Anterior cruciate ligament reconstruction (ACLR) is one of the most commonly performed procedures in orthopaedic sports medicine. Despite developments in understanding the anatomy and biomechanics of the knee joint, a fairly large subset of patients has ACLR failure. Outcomes after revision ACLR are historically inferior to primary ACLR. Thus, a systematic approach is necessary to identify all potential causes of failure and addressing them in conjunction with a revision ACLR to mitigate the risk of revision failure and to maximise improved patient outcomes.

To create a practice guideline for the appropriate indications of an extra-articular procedure in primary anterior cruciate ligament reconstruction (ACLR). The formal consensus method described by the Haute Autorité de Santé was used. The Latin American Society of Arthroscopy, Articular Replacement, and Sports Injuries (SLARD) recruited three groups of experts on ACLR. Initially, the steering group, consisting of eight surgeons, performed a systematic review of the literature and elaborated on 192 scenarios for primary ACLR. The rating group, composed of 23 surgeons, rated each scenario in two rounds, with an in-between in-person meeting for discussion. Median scores and agreement levels were estimated to classify each scenario as inappropriate, uncertain or appropriate for adding anterolateral reconstruction. Finally, the lecture group, consisting of 10 surgeons, revised each stage of the method, results and interpretation. Of the scenarios, 11.97% were rated as appropriate for adding an extra-articular lateral procedure, 7.81% as inappropriate and 80.21% as uncertain. The key recommendations for the addition of extra-articular lateral techniques were as follows: it is appropriate when the patient is under 25 years of age, has high-grade physical examination findings, practises a pivoting sport and has hyperlaxity; meanwhile, it is inappropriate when the patient has low-grade physical examination findings, has normal laxity and does not practise a pivoting sport. The appropriate indications of extra-articular lateral procedures in primary ACLR were determined on the basis of the best available evidence and expert opinion following a formal consensus method. V.

It is well known that the posterior cruciate ligament (PCL) is the main stabilizer to posterior tibial translation in the knee. Anatomic double‐bundle reconstruction has recently been proposed to best restore posterior and rotational tibial instability, especially compared with a single‐bundle PCL reconstruction (PCLR). Most publications in the peer‐reviewed literature on double‐bundle PCLR have used allografts. However, in many countries, allografts are not available. This Technical Note describes an all‐autograft arthroscopic technique for PCLR using the quadriceps and semitendinosus tendons. Technique Video: video See video under supplementary data.

The quantitative dynamic monitoring of the performance of hamstring muscles during rehabilitation and training cannot currently be undertaken using elastic resistance bands. Hip extension with a fully extended knee involves hamstring agonists, while knee flexion involves only the hamstring. The purpose of this study is to provide normative values of torque, velocity and power involving hamstring muscles opposing elastic bands. Twenty amateur athletes aged 25.7 ± 4.9, were studied during two motor tasks—hip extension and knee flexion, both isometric & dynamic—with an elastic resistance band and DINABANG portable instrument. We compared the peak isometric torque in hip extension with agonists (2.93 Nm/kg) and without them (1.21 Nm/kg): the difference is significant. The peak angular limb velocity—starting at 50% of the maximum torque—is smaller in hip extension with agonists (215.96°/s) than in a knee flexion without them (452.56°/s). The combination of peak torque and peak velocity estimates power and there is no difference (p = 0.051) with and without agonists: 452.56°Nm/s.kg without agonists and 542.13°Nm/s.kg with them. This study opens the possibility of monitoring torque–velocity–power profiles for hamstring exercise in open chain.

Purpose: To evaluate the possibility to access the anatomic femoral insertion of the anterior cruciate ligament (ACL) through trans‐tibial (TT) and trans‐portal technique, for ACL reconstruction in an independent way. To register anatomical characteristics of the TT tunnels.Methods: Ten formaldehyde preserved knee anatomic articular specimens were dissected. Femoral tunnels were confectioned reproducing the original topography of the ACL. First, the femoral tunnel was made with the independent trans‐portal technique. Then, utilizing the tibial stump of the ACL and tibial guides at 45°, the TT tunnels were confectioned trying to match the previously made femoral tunnel by trans‐portal technique.Results: In all specimens, match between the TT tunnel with the independent trans‐portal tunnel was achieved. Mean values for TT coronal angle was 53,0°, for transversal angle 43,3° and for distance from tunnel to joint line 2,55 cm. A horizontalization and medialization of the TT tunnels had to be made to adequately match with the femoral tunnel made by the independent trans‐portal technique.Conclusions: By macroscopic anatomic and independent means, an anatomic femoral tunnel was confectioned with the TT technique matching with the anatomic femoral tunnel made in an independent way. As clinical relevance, the present study allows to anatomically assess the possibility to perform an anatomic femoral tunnel through the TT technique.Level of evidence: V

Patients with ligamentous hyperlaxity or knee hyperextension seem to be at a higher risk of failure following anterior cruciate ligament (ACL) reconstruction. The objective of this study was to better understand global practices for the treatment of ACL injuries in patients with knee hyperextension and ligamentous hyperlaxity among knee and sports medicine surgeons worldwide. A survey invitation was sent to members of the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS) who were identified as knee and sports surgeons. The survey consisted of a total of 25 questions, covering topics related to preoperative assessment, surgical technique, and postoperative management of patients with knee hyperextension. Survey responses were tabulated and reported using descriptive statistics. In total, 427 responses to the survey were obtained from ISAKOS members. All continents participated, with the largest number of responses coming from Latin America (36.8 ​%). 75.4 ​% of respondents believe that patients with knee hyperextension tend to have more ACL tears, and 90.4 ​% believe that those who undergo ACL reconstruction have higher rates of reconstruction failure. Regarding surgical technique and graft type, 66.7 ​% of respondents modify their approach when treating patients with knee hyperextension. 82.7 ​% of respondents do not change the position of the bone tunnels, while 12.9 ​% reported placing the tibial tunnel more posteriorly. The most used grafts are hamstrings (38.4 ​%) and bone-patellar tendon-bone (BTB) (37.2 ​%). Allografts are preferred by only 5.9 ​% of respondents, and 75.9 ​% of surgeons are not concerned about using autografts, even in cases of suspected collagen disorders. 89.5 ​% of respondents believe adding an extra-articular procedure could minimize failure risk. The most used extra-articular procedure is lateral extra-articular tenodesis (LET) (63.9 ​%). ACL surgeons across diverse regions, demographics, experience levels, and surgical volumes tend to modify their approach for patients with knee hyperextension or ligamentous hyperlaxity. Hamstring and BTB grafts are most commonly used, with the vast majority not changing tunnel positioning. Most fix the graft at 20-30° of knee flexion and believe that lateral augmentations reduce failure rates in this population, with LET being the preferred technique. Level V, expert opinion study.