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ACL reconstruction

221 citationsUpdated Oct 2026

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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 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 ACL repair remains a valuable asset in the surgeon's armamentarium [11], it is currently indicated for a limited subset of patients [54]. Repair offers potential advantages over reconstruction, including decreased surgical morbidity, faster return of range of motion, and minimally invasive surgery [7]. It has demonstrated significant clinical improvement in appropriately selected cohorts [25] and may serve as a viable alternative for older or less active patients who prefer or are unable to undergo reconstruction [52]. However, current evidence does not justify expansion of indications for repair [47], and young, active athletes should continue to receive traditional autograft reconstruction because repair failure rates of 20% to 30% remain unacceptable for this group [52].

Graft selection is critical, as the right choice determines surgical success [162]. Quadriceps tendon autograft with or without bone block yields comparable clinical outcomes, complications, and revision rates [142]. Both hamstring tendon and bone-patellar tendon-bone autografts remain viable options for ACLR plus lateral extra-articular procedure (LEP) [188], though the benefit of LEP requires further validation [188]. 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 allograft reconstruction [34]. For patients with isolated rupture, hamstring tendon autograft is associated with good long-term outcomes and does not appear to cause osteoarthritis regardless of age [48]. Early ACL reconstruction is associated with superior overall knee function and acceptable knee function compared with crossover from nonreconstructive treatment [165].

Combined ACL and ALLR procedures result in significantly better long-term graft survivorship and lower overall reoperation rates compared with isolated ACLR, without an increase in complications [19]. Primary ACL repair has promising results in clearly defined subsets [7] and may have a future alongside reconstruction and nonsurgical therapy [6]. In young children, repair using temporary internal bracing negates the requirement and potential morbidity of graft harvest, demonstrating potential for excellent outcomes where an adequate remnant permits direct repair [43]. Individualized approaches to graft size selection are necessary to prevent complications such as intraoperative Hoffa fracture [44]. Recommendations for new criteria are provided for the sports medicine community to consider before allowing athletes to return to sports [1]. Larger-scale studies with long-term follow-ups are needed to better understand the outcomes of modern ACLR techniques [186], and comparative studies are lacking for dynamic intraligamentary stabilization, which should be compared to reconstruction with failure as an endpoint in upcoming studies [57].

Anatomy & Pathophysiology

Injury Mechanism and Epidemiology

ACL injury accounts for between 40% and 50% of all knee ligament injuries [228]. Female athletes face a two to eight times higher risk of ACL tear than male athletes [228]. The typical mechanism involves a valgus load with internal tibial rotation and anterior tibial translation while the knee is in almost full extension [228]. Skiing, soccer, basketball, and football represent the highest-risk sports for ACL injury [228].

Ligament Anatomy and Function

The anteromedial bundle of the ACL provides anterior restraint and is evaluated by Lachman and anterior drawer tests [228]. Conversely, the posterolateral bundle provides rotatory restraint and is assessed via the pivot shift test [228]. The in situ force of the ACL is highest at 30 degrees of flexion in response to anterior tibial load [228].

Associated Injuries

Acute lateral meniscal tears are more common than acute medial tears, whereas medial tears occur more often with chronic ACL deficiency [228]. MCL injuries occur in approximately 25% of cases associated with ACL injury [228], while PLC injuries occur in approximately 10% of cases [228]. Lack of recognition of a PLC injury has been cited as a common cause of ACL reconstruction failure [228]. Chronic ACL deficiency is associated with higher incidences of both complex meniscal tears not amenable to repair and chondral injury [228].

Biological Healing and Graft Integration

Primary repair of ACL tears is not currently recommended because myofibroblasts "coat" the ends of the ACL stumps, making primary healing unlikely [2]. 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 [46]. The gradual healing at the enthesis and the intra-articular ligamentization process together constitute the two main sites of biological incorporation after ACL reconstruction [46]. BPTB demonstrates faster incorporation into the bone tunnels than hamstring autograft [2], whereas allografts have been demonstrated to incorporate into bone tunnels more slowly than autografts [2]. A consistent increased release of monocyte-driven, non-specific, IL-1 and IL-6 was found in the very early host production of key cytokines after ACL reconstruction [276]. Additionally, very early high concentrations of secondary growth factors PDGF and TGF-b suggestive of an anabolic response were found after ACL reconstruction [276].

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 [53]. Altered tibial position in the ACL reconstructed knee correlates to degenerative cartilage changes in the contacting regions of the medial compartment of the knee as early as 1 year following ACL reconstruction [69]. 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 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]. Both anatomic single- and double-bundle ACL reconstruction adequately restore tibial rotational excursion in a human, in vivo kinematic model [181]. While neither procedure fully restored normal knee kinematics, both anatomic reconstructions were similarly effective for restoring near-normal dynamic knee function [76]. 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].

Neuromuscular Adaptations

Following ACL injury, more functional ACL deficient patients are thought to use sensory feedback to build a new internal model to compensate for mechanical instability rather than relying upon reflexive muscular activation [270]. A knee with an ACL graft that is capable of providing mechanical support, and yet is 'inert' from a neurosensory perspective, may require compensatory neuromuscular adaptations to maintain functionality [270]. Knee self-efficacy was consistently associated with asymmetries in quadriceps neuromuscular function and jump-landing biomechanics following ACLR [115]. Knee biomechanics in the leg with ACLR were altered mainly in the sagittal plane during side-cutting compared with the contralateral leg [81].

Classification

Gächter: The Gächter classification system stages septic knee arthritis following ACL reconstruction [17]. Stage 1 presents with synovial inflammation, no cartilage damage, and no visible radiographic changes [17]. Stage 2 involves thickened synovium with no cartilage damage and no visible radiographic changes [17]. Stage 3 features markedly thickened synovium transformed into a sponge-like structure with beginning cartilage damage but no visible radiologic changes to bony structures [17]. Stage 4 involves destruction of the synovial structure with radiologic signs of subchondral bone involvement [17].

Howell: The Howell classification determines graft maturity based on signal intensity within the knee joint [226]. Grade 1 is defined as a homogeneous, low-intensity signal indistinguishable from the posterior cruciate ligament and patellar tendon [226]. Grade 2 is defined as normal ligament signal over at least 50% of its volume intermingled with portions of increased signal intensity [226]. Grade 3 is defined as increased signal intensity over at least 50% of its volume intermingled with portions of normal ligament signal [226]. Grade 4 is defined as a diffuse increase in signal intensity without strands with a normal ligament appearance [226].

Ge et al.: The protocol by Ge et al. measures graft healing at the bone-graft interface in the tibial tunnel [226]. Grade 1 is defined as low intensity with no fibrosis at the bone-graft interface and full attachment [226]. Grade 2 is defined as high intensity over a portion of the interface [226]. Grade 3 is defined as high intensity over the entire bone-graft interface with poor attachment [226].

Kellgren & Lawrence: The Kellgren & Lawrence radiographic osteoarthritis classification assesses the presence of osteoarthritis in patients after ACL reconstruction [231]. In this classification, Grade I is considered as the presence of osteoarthritis [231].

Modified Sherman: The modified Sherman classification by van der List et al. classifies ACL tear location on preoperative MRI [235]. Type I is a proximal avulsion tear with a distal remnant length greater than 90% [235]. Type II is a proximal tear with a distal remnant length of 75–90% [235]. Type III is a mid-substance tear located in the middle 25–75% of the ligament [235].

Sherman et al.: The Sherman et al. classification grades ACL tissue quality [235]. Good tissue quality is defined as (nearly) all fibres running in the same direction with a homogenous signal [235]. Fair tissue quality is defined as part of the fibres running in the same direction with a mildly heterogeneous signal [235]. Poor tissue quality is defined as most fibres running in different directions [235].

Henle et al.: The Henle et al. classification reports the ACL state and location of rupture intraoperatively [249].

ICRS: The International Cartilage Repair Society (ICRS) Classification System grades cartilage injuries [256].

ACLISS: The ACLISS (Anterior Cruciate Ligament Injury Severity Scale) predicts short-term reoperation and functional outcomes after ACL reconstruction [12]. Patients with grades 2 and 3 experienced earlier reoperations compared to grade 1 [12].

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) [17].

Clinical Presentation

History and Initial Symptoms

Young athletes with ACL tears frequently report the sudden onset of knee pain, which may be accompanied by a popping sensation following a noncontact, twisting-type injury [21]. Difficulty bearing weight and hemarthrosis are commonly present in these patients [21].

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 [21]. Clinical tests for ACL deficiency include the Lachman, anterior drawer, and pivot shift tests [21]. Because these tests may be difficult to perform 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 [21].

Associated injuries are evaluated through specific maneuvers. The presence of associated meniscal injuries may be established by evaluating for tenderness of the joint line [21]. Decreased passive knee motion may indicate a meniscal injury with displacement [21]. Injuries of the collateral ligaments may be evaluated by varus and valgus stress testing of the knee performed at 0° and 30° of flexion [21]. 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 [21].

In skeletally immature patients, limb alignment and lengths are assessed clinically if ACL injury is suspected [21]. The patient’s degree of physiologic maturity may be gauged by use of Tanner staging of sexual maturation [21].

Imaging and Diagnostic Confirmation

Orthogonal radiographs of the affected knee should be obtained, with additional radiographs obtained as suggested by the physical examination findings [21]. MRI of the knee is helpful for confirming an ACL tear with 95% sensitivity and 88% specificity [21]. MRI is also helpful for elucidating additional injuries and assessing physeal patency [21]. 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].

Before surgical treatment, a bone age study (a PA radiograph of the left hand, which is then compared with the Greulich and Pyle atlas of normal standards) is generally performed for skeletally immature patients to estimate the amount of remaining skeletal growth [21]. 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 [21]. Knee radiographs support the validity of determining skeletal age in pediatric patients undergoing ACL reconstruction [27].

Decision-Making Factors

The subjective instability of the patient is appraised as the most important criteria for the determination of performing surgery, followed by the Lachman test [30]. The Pivot shift test, the anterior drawer test, and the MRI follow as equally evaluated diagnostic tools for determining surgical indications [30]. 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 [85]. Consequently, functional tests should be accentuated more in the decision for ACL reconstruction [85]. Treatment-dependent differences in prognostic factors for 5-year outcomes may support individualised treatment after acute ACL rupture in young active individuals [96].

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 [21]. The patient’s degree of physiologic maturity may be gauged by use of Tanner staging of sexual maturation [21].

Imaging

Plain radiography: 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 [21]. Knee radiographs are valid for determining skeletal age in pediatric patients undergoing ACL reconstruction [27]. 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 [253]. Patients who underwent bilateral ACLR had a significantly greater posterior tibial slope on radiography compared with those who underwent unilateral ACLR [217, 220]. 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 [265].

MRI: MRI of the knee has 95% sensitivity and 88% specificity for confirming an ACL tear [21]. MRI can be used as a valuable tool in anatomic ACL reconstruction [157]. Both MRI and SPECT/CT play an important role in postoperative diagnostics of patients with problems after ACL reconstruction [22]. 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]. 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 [264]. High resolution 3T MRI scan 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 [241]. 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 [195]. Development of new cartilage lesions was evident after 2-year follow-up in patients with arthroscopic ACLR as detected by MR imaging [266]. Patients who underwent bilateral ACLR had a significantly greater lateral posterior tibial slope on MRI compared with those who underwent unilateral ACLR [217, 220]. 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 [271]. This study is the first step in potentially informing normal ACL size in pediatric patients based on an intact PCL on MRI [248]. This is the first study that quantifies the two anatomic bundles of the ACL based on MRI [254].

CT: 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 [262].

Other Considerations: ACL reconstruction with the aid of mixed reality technology allowed for more accurate positioning and orientation of the femoral tunnel during surgery when compared with conventional reconstruction [224]. The authors believe that this study will contribute to an accurate tunnel placement during ACL reconstruction surgery and provide reference data for postoperative radiographic evaluation [263]. Reproducible and clinically meaningful quantification of pivot shift elements may allow for more accurate evaluation of different ACL reconstruction constructs [56].

Outcome Measures

The Knee Injury and Osteoarthritis Outcome Score (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 has been validated for ACL and cartilage injury, as well as other knee injuries [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]. Each KOOS subscale ranges from 0 (worst) to 100 (best) and it is recommended to use each subscale independently in outcome evaluations [4]. A difference or change of 10 points or more in either of the KOOS subscales was considered as clinically relevant [4].

Failure of ACL reconstruction can be objectively defined as a deficit of 10° of knee extension or 10° of knee flexion compared with the contralateral, uninjured side [16]. Objective failure of ACL reconstruction includes demonstration of knee instability as assessed by the Lachman test, pivot-shift test, or arthrometer (>3 mm side-to-side difference) [16]. Objective failure of ACL reconstruction includes absence of an intact graft on magnetic resonance imaging (MRI) or during arthroscopy [16]. Subjective outcome measures are important in defining failure of ACL reconstruction, including pain, subtle instability, or a report that the knee is "not feeling quite right" [16].

Treatment

Non-Operative

Initial management of ACL injury consists of physical therapy to restore motion, with immobilization avoided [2]. Treatment should be individualized based on age, activity level, instability, associated injuries, and other medical factors [2]. Full range of motion and good quadriceps control should be achieved prior to surgery [2].

Operative

Indications: ACL reconstruction is the standard of care and preferred treatment for young and highly active patients [11]. In youth athletes, reconstruction results in an improved rate of return to athletic activity compared with non-operative treatment [175]. For patients older than 50 years with ACL insufficiency, especially those with high functional demand, reconstruction is recommended [170]. 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 [52].

Surgical Approach / Technique: Single-bundle reconstruction is the most commonly performed technique, with no current difference in patient-reported outcomes between single-bundle and double-bundle techniques [2]. The evolution of ACL surgery has been iterative, shifting between anatomical restoration and decreased morbidity, with recent developments aiming to achieve both [23]. An evidence-based approach integrates best available research with clinical expertise and patient values, emphasizing appropriately powered expertise-based trials and best-practice rehabilitation protocols [5]. 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 central anteromedial portal allows a straightforward view of the femoral ACL bundles insertion sites that are unlikely visualized with the standard anterolateral portal [306]. In particular, non-experienced ACL surgeons will benefit from the posterior horn of the lateral meniscus as an apparent landmark and the corresponding easy-to-use ACL reconstruction method [114]. 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 [204]. 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 [223]. 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]. Several methods that are simple and reproducible have been published lately to address potential events when performing an ACL reconstruction [79].

Graft Selection: Graft selection depends on patient factors and surgeon preference, with choices including bone–patellar tendon–bone (BPTB) autograft, four-strand hamstring autograft, quadriceps tendon autograft, and allograft [2]. Graft choice should be tailored to the individual patient and their sport or activity level rather than being a debate about the 'best' graft type [183]. BPTB demonstrates faster incorporation into the bone tunnels than hamstring autograft and is often the graft of choice in patients who desire an early return to sports activity [2]. However, 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]. 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]. 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 [70]. 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 [240]. Primary ACL reconstruction using quadriceps tendon grafts appears to have successful short-term outcomes with a short-term graft failure rate of 3% independent of fixation method [73].

Fixation: Longer and wider interference screws provide better fixation in tibial ACL graft fixation [208]. 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 [215]. The tendon-bone healing after ACL reconstruction was affected by the method of graft fixation [239]. Adult non-cultivated bone marrow stem cells do not seem to accelerate graft-to-bone healing in ACL reconstruction [201]. The choice of fixation after ACL reconstruction with a hamstring tendon has a significant effect on a patient's risk of revision [259]. The outcome studies of implant-free ACL reconstruction report clinical results similar to ACL reconstruction with conventional implants [242]. 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]. The press-fit femoral fixation technique can be a good alternative in ACL surgery due to its implant-free nature [80]. 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 [59].

Primary ACL Repair: 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]. 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 [18]. Modern ACL repair is less invasive than reconstruction, avoids autograft harvest comorbidities, and leads to improved early rehabilitation and forgotten knee scores [35]. ACL repair in young children using a technique with temporary internal bracing 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 [43]. Current evidence may support the feasibility of anterior cruciate ligament repair under favorable conditions, but does not justify expansion of its indications [47]. Based on survey results, ACL repair remains a procedure with limited indications [54]. The short-term results of bridge-enhanced anterior cruciate ligament repair are promising, showing noninferiority to traditional ACL reconstruction at 2 years postoperatively and a higher rate of return to sport at 6 months [58]. This implant has demonstrated noninferiority to ACL reconstruction with autograft at 2-year follow-up [236]. Combined ACL repair and ALL internal brace augmentation resulted in significant improvements in patient-reported outcome measures at 2 years [260]. 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 [222]. Both bioenhanced anterior cruciate ligament repair and anterior cruciate ligament reconstruction produced significantly improved results over ACL transection in a porcine model, showing that both were effective treatments [118]. 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 [200]. The primary aim of a technical note is to describe step-by-step the ACL repair technique with and without suture augmentation [109]. The authors emphasize the need for more individualized approaches to graft size selection in ACL repairs to prevent complications such as intraoperative Hoffa fracture [44].

Pediatric and Special Populations: The meta-analysis found overall similar results with physeal-sparing, partial transphyseal, and complete transphyseal ACL reconstruction approaches in the pediatric population [15]. 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 in children [182]. 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 [210]. 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 [212]. 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]. 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 [48]. 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]. Knee hyperextension is not associated with revision ACL reconstruction or anterior knee laxity in children and adolescents [71].

Pain Management: Significant variability exists in pain management practices in pediatric ACL reconstruction [156]. Total doses of postoperative opioids prescribed for pain management in pediatric ACL reconstruction have declined in recent years, which appears related to preoperative counseling through mandated opioid consenting and paralleled by greater utilization of non-opioid medications [246]. Pediatric and adolescent patients treated with a femoral nerve block for postoperative pain control after ACL reconstruction had significant isokinetic deficits in knee extension and flexion strength at six months when compared to patients who did not receive a nerve block [218]. Contrary to previous research, findings indicate only minimal difference in quadriceps strength among adolescents approximately 6 months after ACL reconstruction using femoral nerve block, adductor canal block, or no nerve block [199]. Intra-articular injection is proposed as a viable alternative for analgesia in adolescent patients undergoing bone–patellar tendon–bone ACL reconstruction [203]. Intra-articular injection is proposed as a viable alternative for analgesia in pediatric patients undergoing bone–patellar tendon–bone ACL reconstruction [216]. In the setting of a multi-modal pain management plan including regional anesthesia, adolescent patients undergoing ACL reconstruction with quadriceps tendon autograft and hamstring autograft have similar pain levels and opioid use in the acute postoperative period [132]. 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]. The CARE trial represents a significant step forward in postoperative pain management, showing that opioid-limiting education and counseling can reduce opioid consumption after ACL reconstruction [134]. The prescription of 15 opioid tablets does not negatively impact pain control or patient satisfaction after ACL reconstruction [250]. Pain intensity is similar after out-patient and in-patient ACL repair [202]. The same local anaesthetic provides similar pain relief when injected intra-articularly or into the hamstring donor site after hamstring tendon ACL reconstruction [49]. Total overall opiate intake was not different between the patients undergoing bridge-enhanced ACL repair through an arthrotomy and those undergoing arthroscopic ACL reconstruction [227]. There was variability in the use and cost of different anesthetics for operative pain relief in arthroscopic ACL reconstruction [173].

Postoperative Rehabilitation: Rehabilitation has evolved, and early motion (emphasis on extension) and weight bearing are encouraged in most protocols [2]. Exercises that do not endanger the ACL graft are dominated by the hamstrings (isometric hamstrings) and involve active knee ROM between 35 and 90 degrees of flexion [2]. Closed kinetic chain rehabilitation and compressive loading have been emphasized because they allow physiologic cocontraction of the muscles around the knee [2]. Open kinetic chain extension exercises, particularly with the knee near full extension, place increased stress on the reconstructed ACL and should be avoided for the first 6 weeks [2]. No difference in outcome has been found between accelerated and nonaccelerated rehabilitation programs [2]. Postoperative bracing has not proved beneficial after ACL reconstruction except in downhill skiers [2]. Early progressive eccentric exercise has yielded good initial results in terms of muscle size and function after ACL reconstruction [2]. To achieve as good results as possible of ACL reconstructions, it is important to focus equally on postoperative pain relief and rehabilitation alongside surgical techniques [99].

Complications and Revision: 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]. Arthrofibrosis is the most common complication following ACL reconstruction and often occurs with reconstruction for acute ACL tears [2]. The risk of arthrofibrosis is minimized by the achievement of full ROM prior to surgery [2]. Aberrant hardware placement (interference screw divergence of >30 degrees for femoral tunnels or >15 degrees for tibial tunnels) can also result in complications [2]. Infection occurs in less than 1% of cases [2]. Irrigation and débridement with graft retention are successful in up to 85% of cases of infection after ACL reconstruction [2]. All causes of graft failure must be considered for revision ACL reconstruction, including technical issues, unrecognized concomitant ligament injuries, coronal or sagittal malalignment, biological failure of graft incorporation, and other patient-related issues [2]. Failure of ACL reconstruction can be defined objectively as a deficit of 10 degrees of knee extension or 10 degrees of knee flexion compared with the contralateral side, demonstration of knee instability as assessed by the Lachman test, pivot-shift test, or arthrometer (>3 mm side-to-side difference), and/or absence of an intact graft on MRI or during arthroscopy [16]. Subjective outcome measures are important in defining failure of ACL reconstruction, as a patient presenting with pain, subtle instability, or a report that the knee is "not feeling quite right" may have a failed procedure even in the absence of objective instability [16]. Intact cartilage and severely abnormal preoperative knee laxity represent indications for lateral extra-articular tenodesis in revision ACL reconstruction [55]. 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]. The over-the-top approach provides a versatile method for the surgical treatment of recurrent ACL tears [116]. Quadriceps tendon autograft is becoming increasingly popular in revision ACL reconstruction [55]. 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 [206]. The mechanism of graft failure is multifactorial in nature and may be attributed to either traumatic or nontraumatic causes [46]. Recurrent trauma, resulting from early aggressive rehabilitation, a premature return to play, or reinjury of a well-healed graft can lead to graft failure [46]. Nontraumatic causes of graft failure may include technical error in tunnel placement, occult limb malalignment or ligamentous laxity, failure of fixation, or poor biological incorporation [46].

Complications

Graft Failure and Revision

The most common technical error leading to graft failure in ACL reconstruction is tunnel malposition [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]. Among all patients receiving primary ACL reconstruction, graft failure remains an uncommon but functionally devastating outcome with an estimated graft survival rate of 91% at 25 years following surgery [66]. Revision ACL reconstruction has a higher incidence of 30-day hospital readmission, reoperation, and surgical complications relative to primary procedures [14]. Patients undergoing ACL revision reported a 1-year outcome that was slightly inferior to the 1-year outcome after their primary ACL reconstruction [63]. Revision and contralateral ACL reconstruction were associated with lower rates of return to preinjury physical activity levels and less favorable patient-reported outcomes between 12 and 24 months after reconstruction compared with primary ACL reconstruction [65]. A reoperation rate of 22% was noted 10 years after index ACL revision reconstruction [335]. In a young cohort, there was a 6% rate of recurrent ACL failure and a 5% rate of subsequent total knee arthroplasty 6 years following a revision ACL reconstruction [326]. Multiple revision ACL reconstruction surgery is associated with a relatively high failure rate [338]. Results following revision anterior cruciate ligament reconstruction are less favorable than primary ACL reconstruction [352]. Overall re-tear rates were higher in patients who underwent revision ACL reconstruction with allograft [344]. The revision rate of primary ACL repair with suture augmentation at a 2-year follow-up was 10% [314]. Arthroscopic primary ACL repair for acute proximal tears showed a 10% failure rate at a minimum 2-year follow-up [315]. The rates of LARS ACL construct failure were 33.3% in a cohort with a minimum of 6-year follow-up [351]. 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]. Young age, female gender, Caucasian race, and workers’ compensation claim are risk factors for reoperation following arthroscopic ACL reconstruction [331]. A 10.7% ipsilateral reoperation rate at an average of 25.9 months after ACL reconstruction and an overall ACL reconstruction revision rate of 3.1% were demonstrated [331]. 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 [67]. Adolescents have twice the revision rate of young adults after ACL reconstruction with hamstring tendon autograft [102]. A greater revision rate was observed among younger patients, female patients, and those receiving allografts during primary surgery [316]. In a young high-risk primary ACL reconstruction population, increased posterior tibial slope was present in nearly 30% of patients and is independently associated with revision ACL reconstruction [321]. Metal interference screw fixation combinations show high revision rates in primary hamstring tendon ACL reconstruction within 2 years [354]. The study identified specific risk factors for unplanned subsequent knee surgery following primary ACL reconstruction, including revision, contralateral ACL reconstruction, meniscus injury surgery, and procedures for loss of motion [108]. Higher BMI predicts additional surgery at the time of ACL reconstruction [343]. Age, time from injury to surgery, and quadriceps strength affect the risk of revision surgery after primary ACL reconstruction [349].

Arthrofibrosis and Stiffness

The risk of arthrofibrosis is minimized by the achievement of full range of motion prior to surgery [2]. Arthrofibrosis remains a rare but potentially devastating complication after ACL reconstruction, with roughly 2% of patients requiring intervention [29]. In a cohort of 902 young patients treated with ACL reconstruction, an overall incidence of arthrofibrosis of 8.3% was reported [20]. Female sex, older age, the use of bone–patellar tendon–bone autograft, and concomitant meniscal repair are additional risk factors for arthrofibrosis in young patients [20]. In a 30-year experience with ACL reconstruction using patellar tendon, 5 reoperations between 30 and 90 days after reconstruction entailed lysis of adhesions for arthrofibrosis [273].

Infection

Infection occurs in less than 1% of cases following ACL reconstruction [2]. Irrigation and débridement with graft retention are successful in up to 85% of cases for infection after ACL reconstruction [2]. The overall surgical site infection rate after ACL reconstruction was 0.48%, with deep surgical site infections identified in 0.32% of cases [322]. The incidence of septic arthritis following ACL reconstruction was 0.92% in a single-center analysis [324]. The prevalence of septic arthritis after an ACL reconstruction was 1.8% in a specific series [345]. The incidence of septic arthritis after ACL reconstruction in a nationwide cohort of 26,014 patients was 1.1% [357]. Rates of infection after ACL reconstruction in pediatric patients are relatively low at 0.52% and similar to rates in young adults [298]. Patients with diabetes undergoing ACL reconstruction have a significantly elevated risk of postoperative infection, with 18.8-times higher odds compared with patients without diabetes [348]. Other risk factors for infection after ACL reconstruction included increased BMI and increased operative time [340]. The incidence of septic arthritis following ACL reconstruction can be reduced dramatically by vancomycin-soaking the grafts intra-operatively [356]. Graft preparation with intraoperative vancomycin decreases infection after ACL reconstruction [340]. Patients who undergo irrigation and debridement for an infection following ACL reconstruction have a high rate of additional surgery but still attain reasonable clinical outcomes 6 years after ACL reconstruction [303]. Septic arthritis after ACL reconstruction results in the same objective knee function as uncomplicated cases [347]. Postoperative infections are classified as either acute (≤2 weeks), subacute (between 2 weeks and 2 months), or late (>2 months) [17]. Most patients have acute or subacute intra-articular knee infections after ACL reconstruction [17]. The ACL graft can serve as a nidus for infection because it is essentially nonviable tissue that can harbor bacteria for a long time until it is replaced by host tissue [17]. Autografts and allografts respond as foreign bodies and their blood supply is initially absent [17]. Inoculation for infection may occur at the time of surgery or shortly thereafter, often from natural skin flora and associated with concomitant extraarticular sites for infection such as the graft site, femoral site, or tibial site [17]. While graft choice may affect rates of septic arthritis after ACL reconstruction, patient characteristics, ACL reconstruction technique, revision ACL reconstruction, and accompanying intra-articular procedures during ACL reconstruction were not associated with postoperative septic arthritis in a single-center analysis [353].

Pediatric-Specific Complications

The most common complications occurring after ACL reconstruction in skeletally immature patients include arthrofibrosis, growth disturbance, and secondary injury of the same or the contralateral ACL [20]. Growth arrest sometimes occurs after ACL reconstruction in skeletally immature patients despite efforts to avoid this complication [20]. Clinically important growth disturbances, including tibial recurvatum and genu valgum, developed after transphyseal ACL reconstruction using physeal-respecting techniques in four patients with an average age of 14.2 years [20]. Focal physeal bone bridges were noted in five knees of 43 patients who had undergone transphyseal ACL reconstruction using soft-tissue graft, although no patient had resultant limb deformity [20]. Growth disturbance has been reported with physeal-sparing techniques, with one patient in a recent series of all-epiphyseal ACL reconstructions developing clinically significant growth arrest [20]. In a systematic review of all-epiphyseal ACL reconstruction, the overall complication rate was 9.8% [299]. Of the complications reported in all-epiphyseal ACL reconstruction, 49.5% were ACL re-ruptures, 15.1% were limb overgrowths, 5.7% were limb length discrepancies, 3.8% were arthrofibrosis, 1.9% was knee stiffness, and 1.9% was soft-tissue infection [299]. Only 1.5% of patients treated with all-epiphyseal ACL reconstruction demonstrated growth disturbances, such as limb-length discrepancy [299].

Secondary and Contralateral Injury

Secondary ACL injury in either the ipsilateral or contralateral knee has been reported to occur with alarming frequency in young athletes [20]. The overall incidence of a second ACL injury in young patients who had returned to sports was more than five times greater than that of healthy control athletes [20]. Nearly 30% of athletes sustained a second ACL injury within 24 months of return to sports, with approximately one-third of the injuries occurring in the ipsilateral knee and two-thirds in the contralateral knee [20]. Patients younger than 20 years at the time of ACL reconstruction had a 29% chance of sustaining a second ACL injury (either knee) within 5 years of the index surgery [20]. A return to cutting and pivoting sports increased the odds of sustaining a second ACL injury [20]. In a cohort of 85 patients younger than 18 years who underwent primary ACL reconstruction, 32% of the overall cohort sustained a second ACL injury [20]. Later return to sport was protective against new ACL injury in patients younger than 18 years [20]. Athletes younger than 25 years who return to sports had a secondary rate of ACL injury (ipsilateral or contralateral knee) of 23% [20]. 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 [319]. The tear rates of the ipsilateral ACL graft and the contralateral native ACL are similar following ACL reconstruction [112]. In a 7-year study period, the mean time to ipsilateral graft tear was 2.64 years with a tear rate of 5.86%, while the mean time to contralateral ACL tear was 2.78 years with a tear rate of 6.66% [112]. There was no significant difference between ipsilateral graft tear and contralateral ACL tear rates or mean time to tears [112]. Younger age is a risk factor for both ipsilateral graft tear and contralateral ACL tear following ACL reconstruction [112]. Subsequent ACL injury rates to either knee after revision ACL reconstruction with patellar tendon autograft are low and appear lower than after primary surgery [337]. Having a revision ACL reconstruction is associated with worse outcomes than tearing the contralateral ACL and undergoing reconstruction [307].

Graft-Specific Complications

Bone–patellar tendon–bone (BPTB) autograft harvest carries the risk of anterior knee pain, pain with kneeling, loss of extension, and poorer recovery of quadriceps strength [2]. In a 30-year experience with ACL reconstruction using patellar tendon, one patient underwent reoperation within 30 days for repair of a traumatic infrapatellar tendon rupture [273]. In a 30-year experience with ACL reconstruction using patellar tendon, one patient underwent reoperation within 90 days for wound exploration for saphenous neuritis [273]. In a 30-year experience with ACL reconstruction using patellar tendon, one patient underwent reoperation within 90 days for removal of a broken intra-articular nitinol guide pin [273]. Primary ACL reconstruction using quadriceps tendon grafts has a short-term graft failure rate of 3% independent of fixation method [73]. In patients younger than 25 years, hamstring tendon ACL reconstruction combined with anterolateral ligament reconstruction was associated with a significantly lower risk of graft failure compared with isolated BPTB ACL reconstruction [284]. Patients who underwent combined ACL and anterolateral ligament reconstruction experienced significantly better long-term ACL graft survivorship, lower overall rates of reoperation, and no increase in complications compared with patients who underwent isolated ACL reconstruction [19]. Those treated with isolated ACL reconstruction remain at extremely high risk of a second ACL injury [329].

Other Considerations

Within 6 months after a first ACL reconstruction surgery, the risk of complication, including infection or device removal, was 5% in the entire cohort [275]. ACL reconstructions performed without tourniquet resulted in a significantly lower incidence of deep venous thrombosis after ACL reconstruction and significantly less bleeding from drains [350]. When compared to historical ACL reconstruction data, combined intra- and extra-articular reconstruction does not increase the complication rate [325]. Additional ACL reconstruction was not associated with a higher increase of osteoarthritis or a higher rate of post-operative complications in a study collective with ACL deficiency and varus osteoarthritis [346]. In a systematic review of randomized controlled trials on graft tensioning, infection occurred in 1 patient in 1 study, and there were 4 cases of reoperation all occurring in 1 study, with causes including arthrofibrosis and infection [238]. In a study of multiligament knee injury treated with anatomical medial and posteromedial ligamentoplasty, complications included two cases of stiffness requiring arthrolysis at 3 months, one revision for a neuroma of the medial saphenous nerve, and one early infection [281].

Recovery

Return to Sport Criteria and Assessment

Success of ACL reconstruction is a complex issue requiring comprehensive subjective and objective evaluation beyond simply returning to activity [26]. 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 activities of daily living [39]. Test results from an ACL-reconstructed patient should be at least classified as a functionally average outcome to support a safe return to sports [234]. 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 [283]. 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 [214].

Rehabilitation Protocols and Interventions

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]. Similarly, 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]. 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]. 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, twenty-six 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]. 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]. 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 [291]. Findings regarding hyperbaric oxygen therapy may help refine strategies to enhance early graft incorporation and support the development of rehabilitation protocols that optimize postoperative outcomes for patients undergoing ACL reconstruction [129].

Long-Term Outcomes and Functional Status

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 [225]. High recovery rates were seen after arthroscopic ACL reconstruction, regardless of leg dominance [323]. At 2 years after ACL reconstruction with tibialis anterior allografts, this subject group displayed satisfactory functional outcomes [33]. Children had good objective physical function 1 and 3 years after ACL reconstruction [36]. 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]. 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]. Conversely, patients with focal full-thickness cartilage lesions benefit less from ACL reconstruction at 2–5 years follow-up [4]. Patients undergoing ACL reconstruction with osteochondral allograft transplantation 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 [309]. Patients receiving a concomitant meniscus allograft transplantation exhibit lower return to sport rates, delayed time to release to activity, and lower subjective function compared to those undergoing an isolated ACL reconstruction [232]. Patients with increased posterolateral tibial plateau bone loss showed lower Tegner activity scores 12 months after ACL reconstruction [285]. 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 [330].

Graft Integrity and Complications

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 [308]. Secondary ACL injury, either through graft failure or contralateral injury, is a known complication and can significantly impact the ability of a patient to return successfully to previous activities [45]. Preserving the remnant tissue of the ACL may facilitate recovery of function and decrease graft rupture after primary reconstruction [296]. Lateral extra-articular tenodesis resulted in improved clinical scores and earlier overall return to sport compared to ACL reconstruction alone [297]. The study suggests that slope-reducing osteotomy 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 [334]. 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 [327]. 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 [328]. 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 [302].

Revision and Secondary Surgery Outcomes

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 [14]. 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 [313]. 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 [310].

Pediatric and Adolescent Considerations

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 [293]. ACL reconstruction using a living related donor allograft is associated with high rates of return to sport and good subjective outcomes in juveniles and adolescents [207]. This work adds to the growing mass of literature supporting the safety and efficacy of hamstring autograft ACL reconstruction in adolescent patients, which is associated with low rates of arthrofibrosis with or without lateral extra-articular tenodesis [211].

Alternative Procedures: Primary Repair

Based on cumulative findings across 2,401 patients from 28 included studies, ACL reconstruction results in better survivorship and patient-perceived postoperative improvement when compared with ACL repair [62]. The short-term results of modified bridge-enhanced anterior cruciate ligament repair are promising, showing noninferiority to traditional ACL reconstruction at 2 years postoperatively and a higher rate of return to sport at 6 months [58]. Early results suggest the knees are stable and recover motion after bridge-enhanced ACL repair [312]. 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 [209].

Graft Selection and Surgical Factors

Surgeons should consider utilizing similar rehabilitation timelines and functional performance goals for patients following ACL reconstruction with quadriceps tendon and patellar tendon graft options [158]. Compared to autografts, allografts offer several potential advantages to both the patient and the surgeon, including the absence of donor site morbidity, shortened operating time, greater availability, more predictable graft sizes, and comparable strength and stiffness to autograft tissue at the time of reconstruction [50]. Disadvantages of allografts that need to be considered include increased time to incorporation, variability in mechanical strength due to sterilisation techniques and use of irradiation, risk of disease transmission, immunogenic reaction, reports of higher failure rates in the young, and higher cost [50]. Experienced ACL surgeons can transition between medical equipment suppliers with acceptable outcomes, comparable surgical times and low complication rates [221].

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] 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. [14] (10.1007/s00167-021-06646-0)
• [L1] The meta-analysis found overall similar results with the three ACL reconstruction approaches. [15] (10.1007/s00167-022-07032-0)
• [L5] [16] (10.2106/jbjs.m.01038)
• [L4] [17] (10.1007/s00167-009-0793-1)
• [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. [18] (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. [19] (10.1177/03635465211028990)
• [L4] Both imaging modalities play an important role in postoperative diagnostics of patients with problems after ACL reconstruction. [22] (10.1177/2325967116s00047)
• [L4] The evolution of ACL surgery has been iterative, shifting between anatomical restoration and decreased morbidity, with recent developments aiming to achieve both. [23] (10.1055/s-0040-1712947)
• [L4] ACL repair has demonstrated significant clinical improvement in an appropriately selected patient cohort. [25] (10.1177/2325967126s00016)
• [L5] Success of ACL reconstruction is a complex issue requiring comprehensive subjective and objective evaluation beyond simply returning to activity. [26] (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. [27] (10.1177/23259671211036897)
• [L3] Arthrofibrosis remains a rare but potentially devastating complication after ACL reconstruction, with roughly 2% of patients requiring intervention. [29] (10.1007/s00167-015-3799-x)
• [L4] [30] (10.1007/s00402-016-2426-8)
• [L4] At 2 years after ACL reconstruction with tibialis anterior allografts, this subject group displayed satisfactory functional outcomes. [33] (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. [34] (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. [35] (10.1016/j.jisako.2023.08.008)
• [L2] The children had good objective physical function 1 and 3 years after ACL reconstruction. [36] (10.1002/ksa.12211)
• [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. [39] (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. [43] (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. [44] (10.1016/j.arthro.2014.05.018)
• [L3] [45] (10.1177/23259671241282316)
• [L5] [46] (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. [47] (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. [48] (10.1177/2325967117s00175)
• [L3] The same local anaesthetic provides similar pain relief when injected intra-articularly or into the hamstring donor site after hamstring tendon ACL reconstruction (STG or ST4). [49] (10.1016/j.otsr.2016.11.011)
• [L3] [50] (10.1007/s00167-019-05440-3)
• [L3] Revision ACLR practices vary widely, with no uniform consensus on graft choice and indications for ALC augmentation. [51] (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. [52] (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. [53] (10.1177/03635465010290061601)
• [L4] Based on the survey results, ACL repair remains a procedure with limited indications. [54] (10.1002/ksa.12788)
• [L3] Intact cartilage and severely abnormal preoperative knee laxity represent indications for LET in revision ACL reconstruction. [55] (10.1007/s00167-021-06478-y)
• [L4] Reproducible and clinically meaningful quantification of these elements may allow for more accurate evaluation of different ACL reconstruction constructs. [56] (10.1007/s00167-008-0504-3)
• [L2] However, comparative studies are lacking and upcoming studies should compare the technique to ACL reconstruction with failure as an endpoint. [57] (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. [58] (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. [59] (10.1016/j.otsr.2011.03.016)
• [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. [62] (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. [63] (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. [65] (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. [66] (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. [67] (10.1186/s13018-025-05935-5)
• [L3] [69] (10.1002/jor.22867)
• [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. [70] (10.1016/j.jisako.2025.100536)
• [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. [71] (10.1016/j.jisako.2025.100535)
• [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. [73] (10.1055/s-0039-1685160)
• [L1] While neither procedure fully restored normal knee kinematics, both anatomic reconstructions were similarly effective for restoring near-normal dynamic knee function. [76] (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. [79] (10.1302/2058-5241.3.170038)
• [L5] The technique can be a good alternative in ACL surgery due to its implant-free nature. [80] (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. [81] (10.1177/03635465221112940)
• [L2] [85] (10.1007/s00167-010-1113-5)
• [L1] Treatment-dependent differences in prognostic factors for 5-year outcomes may support individualised treatment after acute ACL rupture in young active individuals. [96] (10.1136/bjsports-2016-097124)
• [L5] To achieve as good results as possible of ACL reconstructions, it is important to focus equally on postoperative pain relief and rehabilitation alongside surgical techniques. [99] (10.1007/s00167-004-0526-4)
• [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] 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)
• [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)
• [L5] Both procedures produced significantly improved results over ACL transection, showing that both were effective treatments in this model. [118] (10.1016/j.arthro.2011.10.008)
• [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] 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)
• [L3] In the setting of a multi-modal pain management plan including regional anesthesia, adolescent patients undergoing ACL reconstruction with quadriceps tendon autograft and hamstring autograft have similar pain levels and opioid use in the acute postoperative period. [132] (10.1177/2325967120s00145)
• [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)
• [L2] The CARE trial represents a significant step forward in postoperative pain management, showing that opioid-limiting education and counseling can reduce opioid consumption after ACL reconstruction. [134] (10.2106/jbjs.25.00221)
• [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)
• [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)
• [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] 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)
• [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)
• [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)
• [L3] There was variability in the use and cost of different anesthetics for operative pain relief in arthroscopic ACL reconstruction. [173] (10.1177/2325967113505270)
• [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)
• [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. [195] (10.1177/2325967117s00431)
• [L3] Contrary to previous research, findings indicate only minimal difference in quadriceps strength among the 3 types of perioperative analgesia in adolescents approximately 6 months after ACL reconstruction. [199] (10.1177/23259671211017516)
• [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. [200] (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. [201] (10.1007/s00167-012-2279-9)
• [L3] Pain intensity is similar after out-patient and in-patient ACL repair. [202] (10.1016/j.otsr.2016.08.009)
• [L3] Given these findings, we propose that intra-articular injection is a viable alternative for analgesia in adolescent patients undergoing BTB ACL reconstruction. [203] (10.1177/2325967120985902)
• [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. [204] (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. [206] (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. [207] (10.1177/2325967117s00184)
• [L5] Longer and wider interference screws provide better fixation in tibial ACL graft fixation. [208] (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. [209] (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. [210] (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. [211] (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. [212] (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. [214] (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. [215] (10.1007/s00167-011-1875-4)
• [L3] Intra-articular injection is proposed as a viable alternative for analgesia in pediatric patients undergoing BTB ACL reconstruction. [216] (10.1177/2325967121s00023)
• [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. [217] (10.1177/03635465231177086)
• [L3] Pediatric and adolescent patients treated with a femoral nerve block for postoperative pain control after ACL reconstruction had significant isokinetic deficits in knee extension and flexion strength at six months when compared to patients who did not receive a nerve block. [218] (10.1177/2325967114s00085)
• [L3] Patients who underwent bilateral ACLR had significantly greater PTS on radiographs and LPTS on MRI compared to those with unilateral ACLR. [220] (10.1177/2325967124s00006)
• [L3] Experienced ACL surgeons can transition between suppliers with acceptable outcomes, comparable surgical times and low complication rates. [221] (10.1002/ksa.12775)
• [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. [222] (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. [223] (10.1007/s00167-017-4615-6)
• [L3] ACL reconstruction with the aid of MR technology allowed for more accurate positioning and orientation of the femoral tunnel during surgery when compared with conventional reconstruction. [224] (10.1177/23259671231184399)
• [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. [225] (10.1007/s00167-017-4623-6)
• [L3] [226] (10.1177/23259671221125493)
• [L3] Total overall opiate intake was not different between the patients undergoing bridge-enhanced ACL repair through an arthrotomy and those undergoing arthroscopic ACLR. [227] (10.1016/j.asmr.2020.02.004)
• [L4] [231] (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. [232] (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. [234] (10.1007/s00167-015-3529-4)
• [L4] [235] (10.1007/s00167-017-4646-z)
• [L5] This implant has demonstrated noninferiority to ACL reconstruction with autograft at 2-year follow-up. [236] (10.1016/j.eats.2022.07.014)
• [L2] [238] (10.1016/j.arthro.2008.07.010)
• [L5] The tendon-bone healing after ACL reconstruction was affected by the method of graft fixation. [239] (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. [240] (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. [241] (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. [242] (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. [246] (10.1177/2325967121s00066)
• [L3] This study is the first step in potentially informing normal ACL size in pediatric patients based on an intact PCL on MRI. [248] (10.1177/2325967121s00376)
• [L4] [249] (10.1002/ksa.12417)
• [L1] The prescription of 15 opioid tablets does not negatively impact pain control or patient satisfaction after ACL reconstruction. [250] (10.2106/jbjs.23.00657)
• [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. [253] (10.1002/ksa.12719)
• [L4] This is the first study that quantifies the two anatomic bundles of the ACL based on MRI. [254] (10.1016/j.arthro.2007.03.023)
• [L3] [256] (10.1177/23259671251399817)
• [L2] The choice of fixation after ACLR with an HT has a significant effect on a patient's risk of revision. [259] (10.1177/0363546515584757)
• [L4] Combined ACL repair and ALL internal brace augmentation resulted in significant improvements in patient-reported outcome measures at 2 years. [260] (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. [262] (10.2106/jbjs.25.00485)
• [L5] The authors believe that this study will contribute to an accurate tunnel placement during ACL reconstruction surgery and provide reference data for postoperative radiographic evaluation. [263] (10.1007/s00167-010-1128-y)
• [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. [264] (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. [265] (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. [266] (10.1007/s00167-016-4153-7)
• [L4] [270] (10.1002/jor.20472)
• [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. [271] (10.1177/23259671241241821)
• [L4] [273] (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. [275] (10.1016/j.arthro.2011.03.070)
• [L4] [276] (10.1007/s00167-011-1486-0)
• [L4] [281] (10.1186/s13018-025-06638-7)
• [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. [283] (10.1007/s00167-016-4252-5)
• [L1] This secondary analysis of a RCT with 5-year follow-up showed that, in patients younger than 25 years, HT-ACLR combined with ALLR was associated with a significantly lower risk of graft failure compared with isolated BPTB-ACLR, whereas patient-reported clinical outcomes were comparable between groups. [284] (10.1002/ksa.70617)
• [L3] Patients with increased posterolateral tibial plateau bone loss showed lower Tegner activity scores 12 months after ACL reconstruction. [285] (10.1007/s00167-022-07282-y)
• [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. [291] (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. [293] (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. [296] (10.1177/2325967113505076)
• [L3] LEAT resulted in improved clinical scores and earlier overall return to sport compared to ACL reconstruction alone. [297] (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. [298] (10.1177/2325967121s00393)
• [L4] [299] (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. [302] (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. [303] (10.1136/jisakos-2018-000264)
• [L4] [306] (10.1007/s00167-011-1426-z)
• [L3] These 2 groups of patients should not be pooled to study outcomes of ACLR. [307] (10.1177/03635465261416923)
• [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. [308] (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. [309] (10.1177/23259671261463928)
• [L4] 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. [310] (10.1016/j.jisako.2023.03.109)
• [L2] Early results suggest the knees are stable and recover motion after bridge-enhanced ACL repair. [312] (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. [313] (10.1177/23259671221133762)
• [L3] The revision rate of primary ACL repair with SA at a 2-year follow-up was 10%. [314] (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. [315] (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. [316] (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. [319] (10.1002/ksa.70471)
• [L3] In a young high-risk primary ACLR population, increased PTS was present in nearly 30% of patients. [321] (10.1177/03635465261473931)
• [L2] The overall SSI rate after ACLR was 0.48%, with deep SSIs identified in 0.32% of cases. [322] (10.1177/0363546513490665)
• [L3] High recovery rates were seen after arthroscopic ACLR, regardless of leg dominance. [323] (10.1177/2325967121995808)
• [L4] ACL reconstruction is a safe procedure with an incidence of septic arthritis of 0.92%. [324] (10.1016/j.arthro.2009.04.048)
• [L4] When compared to historical ACL reconstruction data, combined intra- and extra-articular reconstruction does not increase the complication rate. [325] (10.1016/j.otsr.2017.09.005)
• [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. [326] (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. [327] (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. [328] (10.1016/j.jisako.2023.03.220)
• [L3] Those treated with isolated ACLR remain at extremely high risk of a second ACL injury. [329] (10.1177/03635465221085027)
• [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. [330] (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. [331] (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. [334] (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. [335] (10.1177/2325967126s00354)
• [L3] Subsequent ACL injury rates to either knee is low and appears lower than after primary surgery. [337] (10.1177/2325967113s00003)
• [L4] Multiple revision ACL reconstruction surgery appears to have reasonable functional outcomes but is associated with a relatively high failure rate. [338] (10.1016/j.asmr.2020.06.013)
• [L3] Other risk factors for infection after ACL reconstruction included increased BMI and increased operative time. [340] (10.2106/jbjs.19.00270)
• [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. [343] (10.1007/s00167-018-5267-x)
• [L3] Overall re-tear rates were higher in patients who underwent revision ACL reconstruction with allograft. [344] (10.1177/2325967124s00296)
• [L4] The prevalence of septic arthritis after an ACL reconstruction in this series was 1.8%. [345] (10.1007/s00167-012-2264-3)
• [L3] Additional ACLR was in the mid term not associated with a higher increase of OA or a higher rate of post-operative complications in our study collective. [346] (10.1007/s00402-016-2604-8)
• [L3] Septic arthritis after ACL reconstruction results in the same objective knee function as uncomplicated cases. [347] (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. [348] (10.2106/jbjs.n.00694)
• [L3] Understanding these risk factors has important implications for appropriate counseling for primary ACLR. [349] (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. [350] (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. [351] (10.1007/s00167-019-05478-3)
• [L3] Results following revision anterior cruciate ligament reconstruction (ACLR) are less favourable than primary ACLR. [352] (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. [353] (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. [354] (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. [356] (10.1007/s00167-019-05353-1)
• [L3] The incidence of septic arthritis after ACLR in this nationwide cohort was 1.1%. [357] (10.1177/0363546521993812)

See Also

• Anterior cruciate ligament injury
• Meniscal repair
• Multiligament knee injury
• High tibial osteotomy

References

[1] Muscle strength and hop performance criteria prior to return to sports after ACL reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy. 2011. DOI: 10.1007/s00167-011-1669-8

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

[4] Patients with focal full‐thickness cartilage lesions benefit less from ACL reconstruction at 2–5 years follow‐up. Knee Surgery, Sports Traumatology, Arthroscopy. 2011. DOI: 10.1007/s00167-011-1739-y

[5] Evidence-Based Practice to Improve Outcomes of Anterior Cruciate Ligament Reconstruction. Clinics in Sports Medicine. 2013. DOI: 10.1016/j.csm.2012.08.008

[6] Editorial Commentary: Back to the Past—Anterior Cruciate Ligament Repair Revisited. Arthroscopy. 2019. DOI: 10.1016/j.arthro.2019.05.003

[7] Primary ACL Repair. Orthopaedic Journal of Sports Medicine. 2023. DOI: 10.1177/2325967121s00863

[9] Magnetic resonance imaging of anterior cruciate ligament rupture. BMC Musculoskeletal Disorders. 2004. DOI: 10.1186/1471-2474-5-21

[11] Expert‐based studies benefit from formal consensus methodology and balanced expert representation: Reconsidering the role of primary ACL repair. Knee Surgery, Sports Traumatology, Arthroscopy. 2025. DOI: 10.1002/ksa.70254

[12] The Anterior Cruciate Ligament Injury Severity Scale (ACLISS) as a Predictor of Short-Term Reoperation and Functional Outcomes After ACL Reconstruction. The American Journal of Sports Medicine. 2026. DOI: 10.1177/03635465261443315

[13] No negative effect on patient-reported outcome of concomitant cartilage lesions 5–9 years after ACL reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy. 2016. DOI: 10.1007/s00167-016-4163-5

[14] Revision ACL reconstruction has higher incidence of 30‐day hospital readmission, reoperation, and surgical complications relative to primary procedures. Knee Surgery, Sports Traumatology, Arthroscopy. 2021. DOI: 10.1007/s00167-021-06646-0

[15] Physeal‐sparing ACL reconstruction provides better knee laxity restoration but similar clinical outcomes to partial transphyseal and complete transphyseal approaches in the pediatric population: a systematic review and meta‐analysis. Knee Surgery, Sports Traumatology, Arthroscopy. 2022. DOI: 10.1007/s00167-022-07032-0

[16] Revision Surgery After Primary Double-Bundle ACL Reconstruction. Journal of Bone and Joint Surgery. 2014. DOI: 10.2106/jbjs.m.01038

[17] Septic knee arthritis following ACL reconstruction: a systematic review. Knee Surgery, Sports Traumatology, Arthroscopy. 2009. DOI: 10.1007/s00167-009-0793-1

[18] Anterior Cruciate Ligament Repair as One Approach in a Multifaceted Treatment Algorithm for the Management of Anterior Cruciate Ligament–Injured Patients. Arthroscopy. 2025. DOI: 10.1016/j.arthro.2025.04.006

[19] Long-term Graft Rupture Rates After Combined ACL and Anterolateral Ligament Reconstruction Versus Isolated ACL Reconstruction: A Matched-Pair Analysis From the SANTI Study Group. The American Journal of Sports Medicine. 2021. DOI: 10.1177/03635465211028990

[20] Orthopaedic Knowledge Update. Ligamentous Knee Injuries > ACL Injuries > Complications.

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[22] Patients with problems after ACL reconstruction - what do help MRI and SPECT/CT?. Orthopaedic Journal of Sports Medicine. 2016. DOI: 10.1177/2325967116s00047

[23] Journey around the Notch: A Systematic Review on the History of ACL Reconstruction in the United States. The Journal of Knee Surgery. 2020. DOI: 10.1055/s-0040-1712947

[25] ACL Repair is a valid alternative to ACL Reconstruction in appropriately chosen patients. Orthopaedic Journal of Sports Medicine. 2025. DOI: 10.1177/2325967126s00016

[26] Return to sports after ACL reconstruction: a paradigm shift from time to function. Knee Surgery, Sports Traumatology, Arthroscopy. 2017. DOI: 10.1007/s00167-017-4559-x

[27] Tibial Tubercle Apophyseal Stage to Determine Skeletal Age in Pediatric Patients Undergoing ACL Reconstruction: A Validation and Reliability Study. Orthopaedic Journal of Sports Medicine. 2021. DOI: 10.1177/23259671211036897

[29] Procedural intervention for arthrofibrosis after ACL reconstruction: trends over two decades. Knee Surgery, Sports Traumatology, Arthroscopy. 2015. DOI: 10.1007/s00167-015-3799-x

[30] Current status of ACL reconstruction in Germany. Archives of Orthopaedic and Trauma Surgery. 2016. DOI: 10.1007/s00402-016-2426-8

[33] Two‐year outcomes following ACL reconstruction with allograft tibialis anterior tendons: a retrospective study. Knee Surgery, Sports Traumatology, Arthroscopy. 2003. DOI: 10.1007/s00167-003-0371-x

[34] Late (≥60 years old) and middle adulthood (40–59 years old) patients achieve similar improvement in patient‐reported outcomes following ACL reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy. 2024. DOI: 10.1002/ksa.12491

[35] Primary anterior cruciate ligament repair: Current concepts. Journal of ISAKOS. 2023. DOI: 10.1016/j.jisako.2023.08.008

[36] Good physical function but reduced quality of life in children 3 years after ACL reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy. 2024. DOI: 10.1002/ksa.12211

[39] Defining Patient Acceptable Symptom State Thresholds for the IKDC Subjective Knee Form and KOOS for Patients Undergoing ACL Reconstruction. Orthopaedic Journal of Sports Medicine. 2013. DOI: 10.1177/2325967113s00069

[43] Paediatric ACL repair reinforced with temporary internal bracing. Knee Surgery, Sports Traumatology, Arthroscopy. 2016. DOI: 10.1007/s00167-016-4150-x

[44] Regarding “Intraoperative Hoffa Fracture During Primary ACL Reconstruction: Can Hamstring Graft and Tunnel Diameter Be Too Large?”. Arthroscopy. 2014. DOI: 10.1016/j.arthro.2014.05.018

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[48] 20 Year Outcomes of ACL Reconstruction with Hamstring Tendon Autograft. Does Age Matter?. Orthopaedic Journal of Sports Medicine. 2017. DOI: 10.1177/2325967117s00175

[49] Analgesia after ACL reconstruction: Hamstring donor-site injection versus intra-articular local anaesthetic injection. Orthopaedics & Traumatology: Surgery & Research. 2017. DOI: 10.1016/j.otsr.2016.11.011

[50] The use of allograft tendons in primary ACL reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy. 2019. DOI: 10.1007/s00167-019-05440-3

[51] Current Trends and Indications for Extra-Articular Reconstruction in Revision ACL Reconstruction: A Cross-Sectional Study. Orthopaedic Journal of Sports Medicine. 2025. DOI: 10.1177/23259671251386878

[52] Editorial Commentary: Anterior Cruciate Ligament Repair Could Be Indicated in Older, Less Active Patients. Arthroscopy. 2024. DOI: 10.1016/j.arthro.2024.11.085

[53] The Position of the Tibia during Graft Fixation Affects Knee Kinematics and Graft Forces for Anterior Cruciate Ligament Reconstruction. The American Journal of Sports Medicine. 2001. DOI: 10.1177/03635465010290061601

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

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

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

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

[63] 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

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

[66] 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

[67] 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

[69] Abnormal tibial position is correlated to early degenerative changes one year following ACL reconstruction. Journal of Orthopaedic Research. 2015. DOI: 10.1002/jor.22867

[70] Long-Term Outcomes of ACL Reconstruction Using Quadriceps-Tendon-Bone Autograft with Anteromedial Portal Technique: A 10-Year Follow Up Study. Journal of ISAKOS. 2025. DOI: 10.1016/j.jisako.2025.100536

[71] 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

[73] 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] 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

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

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

[81] 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

[85] 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

[96] Delaying ACL reconstruction and treating with exercise therapy alone may alter prognostic factors for 5-year outcome: an exploratory analysis of the KANON trial. British Journal of Sports Medicine. 2017. DOI: 10.1136/bjsports-2016-097124

[99] Pain relief after ACL reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy. 2004. DOI: 10.1007/s00167-004-0526-4

[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

[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

[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

[118] Biomechanical Outcomes After Bioenhanced Anterior Cruciate Ligament Repair and Anterior Cruciate Ligament Reconstruction Are Equal in a Porcine Model. Arthroscopy. 2012. DOI: 10.1016/j.arthro.2011.10.008

[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

[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

[132] DIFFERENCES IN ACUTE POSTOPERATIVE PAIN AFTER ACL RECONSTRUCTION IN ADOLESCENT PATIENTS: ALL SOFT-TISSUE QUADRICEPS VERSUS HAMSTRING AUTOGRAFT. Orthopaedic Journal of Sports Medicine. 2020. DOI: 10.1177/2325967120s00145

[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

[134] CARE Trial: Patient Education Reduces Opioid Use After ACL Reconstruction. Journal of Bone and Joint Surgery. 2025. DOI: 10.2106/jbjs.25.00221

[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

[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

[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

[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

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[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

[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

[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

[173] Hospital Charges and Practice Patterns for General and Regional Anesthesia in Arthroscopic Anterior Cruciate Ligament Repair. Orthopaedic Journal of Sports Medicine. 2013. DOI: 10.1177/2325967113505270

[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

[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

[195] 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

[199] Quadriceps and Hamstring Strength in Adolescents 6 Months After ACL Reconstruction With Femoral Nerve Block, Adductor Canal Block, or No Nerve Block. Orthopaedic Journal of Sports Medicine. 2021. DOI: 10.1177/23259671211017516

[200] 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

[201] 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] Pain after out-patient vs. in-patient ACL reconstruction: French prospective study of 1076 patients. Orthopaedics & Traumatology: Surgery & Research. 2016. DOI: 10.1016/j.otsr.2016.08.009

[203] Intra-articular Morphine and Ropivacaine Injection Provides Efficacious Analgesia As Compared With Femoral Nerve Block in the First 24 Hours After ACL Reconstruction: Results From a Bone–Patellar Tendon–Bone Graft in an Adolescent Population. Orthopaedic Journal of Sports Medicine. 2021. DOI: 10.1177/2325967120985902

[204] 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

[206] 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

[207] 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

[208] 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

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

[210] 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

[211] 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

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

[214] 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

[215] 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

[216] INTRA-ARTICULAR MORPHINE AND ROPIVACAINE INJECTION PROVIDES EFFICACIOUS ANALGESIA COMPARED TO FEMORAL NERVE BLOCK IN THE FIRST 24 HOURS POST-OPERATIVELY AFTER ACL RECONSTRUCTION WITH BTB IN AN ADOLESCENT COHORT. Orthopaedic Journal of Sports Medicine. 2021. DOI: 10.1177/2325967121s00023

[217] 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] Femoral Nerve Blockade is Associated with Persistent Strength Deficits at Six Months Post ACL Reconstruction in Pediatric and Adolescent Patients. Orthopaedic Journal of Sports Medicine. 2014. DOI: 10.1177/2325967114s00085

[220] 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

[221] Transitioning between medical equipment suppliers does not affect ACL reconstruction outcomes in a high‐volume setting. Knee Surgery, Sports Traumatology, Arthroscopy. 2025. DOI: 10.1002/ksa.12775

[222] 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

[223] 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

[224] Accuracy of Femoral Tunnel Localization With Mixed Reality Technology–Assisted Single-Bundle ACL Reconstruction. Orthopaedic Journal of Sports Medicine. 2023. DOI: 10.1177/23259671231184399

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

[226] 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

[227] Resolution of Pain and Predictors of Postoperative Opioid use after Bridge‐Enhanced Anterior Cruciate Ligament Repair and Anterior Cruciate Ligament Reconstruction. Arthroscopy, Sports Medicine, and Rehabilitation. 2020. DOI: 10.1016/j.asmr.2020.02.004

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

[232] 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

[234] 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

[235] 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

[236] 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

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[239] 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

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

[241] 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

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

[246] 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

[248] Can the Posterior Cruciate Ligament (Pcl) Predict Anterior Cruciate Ligament (Acl) Size For Planning During Acl Reconstruction?. Orthopaedic Journal of Sports Medicine. 2022. DOI: 10.1177/2325967121s00376

[249] 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

[250] Lower Opioid Prescription Quantity Does Not Negatively Impact Pain Control or Patient Satisfaction After ACL Reconstruction. Journal of Bone and Joint Surgery. 2024. DOI: 10.2106/jbjs.23.00657

[253] 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] Tunnel Positioning of AM and PL Bundle in Anatomic ACL Reconstruction (SS‐10). Arthroscopy. 2007. DOI: 10.1016/j.arthro.2007.03.023

[256] 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

[259] 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

[260] 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

[262] 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

[263] Evaluation of the tunnel placement in the anatomical double‐bundle ACL reconstruction: a cadaver study. Knee Surgery, Sports Traumatology, Arthroscopy. 2010. DOI: 10.1007/s00167-010-1128-y

[264] 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

[265] 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

[266] 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

[270] Neuromuscular adaptations and correlates of knee functionality following ACL reconstruction. Journal of Orthopaedic Research. 2007. DOI: 10.1002/jor.20472

[271] 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

[273] 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

[275] 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

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

[281] Anatomical medial and posteromedial ligamentoplasty for multiligament knee injury: an original technique using a pediculated autograft. Journal of Orthopaedic Surgery and Research. 2026. DOI: 10.1186/s13018-025-06638-7

[283] 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

[284] Fourfold higher graft failure risk with isolated BPTB versus hamstring ACL reconstruction with ALL in patients under 25 years: A prespecified subgroup analysis of a randomized controlled trial. Knee Surgery, Sports Traumatology, Arthroscopy. 2026. DOI: 10.1002/ksa.70617

[285] 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

[291] 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

[293] 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

[296] 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

[297] 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

[298] 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

[299] 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

[302] 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

[303] 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

[306] 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

[307] Having a Revision ACL Reconstruction Is Worse Than Tearing the Contralateral ACL and Undergoing Reconstruction: A MOON Cohort Study. The American Journal of Sports Medicine. 2026. DOI: 10.1177/03635465261416923

[308] 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

[309] 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

[310] 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. Journal of ISAKOS. 2023. DOI: 10.1016/j.jisako.2023.03.109

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

[313] 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

[314] 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

[315] 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

[316] 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

[319] 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

[321] 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

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

[323] 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

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

[325] Midterm results of combined intra- and extra-articular ACL reconstruction compared to historical ACL reconstruction data. Multicenter study of the French Arthroscopy Society. Orthopaedics & Traumatology: Surgery & Research. 2017. DOI: 10.1016/j.otsr.2017.09.005

[326] 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

[327] 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

[328] 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

[329] Risk of Graft Rupture After Adding a Lateral Extra-articular Procedure at the Time of ACL Reconstruction: A Retrospective Comparative Study of Elite Alpine Skiers From the French National Team. The American Journal of Sports Medicine. 2022. DOI: 10.1177/03635465221085027

[330] 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

[331] 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

[334] 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

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

[337] Return to Sports and Subsequent ACL Injury Rates after Revision ACL reconstruction with Patellar Tendon Autograft. Orthopaedic Journal of Sports Medicine. 2013. DOI: 10.1177/2325967113s00003

[338] 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

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

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

[344] 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

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

[346] ACL deficiency and varus osteoarthritis: high tibial osteotomy alone or combined with ACL reconstruction?. Archives of Orthopaedic and Trauma Surgery. 2016. DOI: 10.1007/s00402-016-2604-8

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

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

[349] 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

[350] 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

[351] 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

[352] 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

[353] 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

[354] 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

[356] 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

[357] 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