. Knee Surgery, Sports Traumatology, Arthroscopy. 2024. DOI: 10.1002/ksa.12417

[251] Posterior tibial slope increases over time in patients undergoing revision ACL reconstruction: A long‐term radiographic follow‐up study. Knee Surgery, Sports Traumatology, Arthroscopy. 2025. DOI: 10.1002/ksa.12719

[254] Incidence and Treatment Strategy of Lateral Meniscus Posterior Root Tears and Ramp Lesions Identified During Isolated ACL Reconstructions: Report From a Nationwide Knee Ligament Register. Orthopaedic Journal of Sports Medicine. 2025. DOI: 10.1177/23259671251399817

[257] Registry Data Highlight Increased Revision Rates for Endobutton/Biosure HA in ACL Reconstruction With Hamstring Tendon Autograft. The American Journal of Sports Medicine. 2015. DOI: 10.1177/0363546515584757

[258] Combined Anterior Cruciate Ligament Repair and Anterolateral Ligament Internal Brace Augmentation: Minimum 2-Year Patient-Reported Outcome Measures. Orthopaedic Journal of Sports Medicine. 2020. DOI: 10.1177/2325967120968557

[260] AI-Driven CT-MRI Image Fusion and Segmentation for Automatic Preoperative Planning of ACL Reconstruction. Journal of Bone and Joint Surgery. 2025. DOI: 10.2106/jbjs.25.00485

[262] ACL Graft Signal Characteristics Measured by Quantitative MRI Are Significantly Correlated with Patient Reported Outcomes Two-Years after Hamstring Autograft ACL Reconstruction. Orthopaedic Journal of Sports Medicine. 2019. DOI: 10.1177/2325967119s00352

[263] Poster 350: Do Early Radiographic Changes at 2 Years Predict Increased Pain at 6 Years After ACL Reconstruction?. Orthopaedic Journal of Sports Medicine. 2024. DOI: 10.1177/2325967124s00316

[264] Articular cartilage status 2 years after arthroscopic ACL reconstruction in patients with or without concomitant meniscal surgery: evaluation with 3.0T MR imaging. Knee Surgery, Sports Traumatology, Arthroscopy. 2016. DOI: 10.1007/s00167-016-4153-7

[265] Fresh‐Frozen Free‐Tendon Allografts Versus Autografts in Anterior Cruciate Ligament Reconstruction: Delayed Remodeling and Inferior Mechanical Function During Long‐term Healing in Sheep. Arthroscopy. 2008. DOI: 10.1016/j.arthro.2007.10.011

[267] Association Between MRI Signal Intensity of the Repaired Lateral Meniscus and Residual Anterolateral Knee Laxity After ACL Reconstruction. Orthopaedic Journal of Sports Medicine. 2024. DOI: 10.1177/23259671241241821

[268] Postoperative evaluation of femoral tunnel position in ACL reconstruction: plain radiography versus computed tomography. Knee Surgery, Sports Traumatology, Arthroscopy. 2005. DOI: 10.1007/s00167-004-0548-y

[269] Thirty-Year Experience With ACL Reconstruction Using Patellar Tendon: A Critical Evaluation of Revision and Reoperation. Orthopaedic Journal of Sports Medicine. 2017. DOI: 10.1177/2325967117724345

[271] Perioperative Morbidity Associated with ACL Reconstruction: A Comparison of Risk Between Soft‐Tissue Allografts and Autogenous Grafts in 413 Patients (SS‐66). Arthroscopy. 2011. DOI: 10.1016/j.arthro.2011.03.070

[272] Analysis of sequential cytokine release after ACL reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy. 2011. DOI: 10.1007/s00167-011-1486-0

[276] Anatomic single-bundle anterior cruciate ligament reconstruction using the outside-in femoral tunnel drilling technique: a prospective study and short- to mid-term results. Archives of Orthopaedic and Trauma Surgery. 2015. DOI: 10.1007/s00402-015-2160-7

[278] Poster 327: Postoperative Physical Activity in the Setting of Delayed ACL Reconstruction is Associated with Increased Local and Systemic Immune Responses in Mice. Orthopaedic Journal of Sports Medicine. 2024. DOI: 10.1177/2325967124s00293

[281] MRI-based ACL graft maturity does not predict clinical and functional outcomes during the first year after ACL reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy. 2016. DOI: 10.1007/s00167-016-4252-5

[283] Extent of posterolateral tibial plateau impaction fracture correlates with anterolateral complex injury and has an impact on functional outcome after ACL reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy. 2022. DOI: 10.1007/s00167-022-07282-y

[284] Double-incision mini-invasive technique for BTB Harvesting: Its superiority in reducing anterior knee pain following ACL reconstruction. Orthopaedics & Traumatology: Surgery & Research. 2009. DOI: 10.1016/j.otsr.2008.09.006

[285] A Technique of Arthroscopic Primary Anterior Cruciate Ligament Repair With Polyester Suture Tape Augmentation. Arthroscopy Techniques. 2024. DOI: 10.1016/j.eats.2024.103241

[286] Arthroscopic All‐Epiphyseal Button and Anchor Technique Anterior Cruciate Ligament Repair With a Collagen‐Based Implant. Arthroscopy Techniques. 2026. DOI: 10.1002/atn2.70141

[287] The long-term followup of primary anterior cruciate ligament repair. The American Journal of Sports Medicine. 1900. DOI: 10.1177/036354659101900307

[289] Factors Influencing the Outcomes of a Validated Return to Sports Test Battery After ACL Reconstruction: A Retrospective Analysis of 676 Patients (187). Orthopaedic Journal of Sports Medicine. 2021. DOI: 10.1177/2325967121s00301

[291] Higher risk of contralateral anterior cruciate ligament (ACL) injury within 2 years after ACL reconstruction in under‐18‐year‐old patients with steep tibial plateau slope. Knee Surgery, Sports Traumatology, Arthroscopy. 2020. DOI: 10.1007/s00167-020-06195-y

[294] ACL Reconstruction Preserving the ACL Remnant Achieves Good Clinical Outcomes and Can Reduce Subsequent Graft Rupture. Orthopaedic Journal of Sports Medicine. 2013. DOI: 10.1177/2325967113505076

[295] Lateral extra-articular tenodesis with ACL reconstruction demonstrates better patient-reported outcomes compared to ACL reconstruction alone at 2 years minimum follow-up. Archives of Orthopaedic and Trauma Surgery. 2019. DOI: 10.1007/s00402-019-03218-3

[296] Rates of Infection After Pediatric ACL Reconstruction: A Marketscan Database Study of 44,501 Patients. Orthopaedic Journal of Sports Medicine. 2022. DOI: 10.1177/2325967121s00393

[297] All-epiphyseal anterior cruciate ligament reconstruction produces good functional outcomes and low complication rates in pediatric patients: a systematic review. Knee Surgery, Sports Traumatology, Arthroscopy. 2020. DOI: 10.1007/s00167-020-06085-3

[300] Infra-Tuberosity Anterior Closing-Wedge Osteotomy for Posterior Tibial Slope Correction Does Not Change the Patellar Height in Patients Undergoing Revision ACL Reconstruction. Journal of ISAKOS. 2025. DOI: 10.1016/j.jisako.2025.100689

[301] Patients treated with surgical irrigation and debridement for infection after ACL reconstruction have a high rate of subsequent knee surgery. Journal of ISAKOS. 2019. DOI: 10.1136/jisakos-2018-000264

[304] Advances in the three‐portal technique for anatomical single‐ or double‐bundle ACL reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy. 2011. DOI: 10.1007/s00167-011-1426-z

[306] Autograft vs Allograft ACL Reconstructions: A Prospective, Randomized Clinical Study with Minimum 10 Year Follow-up. Orthopaedic Journal of Sports Medicine. 2014. DOI: 10.1177/2325967114s00043

[307] Two-Year Outcomes of ACL Reconstruction With Osteochondral Allograft Transplantation Versus Isolated ACL Reconstruction: A Matched Cohort Study. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/23259671261463928

[308] Delayed ACL Reconstruction Increases the Incidence of Concurrent Intra-Articular Pathology In Adolescent Patients. Journal of ISAKOS. 2023. DOI: 10.1016/j.jisako.2023.03.108

[310] Bridge-enhanced ACL Repair: Mid-term Results of the First-in-human Study. Orthopaedic Journal of Sports Medicine. 2017. DOI: 10.1177/2325967117s00305

[311] Return to Sport After Revision ACL Reconstruction: A Comparative Cohort Study of Outcomes After Single- Versus Multiple-Revision Surgeries. Orthopaedic Journal of Sports Medicine. 2022. DOI: 10.1177/23259671221133762

[312] Rate of Revision Surgery and Associated Risk Factors After Primary Arthroscopic ACL Repair With Additional Suture Augmentation. Orthopaedic Journal of Sports Medicine. 2024. DOI: 10.1177/23259671241244734

[313] Primary Anterior Cruciate Ligament Repair for Acute Proximal Tears Shows High Return to Sport and a 10% Failure Rate at a Minimum 2‐Year Follow‐Up. Arthroscopy. 2026. DOI: 10.1002/arj.70218

[314] A Single-Surgeon 35-Year Experience With ACL Reconstruction Using Patellar Tendon Auto- and Allografts With the Transtibial Technique. Orthopaedic Journal of Sports Medicine. 2024. DOI: 10.1177/23259671241265074

[316] Second ACL injuries in football players after ACL reconstruction: A systematic review and meta‐analysis. Knee Surgery, Sports Traumatology, Arthroscopy. 2026. DOI: 10.1002/ksa.70471

[317] Poster 17. Oral Contraceptive Use at Time of ACL Reconstruction Decreases Risk of Revision Surgery. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/2325967126s00333

[318] Increased Posterior Tibial Slope and Lateral Extra-articular Tenodesis Are Independently Associated With Revision ACL Reconstruction in a Young High-Risk Population. The American Journal of Sports Medicine. 2026. DOI: 10.1177/03635465261473931

[319] Incidence of Postoperative Anterior Cruciate Ligament Reconstruction Infections. The American Journal of Sports Medicine. 2013. DOI: 10.1177/0363546513490665

[320] Effect of Leg Dominance on Medium- to Long-Term Functional Outcomes, Quality of Life, and Revision Rates After Isolated ACL Reconstruction. Orthopaedic Journal of Sports Medicine. 2021. DOI: 10.1177/2325967121995808

[321] Septic Arthritis Following ACL Reconstruction: The Ottawa Treatment Protocol and Outcomes (SS‐49). Arthroscopy. 2009. DOI: 10.1016/j.arthro.2009.04.048

[323] Reoperation and Failure Rate at Six Years Following Revision ACL Reconstruction: A MARS Cohort Study. Orthopaedic Journal of Sports Medicine. 2019. DOI: 10.1177/2325967119s00292

[324] LET and Tibial Slope in ACL Reconstruction: Without Rigorous Methods and Controls, Conclusions Fall Short: Response. The American Journal of Sports Medicine. 2025. DOI: 10.1177/03635465251387704

[325] Outcomes at 3 Years After Slope-Reducing High Tibial Osteotomy with Revision ACL Reconstruction. A Prospective Cohort Study. Journal of ISAKOS. 2023. DOI: 10.1016/j.jisako.2023.03.220

[327] Anatomic Features of the Tibial Plateau Predict Outcomes of ACL Reconstruction Within 7 Years After Surgery. The American Journal of Sports Medicine. 2019. DOI: 10.1177/0363546518823556

[328] Young age, female gender, Caucasian race, and workers’ compensation claim are risk factors for reoperation following arthroscopic ACL reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy. 2019. DOI: 10.1007/s00167-019-05798-4

[331] Paper 01: Clinical Outcomes Following ACL Reconstruction with Slope Reducing High-Tibial Osteotomy: A Matched Case-Control Study. Orthopaedic Journal of Sports Medicine. 2024. DOI: 10.1177/2325967124s00014

[332] Poster 41. Reoperation Rate at Ten Years After Revision ACL Reconstruction. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/2325967126s00354

[335] Patient‐Reported Outcomes After Multiple‐Revision ACL Reconstruction: Good but Not Great. Arthroscopy, Sports Medicine, and Rehabilitation. 2020. DOI: 10.1016/j.asmr.2020.06.013

[337] Graft Preparation with Intraoperative Vancomycin Decreases Infection After ACL Reconstruction. Journal of Bone and Joint Surgery. 2019. DOI: 10.2106/jbjs.19.00270

[338] Poster 330: Graft Selection and Lateral Augmentation in Revision ACL Reconstruction: Experience of a Large Tertiary Academic Center. Orthopaedic Journal of Sports Medicine. 2024. DOI: 10.1177/2325967124s00296

[341] Higher BMI predicts additional surgery at the time of ACL reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy. 2018. DOI: 10.1007/s00167-018-5267-x

[342] Knee joint infection after ACL reconstruction: prevalence, management and functional outcomes. Knee Surgery, Sports Traumatology, Arthroscopy. 2012. DOI: 10.1007/s00167-012-2264-3

[344] Paper #236: Postoperative Septic Arthritis After ACL Reconstruction – Does it Affect the Outcome?. Arthroscopy. 2013. DOI: 10.1016/j.arthro.2013.07.242

[345] Factors Associated with Infection Following Anterior Cruciate Ligament Reconstruction. Journal of Bone and Joint Surgery. 2015. DOI: 10.2106/jbjs.n.00694

[346] Age, time from injury to surgery and quadriceps strength affect the risk of revision surgery after primary ACL reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy. 2021. DOI: 10.1007/s00167-021-06517-8

[347] Not Using a Tourniquet May Reduce the Incidence of Asymptomatic Deep Venous Thrombosis After ACL Reconstruction: An Observational Study. Orthopaedic Journal of Sports Medicine. 2021. DOI: 10.1177/23259671211056677

[348] Primary ACL reconstruction using the LARS device is associated with a high failure rate at minimum of 6‐year follow‐up. Knee Surgery, Sports Traumatology, Arthroscopy. 2019. DOI: 10.1007/s00167-019-05478-3

[349] Revision ACL Reconstruction - A retrospective failure analysis with a mean follow up of 35 months. Orthopaedic Journal of Sports Medicine. 2020. DOI: 10.1177/2325967120s00305

[350] Rates of Septic Arthritis After ACL Reconstruction: A Single-Center Analysis Highlighting Quadriceps Tendon Grafts. The American Journal of Sports Medicine. 2023. DOI: 10.1177/03635465231165509

[351] Metal interference screw fixation combinations show high revision rates in primary hamstring tendon ACL reconstruction. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-023-07109-y

[353] Vancomycin-soaking of the graft reduces the incidence of septic arthritis following ACL reconstruction: results of a systematic review and meta-analysis. Knee Surgery, Sports Traumatology, Arthroscopy. 2019. DOI: 10.1007/s00167-019-05353-1

[354] Risk Factors for Septic Arthritis After Anterior Cruciate Ligament Reconstruction: A Nationwide Analysis of 26,014 ACL Reconstructions. The American Journal of Sports Medicine. 2021. DOI: 10.1177/0363546521993812

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