Korean J Sports Med.  2023 Dec;41(4):185-200. 10.5763/kjsm.2023.41.4.185.

Current Trends and Future Developments in Anterior Cruciate Ligament Reconstruction: Current Concepts Review

• Lee DW
• Kim JN
• Kim SW
• Cho SI
• Kim NY
• Park BS

• KMID: 2548992
• DOI: http://doi.org/10.5763/kjsm.2023.41.4.185

Abstract

As the number of anterior cruciate ligament (ACL) reconstructions has increased significantly, surgical techniques have also made a lot of progress, and clinical outcomes are improving accordingly. However, the authors still have different opinions on ACL anatomy, femoral tunnel position, how to make a femoral tunnel, and graft selection, and many parts are controversial. Major factors contributing to the failure of ACL reconstruction, such as technical errors and biological healing failures. To reduce technical errors, a comprehensive understanding of ACL anatomy and the ability to create a well-positioned femoral tunnel are crucial. This involves recognizing the advantages and disadvantages of three surgical techniques: modified transtibial, transanteromedial portal, and outside-in. To improve biological healing, the four principles of tissue engineering (cells, growth factors, scaffolds, and mechanical stimuli) have been increasingly explored in various methods of bioaugmentation. Residual rotational instability of the knee joint remains a significant concern. Since the rediscovery of the anterolateral ligament (ALL) in the knee joint, the role of anterolateral complex, including the ALL and the deep iliotibial band, as secondary stabilizers of anterolateral rotatory instability, has gained attention. In the quest to reinforce the anterolateral complex, there are two approaches: ALL reconstruction as anatomical reconstruction concept and lateral extraarticular tenodesis as a nonanatomical reinforcement concept.

Keyword

Anterior cruciate ligament; Anterolateral ligament; Anterior cruciate ligament anatomy; Anterior cruciate ligament reconstruction; Anatomical reconstruction

Figure

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  Fig. 1 Anterior cruciate ligament consists of anteromedial (AM) and posterolateral (PL) bundles. (A) Sagittal view. (B) Coronal view.

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  Fig. 2 Lateral wall of intercondylar notch showing lateral intercondylar ridge and lateral bifurcate ridge together with origins of anteromedial (AM) and posterolateral (PL) bundles.

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  Fig. 3 Anterior cruciate ligament femoral footprint is divided into direct (shaded area) and indirect (dotted area) fibers.

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  Fig. 4 (A) When the reamer passes over the bending point of the guide pin, the knee should be moved to extension. (B) After the reamer passes through the bending point of the guide pin, the knee is returned to a flexion position in order to avoid posterior wall blowout. Reprinted from Lee et al.32 (Arthrosc Tech 2017;6:e227-32) according to the Creative Commons License.

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  Fig. 5 Schematic illustration of transanteromedial portal method.

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  Fig. 6 (A) Flexible reamer (VersiTomic; Stryke). Reprinted with permission from Stryker. (B) Schematic illustration of transanteromedial portal method using flexible reamer system.

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  Fig. 7 A flexible guide pin is inserted through the curved drill guide. Reprinted from Stryker.

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  Fig. 8 The sagittal graft inclination (A) and the coronal graft inclination (B).

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  Fig. 9 Schematic illustration of outside-in method.

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  Fig. 10 The femoral tunnel position is presented using the quadrant method described by Bernard et al.47 (Am J Knee Surg 1997;10:14-22).

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  Fig. 11 Schematic illustration of autografts.

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  Fig. 12 The process of making a quadruple hamstring graft (semitendinosus tendon).

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  Fig. 13 Anatomical configuration of the anterolateral complex including anterolateral ligament (ALL) and superficial and deep layers of iliotibial band.

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  Fig. 14 Schematic illustration of the anterolateral ligament reconstruction. LCL, lateral collateral ligament.

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  Fig. 15 Lateral extraarticular tenodesis. (A) The iliotibial (IT) band is stripped and left attached distally to Gerdy’s tubercle. (B) Lemaire technique: the proximal strip of IT band is passed beneath the lateral collateral ligament (LCL). (C) Modified Andrews technique: the proximal strip of IT band is passed over the LCL.

Reference

1. Chung KS, Kim JH, Kong DH, Park I, Kim JG, Ha JK. 2022; An increasing trend in the number of anterior cruciate ligament reconstruction in Korea: a nationwide epidemiologic study. Clin Orthop Surg. 14:220–6. DOI: 10.4055/cios20276. PMID: 35685966. PMCID: PMC9152897.

2. Risberg MA, Grindem H, Øiestad BE. 2016; We need to implement current evidence in early rehabilitation programs to improve long-term outcome after anterior cruciate ligament injury. J Orthop Sports Phys Ther. 46:710–3. DOI: 10.2519/jospt.2016.0608. PMID: 27581178.

3. Golberg E, Sommerfeldt M, Pinkoski A, Dennett L, Beaupre L. Anterior cruciate ligament reconstruction return-to-sport decision-making: a scoping review. Sports Health. 2023; Jan. 27. [Epub]. https://doi.org/10.1177/19417381221147524. DOI: 10.1177/19417381221147524. PMID: 36707977.

4. Niederer D, Behringer M, Stein T. 2023; Functional outcomes after anterior cruciate ligament reconstruction: unravelling the role of time between injury and surgery, time since reconstruction, age, gender, pain, graft type, and concomitant injuries. BMC Sports Sci Med Rehabil. 15:49. DOI: 10.1186/s13102-023-00663-x. PMID: 37005699. PMCID: PMC10068137.

5. Cohen D, Yao PF, Uddandam A, de Sa D, Arakgi ME. 2022; Etiology of failed anterior cruciate ligament reconstruction: a scoping review. Curr Rev Musculoskelet Med. 15:394–401. DOI: 10.1007/s12178-022-09776-1. PMID: 35852699. PMCID: PMC9463419.

6. Morales-Avalos R, Torres-González EM, Padilla-Medina JR, Monllau JC. ACL anatomy: is there still something to learn? Rev Esp Cir Ortop Traumatol. 2023; Feb. 12. [Epub]. https://doi.org/10.1016/j.recot.2023.02.005. DOI: 10.1016/j.recot.2023.02.005. PMID: 36787832.

7. Woo SL, Hollis JM, Adams DJ, Lyon RM, Takai S. 1991; Tensile properties of the human femur-anterior cruciate ligament-tibia complex: the effects of specimen age and orientation. Am J Sports Med. 19:217–25. DOI: 10.1177/036354659101900303. PMID: 1867330.

8. Cone SG, Howe D, Fisher MB. 2019; Size and shape of the human anterior cruciate ligament and the impact of sex and skeletal growth: a systematic review. JBJS Rev. 7:e8. DOI: 10.2106/JBJS.RVW.18.00145. PMID: 31246862. PMCID: PMC7771555.

9. Musahl V, Nazzal EM, Lucidi GA, et al. 2022; Current trends in the anterior cruciate ligament part 1: biology and biomechanics. Knee Surg Sports Traumatol Arthrosc. 30:20–33. DOI: 10.1007/s00167-021-06826-y. PMID: 34927221.

10. Kondo E, Merican AM, Yasuda K, Amis AA. 2014; Biomechanical analysis of knee laxity with isolated anteromedial or posterolateral bundle-deficient anterior cruciate ligament. Arthroscopy. 30:335–43. DOI: 10.1016/j.arthro.2013.12.003. PMID: 24581258.

11. Amis AA. 2012; The functions of the fibre bundles of the anterior cruciate ligament in anterior drawer, rotational laxity and the pivot shift. Knee Surg Sports Traumatol Arthrosc. 20:613–20. DOI: 10.1007/s00167-011-1864-7. PMID: 22278656.

12. Sabzevari S, Shaikh H, Marshall B, et al. 2020; The femoral posterior fan-like extension of the ACL insertion increases the failure load. Knee Surg Sports Traumatol Arthrosc. 28:1113–8. DOI: 10.1007/s00167-019-05753-3. PMID: 31642946.

13. Śmigielski R, Zdanowicz U, Drwięga M, Ciszek B, Williams A. 2016; The anatomy of the anterior cruciate ligament and its relevance to the technique of reconstruction. Bone Joint J. 98-B:1020–6. DOI: 10.1302/0301-620X.98B8.37117. PMID: 27482012.

14. Morales-Avalos R, Perelli S, Vilchez-Cavazos F, et al. 2022; The morphology of the femoral footprint of the anterior cruciate ligament changes with aging from a large semicircular shape to a small flat ribbon-like shape. Knee Surg Sports Traumatol Arthrosc. 30:3402–13. DOI: 10.1007/s00167-022-06935-2. PMID: 35318508. PMCID: PMC9464138.

15. Costa GG, Grassi A, Perelli S, et al. 2019; Age over 50 years is not a contraindication for anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 27:3679–91. DOI: 10.1007/s00167-019-05450-1. PMID: 30944945.

16. Hiramatsu K, Mae T, Tachibana Y, Nakagawa S, Shino K. 2018; Contact area between femoral tunnel and interference screw in anatomic rectangular tunnel ACL reconstruction: a comparison of outside-in and trans-portal inside-out techniques. Knee Surg Sports Traumatol Arthrosc. 26:519–25. DOI: 10.1007/s00167-017-4732-2. PMID: 29058021.

17. Fink C, Lawton R, Förschner F, Gföller P, Herbort M, Hoser C. 2018; Minimally invasive quadriceps tendon single-bundle, arthroscopic, anatomic anterior cruciate ligament reconstruction with rectangular bone tunnels. Arthrosc Tech. 7:e1045–56. DOI: 10.1016/j.eats.2018.06.012. PMID: 30377585. PMCID: PMC6203691.

18. Takata Y, Nakase J, Oshima T, Shimozaki K, Asai K, Tsuchiya H. 2018; No difference in the graft shift between a round and a rounded rectangular femoral tunnel for anterior cruciate ligament reconstruction: an experimental study. Arch Orthop Trauma Surg. 138:1249–55. DOI: 10.1007/s00402-018-2958-1. PMID: 29770879.

19. Lim HC, Yoon YC, Wang JH, Bae JH. 2012; Anatomical versus non-anatomical single bundle anterior cruciate ligament reconstruction: a cadaveric study of comparison of knee stability. Clin Orthop Surg. 4:249–55. DOI: 10.4055/cios.2012.4.4.249. PMID: 23205233. PMCID: PMC3504688.

20. Byrne KJ, Hughes JD, Gibbs C, et al. 2022; Non-anatomic tunnel position increases the risk of revision anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 30:1388–95. DOI: 10.1007/s00167-021-06607-7. PMID: 33983487.

21. Wan F, Chen T, Ge Y, Zhang P, Chen S. 2019; Effect of nearly isometric ACL reconstruction on graft-tunnel motion: a quantitative clinical study. Orthop J Sports Med. 7:2325967119890382. DOI: 10.1177/2325967119890382. PMID: 32656282. PMCID: PMC7333503.

22. Musahl V, Engler ID, Nazzal EM, et al. 2022; Current trends in the anterior cruciate ligament part II: evaluation, surgical technique, prevention, and rehabilitation. Knee Surg Sports Traumatol Arthrosc. 30:34–51. DOI: 10.1007/s00167-021-06825-z. PMID: 34865182.

23. Tuca M, Valderrama I, Eriksson K, Tapasvi S. 2023; Current trends in anterior cruciate ligament surgery: a worldwide benchmark study. J ISAKOS. 8:2–10. DOI: 10.1016/j.jisako.2022.08.009. PMID: 36154898.

24. Oh JY, Kim KT, Park YJ, et al. 2020; Biomechanical comparison of single-bundle versus double-bundle anterior cruciate ligament reconstruction: a meta-analysis. Knee Surg Relat Res. 32:14. DOI: 10.1186/s43019-020-00033-8. PMID: 32660562. PMCID: PMC7219200.

25. Goldsmith MT, Jansson KS, Smith SD, Engebretsen L, LaPrade RF, Wijdicks CA. 2013; Biomechanical comparison of anatomic single- and double-bundle anterior cruciate ligament reconstructions: an in vitro study. Am J Sports Med. 41:1595–604. DOI: 10.1177/0363546513487065. PMID: 23696212.

26. Kondo E, Merican AM, Yasuda K, Amis AA. 2011; Biomechanical comparison of anatomic double-bundle, anatomic single-bundle, and nonanatomic single-bundle anterior cruciate ligament reconstructions. Am J Sports Med. 39:279–88. DOI: 10.1177/0363546510392350. PMID: 21239692.

27. Torkaman A, Yazdi H, Hosseini MG. 2016; The results of single bundle versus double bundle ACL reconstruction surgery, a retrospective study and review of literature. Med Arch. 70:351–3. DOI: 10.5455/medarh.2016.70.351-353. PMID: 27994295. PMCID: PMC5136424.

28. Alomari MS, Ghaddaf AA, Abdulhamid AS, Alshehri MS, Ashraf M, Alharbi HH. 2022; Single bundle versus double bundle anterior cruciate ligament reconstruction: a systematic review and meta-analysis. Indian J Orthop. 56:1669–84. DOI: 10.1007/s43465-022-00718-0. PMID: 36187591. PMCID: PMC9485407.

29. Björnsson H, Desai N, Musahl V, et al. 2015; Is double-bundle anterior cruciate ligament reconstruction superior to single-bundle?: a comprehensive systematic review. Knee Surg Sports Traumatol Arthrosc. 23:696–739. DOI: 10.1007/s00167-013-2666-x.

30. Sherman SL, Calcei J, Ray T, et al. 2021; ACL Study Group presents the global trends in ACL reconstruction: biennial survey of the ACL Study Group. J ISAKOS. 6:322–8. DOI: 10.1136/jisakos-2020-000567. PMID: 34272329.

31. Lee YH, Kuroda R, Chan KM. 2015; Anterior cruciate ligament reconstruction: a 2015 global perspective of the Magellan Society. Asia Pac J Sports Med Arthrosc Rehabil Technol. 2:122–8. DOI: 10.1016/j.asmart.2015.08.003. PMID: 29264251. PMCID: PMC5730661.

32. Lee DW, Kim JG. 2017; Anatomic single-bundle anterior cruciate ligament reconstruction using the modified transtibial technique. Arthrosc Tech. 6:e227–32. DOI: 10.1016/j.eats.2016.09.028. PMID: 28409105. PMCID: PMC5382429.

33. Lee DW, Kim JG, Lee JH, Park JH, Kim DH. 2018; Comparison of modified transtibial and outside-in techniques in anatomic single-bundle anterior cruciate ligament reconstruction. Arthroscopy. 34:2857–70. DOI: 10.1016/j.arthro.2018.05.041. PMID: 30197202.

34. Lee JK, Lee S, Seong SC, Lee MC. 2014; Modified transtibial technique for anterior cruciate ligament reconstruction with quadriceps tendon autograft. JBJS Essent Surg Tech. 4:e15. DOI: 10.2106/JBJS.ST.N.00078. PMID: 30775122. PMCID: PMC6359920.

35. Youm YS, Cho SD, Lee SH, Youn CH. 2014; Modified transtibial versus anteromedial portal technique in anatomic single-bundle anterior cruciate ligament reconstruction: comparison of femoral tunnel position and clinical results. Am J Sports Med. 42:2941–7. DOI: 10.1177/0363546514551922. PMID: 25269655.

36. Silver AG, Kaar SG, Grisell MK, Reagan JM, Farrow LD. 2010; Comparison between rigid and flexible systems for drilling the femoral tunnel through an anteromedial portal in anterior cruciate ligament reconstruction. Arthroscopy. 26:790–5. DOI: 10.1016/j.arthro.2009.10.012. PMID: 20511037.

37. Steiner ME, Smart LR. 2012; Flexible instruments outperform rigid instruments to place anatomic anterior cruciate ligament femoral tunnels without hyperflexion. Arthroscopy. 28:835–43. DOI: 10.1016/j.arthro.2011.11.029. PMID: 22289428.

38. Lee DW, Lee DH, Moon SG, Kang JH, Woo YJ, Kim WJ. 2023; Femoral tunnel geometry and graft inclination angles in anterior cruciate ligament reconstruction using a flexible reamer system. Medicina (Kaunas). 59:1031. DOI: 10.3390/medicina59061031. PMID: 37374234. PMCID: PMC10302174.

39. Yoon KH, Kim JH, Kwon YB, Kim EJ, Lee SH, Kim SG. 2020; A two-portal technique using a flexible reamer system is a safe and effective method for transportal anterior cruciate ligament reconstruction. Arch Orthop Trauma Surg. 140:383–90. DOI: 10.1007/s00402-020-03343-4. PMID: 31970504.

40. Ahn JH, Jeong HJ, Lee YS, Park JH, Lee JH, Ko TS. 2016; Graft bending angle is correlated with femoral intraosseous graft signal intensity in anterior cruciate ligament reconstruction using the outside-in technique. Knee. 23:666–73. DOI: 10.1016/j.knee.2015.10.006. PMID: 26968485.

41. Kim JG, Wang JH, Lim HC, Ahn JH. 2012; Femoral graft bending angle and femoral tunnel geometry of transportal and outside-in techniques in anterior cruciate ligament reconstruction: an in vivo 3-dimensional computed tomography analysis. Arthroscopy. 28:1682–94. DOI: 10.1016/j.arthro.2012.05.884. PMID: 23107250.

42. Niki Y, Nagai K, Harato K, Suda Y, Nakamura M, Matsumoto M. 2017; Effects of femoral bone tunnel characteristics on graft-bending angle in double-bundle anterior cruciate ligament reconstruction: a comparison of the outside-in and transportal techniques. Knee Surg Sports Traumatol Arthrosc. 25:1191–8. DOI: 10.1007/s00167-015-3761-y. PMID: 26294057.

43. van Eck CF, Gravare-Silbernagel K, Samuelsson K, et al. 2013; Evidence to support the interpretation and use of the Anatomic Anterior Cruciate Ligament Reconstruction Checklist. J Bone Joint Surg Am. 95:e153. DOI: 10.2106/JBJS.L.01437. PMID: 24132368.

44. Inderhaug E, Larsen A, Strand T, Waaler PA, Solheim E. 2016; The effect of feedback from post-operative 3D CT on placement of femoral tunnels in single-bundle anatomic ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. 24:154–60. DOI: 10.1007/s00167-014-3355-0. PMID: 25274095.

45. Sirleo L, Innocenti M, Innocenti M, Civinini R, Carulli C, Matassi F. 2018; Post-operative 3D CT feedback improves accuracy and precision in the learning curve of anatomic ACL femoral tunnel placement. Knee Surg Sports Traumatol Arthrosc. 26:468–77. DOI: 10.1007/s00167-017-4614-7. PMID: 28631143.

46. Mhaskar VA, Jain Y, Soni P, Fiske R, Maheshwari J. 2021; How important is the tunnel position in outcomes post-ACL reconstruction: a 3D CT-based study. Indian J Orthop. 56:312–8. DOI: 10.1007/s43465-021-00485-4. PMID: 35140863. PMCID: PMC8789976.

47. Bernard M, Hertel P, Hornung H, Cierpinski T. 1997; Femoral insertion of the ACL: radiographic quadrant method. Am J Knee Surg. 10:14–22.

48. Domnick C, Raschke MJ, Herbort M. 2016; Biomechanics of the anterior cruciate ligament: physiology, rupture and reconstruction techniques. World J Orthop. 7:82–93. DOI: 10.5312/wjo.v7.i2.82. PMID: 26925379. PMCID: PMC4757662.

49. Runer A, Keeling L, Wagala N, et al. 2023; Current trends in graft choice for anterior cruciate ligament reconstruction - part I: anatomy, biomechanics, graft incorporation and fixation. J Exp Orthop. 10:37. DOI: 10.1186/s40634-023-00600-4. PMID: 37005974. PMCID: PMC10067784.

50. Chu CR, Williams AA. 2019; Quantitative MRI UTE-T2* and T2* show progressive and continued graft maturation over 2 years in human patients after anterior cruciate ligament reconstruction. Orthop J Sports Med. 7:2325967119863056. DOI: 10.1177/2325967119863056. PMID: 31448301. PMCID: PMC6693027.

51. Irvine JN, Arner JW, Thorhauer E, et al. 2016; Is there a difference in graft motion for bone-tendon-bone and hamstring autograft ACL reconstruction at 6 weeks and 1 year? Am J Sports Med. 44:2599–607. DOI: 10.1177/0363546516651436. PMID: 27411358.

52. Ma R, Schär M, Chen T, et al. 2018; Effect of dynamic changes in anterior cruciate ligament in situ graft force on the biological healing response of the graft-tunnel interface. Am J Sports Med. 46:915–23. DOI: 10.1177/0363546517745624.

53. Biset A, Douiri A, Robinson JR, et al. 2023; Tibial tunnel expansion does not correlate with four-strand graft maturation after ACL reconstruction using adjustable cortical suspensory fixation. Knee Surg Sports Traumatol Arthrosc. 31:1761–70. DOI: 10.1007/s00167-022-07051-x. PMID: 35876906.

54. Chee MY, Chen Y, Pearce CJ, et al. 2017; Outcome of patellar tendon versus 4-strand hamstring tendon autografts for anterior cruciate ligament reconstruction: a systematic review and meta-analysis of prospective randomized trials. Arthroscopy. 33:450–63. DOI: 10.1016/j.arthro.2016.09.020. PMID: 28040335.

55. Lee DW, Shim JC, Yang SJ, Cho SI, Kim JG. 2019; Functional effects of single semitendinosus tendon harvesting in anatomic anterior cruciate ligament reconstruction: comparison of single versus dual hamstring harvesting. Clin Orthop Surg. 11:60–72. DOI: 10.4055/cios.2019.11.1.60. PMID: 30838109. PMCID: PMC6389538.

56. Wang HD, Gao SJ, Zhang YZ. 2020; Hamstring autograft versus hybrid graft for anterior cruciate ligament reconstruction: a systematic review. Am J Sports Med. 48:1014–22. DOI: 10.1177/0363546519849483. PMID: 31166113.

57. Marques FD, Barbosa PH, Alves PR, et al. 2020; Anterior knee pain after anterior cruciate ligament reconstruction. Orthop J Sports Med. 8:2325967120961082. DOI: 10.1177/2325967120961082. PMID: 33195725. PMCID: PMC7605008.

58. Johnston PT, McClelland JA, Feller JA, Webster KE. 2021; Knee muscle strength after quadriceps tendon autograft anterior cruciate ligament reconstruction: systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc. 29:2918–33. DOI: 10.1007/s00167-020-06311-y. PMID: 33026536.

59. Cruz AI Jr, Beck JJ, Ellington MD, et al. 2020; Failure rates of autograft and allograft ACL reconstruction in patients 19 years of age and younger: a systematic review and meta-analysis. JB JS Open Access. 5:e20.00106. DOI: 10.2106/JBJS.OA.20.00106. PMID: 34322650. PMCID: PMC8312832.

60. Yao LW, Wang Q, Zhang L, et al. 2015; Patellar tendon autograft versus patellar tendon allograft in anterior cruciate ligament reconstruction: a systematic review and meta-analysis. Eur J Orthop Surg Traumatol. 25:355–65. DOI: 10.1007/s00590-014-1481-5. PMID: 24831306.

61. Cvetanovich GL, Mascarenhas R, Saccomanno MF, et al. 2014; Hamstring autograft versus soft-tissue allograft in anterior cruciate ligament reconstruction: a systematic review and meta-analysis of randomized controlled trials. Arthroscopy. 30:1616–24. DOI: 10.1016/j.arthro.2014.05.040. PMID: 25108904.

62. Yao S, Fu BS, Yung PS. 2021; Graft healing after anterior cruciate ligament reconstruction (ACLR). Asia Pac J Sports Med Arthrosc Rehabil Technol. 25:8–15. DOI: 10.1016/j.asmart.2021.03.003. PMID: 34094881. PMCID: PMC8134949.

63. Ristaniemi A, Stenroth L, Mikkonen S, Korhonen RK. 2018; Comparison of elastic, viscoelastic and failure tensile material properties of knee ligaments and patellar tendon. J Biomech. 79:31–8. DOI: 10.1016/j.jbiomech.2018.07.031. PMID: 30082085.

64. Looney AM, Leider JD, Horn AR, Bodendorfer BM. 2020; Bioaugmentation in the surgical treatment of anterior cruciate ligament injuries: a review of current concepts and emerging tech-niques. SAGE Open Med. 8:2050312120921057. DOI: 10.1177/2050312120921057. PMID: 32435488. PMCID: PMC7222656.

65. Rodeo SA, Arnoczky SP, Torzilli PA, Hidaka C, Warren RF. 1993; Tendon-healing in a bone tunnel: a biomechanical and histological study in the dog. J Bone Joint Surg Am. 75:1795–803. DOI: 10.2106/00004623-199312000-00009. PMID: 8258550.

66. Wang C, Hu Y, Zhang S, et al. 2021; Application of stem cell therapy for ACL graft regeneration. Stem Cells Int. 2021:6641818. DOI: 10.1155/2021/6641818. PMID: 34381504. PMCID: PMC8352687.

67. Chen B, Li B, Qi YJ, et al. 2016; Enhancement of tendon-to-bone healing after anterior cruciate ligament reconstruction using bone marrow-derived mesenchymal stem cells genetically modified with bFGF/BMP2. Sci Rep. 6:25940. DOI: 10.1038/srep25940. PMID: 27173013. PMCID: PMC4865959.

68. Dong Y, Zhang Q, Li Y, Jiang J, Chen S. 2012; Enhancement of tendon-bone healing for anterior cruciate ligament (ACL) reconstruction using bone marrow-derived mesenchymal stem cells infected with BMP-2. Int J Mol Sci. 13:13605–20. DOI: 10.3390/ijms131013605. PMID: 23202970. PMCID: PMC3497344.

69. Bessa PC, Casal M, Reis RL. 2008; Bone morphogenetic proteins in tissue engineering: the road from laboratory to clinic, part II (BMP delivery). J Tissue Eng Regen Med. 2:81–96. DOI: 10.1002/term.74. PMID: 18383454.

70. Andriolo L, Di Matteo B, Kon E, Filardo G, Venieri G, Marcacci M. 2015; PRP augmentation for ACL reconstruction. Biomed Res Int. 2015:371746. DOI: 10.1155/2015/371746. PMID: 26064903. PMCID: PMC4430629.

71. Murray MM, Fleming BC. 2013; Use of a bioactive scaffold to stimulate anterior cruciate ligament healing also minimizes post-traumatic osteoarthritis after surgery. Am J Sports Med. 41:1762–70. DOI: 10.1177/0363546513483446. PMID: 23857883. PMCID: PMC3735821.

72. Mutsuzaki H, Nakajima H, Nomura S, Sakane M. 2017; Differences in placement of calcium phosphate-hybridized tendon grafts within the femoral bone tunnel during ACL reconstruction do not influence tendon-to-bone healing. J Orthop Surg Res. 12:80. DOI: 10.1186/s13018-017-0583-2. PMID: 28577573. PMCID: PMC5455123.

73. Leong NL, Petrigliano FA, McAllister DR. 2014; Current tissue engineering strategies in anterior cruciate ligament reconstruction. J Biomed Mater Res A. 102:1614–24. DOI: 10.1002/jbm.a.34820. PMID: 23737190.

74. Moreau JE, Bramono DS, Horan RL, Kaplan DL, Altman GH. 2008; Sequential biochemical and mechanical stimulation in the development of tissue-engineered ligaments. Tissue Eng Part A. 14:1161–72. DOI: 10.1089/ten.tea.2007.0147. PMID: 18380592.

75. Vincent JP, Magnussen RA, Gezmez F, et al. 2012; The anterolateral ligament of the human knee: an anatomic and histologic study. Knee Surg Sports Traumatol Arthrosc. 20:147–52. DOI: 10.1007/s00167-011-1580-3. PMID: 21717216.

76. Claes S, Vereecke E, Maes M, Victor J, Verdonk P, Bellemans J. 2013; Anatomy of the anterolateral ligament of the knee. J Anat. 223:321–8. DOI: 10.1111/joa.12087. PMID: 23906341. PMCID: PMC3791125.

77. Pomajzl R, Maerz T, Shams C, Guettler J, Bicos J. 2015; A review of the anterolateral ligament of the knee: current knowledge regarding its incidence, anatomy, biomechanics, and surgical dissection. Arthroscopy. 31:583–91. DOI: 10.1016/j.arthro.2014.09.010. PMID: 25447415.

78. Roessler PP, Schüttler KF, Heyse TJ, Wirtz DC, Efe T. 2016; The anterolateral ligament (ALL) and its role in rotational extra-articular stability of the knee joint: a review of anatomy and surgical concepts. Arch Orthop Trauma Surg. 136:305–13. DOI: 10.1007/s00402-015-2395-3. PMID: 26714471.

79. DePhillipo NN, Cinque ME, Chahla J, Geeslin AG, LaPrade RF. 2017; Anterolateral ligament reconstruction techniques, biomechanics, and clinical outcomes: a systematic review. Arthroscopy. 33:1575–83. DOI: 10.1016/j.arthro.2017.03.009. PMID: 28502387.

80. Van der Watt L, Khan M, Rothrauff BB, et al. 2015; The structure and function of the anterolateral ligament of the knee: a systematic review. Arthroscopy. 31:569–82. DOI: 10.1016/j.arthro.2014.12.015. PMID: 25744324.

81. Kraeutler MJ, Welton KL, Chahla J, LaPrade RF, McCarty EC. 2018; Current concepts of the anterolateral ligament of the knee: anatomy, biomechanics, and reconstruction. Am J Sports Med. 46:1235–42. DOI: 10.1177/0363546517701920. PMID: 28426251.

82. Getgood A, Brown C, Lording T, et al. 2019; The anterolateral complex of the knee: results from the International ALC Consensus Group Meeting. Knee Surg Sports Traumatol Arthrosc. 27:166–76. DOI: 10.1007/s00167-018-5072-6. PMID: 30046994.

83. Sonnery-Cottet B, Daggett M, Fayard JM, et al. 2017; Anterolateral Ligament Expert Group consensus paper on the management of internal rotation and instability of the anterior cruciate ligament - deficient knee. J Orthop Traumatol. 18:91–106. DOI: 10.1007/s10195-017-0449-8. PMID: 28220268. PMCID: PMC5429259.

84. Devitt BM, Neri T, Fritsch BA. 2023; Combined anterolateral complex and anterior cruciate ligament injury: anatomy, biomechanics, and management-State-of-the-art. J ISAKOS. 8:37–46. DOI: 10.1016/j.jisako.2022.10.004. PMID: 36368633.

85. Nazzal EM, Keeling LE, Ryan PM, Herman ZJ, Hughes JD. 2023; The role of lateral extra-articular tenodesis in anterior cruciate ligament reconstruction and treatment of rotatory knee instability: a scoping review. Curr Rev Musculoskelet Med. 16:235–45. DOI: 10.1007/s12178-023-09832-4. PMID: 36995532. PMCID: PMC10234940.

86. Inderhaug E, Stephen JM, Williams A, Amis AA. 2017; Biomechanical comparison of anterolateral procedures combined with anterior cruciate ligament reconstruction. Am J Sports Med. 45:347–54. DOI: 10.1177/0363546516681555. PMID: 28027653.

87. Littlefield CP, Belk JW, Houck DA, et al. 2021; The anterolateral ligament of the knee: an updated systematic review of anatomy, biomechanics, and clinical outcomes. Arthroscopy. 37:1654–66. DOI: 10.1016/j.arthro.2020.12.190. PMID: 33340678.

88. Daggett M, Ockuly AC, Cullen M, et al. 2016; Femoral origin of the anterolateral ligament: an anatomic analysis. Arthroscopy. 32:835–41. DOI: 10.1016/j.arthro.2015.10.006. PMID: 26725451.

89. Helito CP, Camargo DB, Sobrado MF, et al. 2018; Combined reconstruction of the anterolateral ligament in chronic ACL injuries leads to better clinical outcomes than isolated ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. 26:3652–9. DOI: 10.1007/s00167-018-4934-2. PMID: 29610972.

90. Helito CP, Sobrado MF, Giglio PN, et al. 2019; Combined reconstruction of the anterolateral ligament in patients with anterior cruciate ligament injury and ligamentous hyperlaxity leads to better clinical stability and a lower failure rate than isolated anterior cruciate ligament reconstruction. Arthroscopy. 35:2648–54. DOI: 10.1016/j.arthro.2019.03.059. PMID: 31421960.

91. Abouljoud MM, Everhart JS, Sigman BO, Flanigan DC, Magnussen RA. 2018; Risk of retear following anterior cruciate ligament reconstruction using a hybrid graft of autograft augmented with allograft tissue: a systematic review and meta-analysis. Arthroscopy. 34:2927–35. DOI: 10.1016/j.arthro.2018.06.044. PMID: 30195958.

92. Sonnery-Cottet B, Saithna A, Cavalier M, et al. 2017; Anterolateral ligament reconstruction is associated with significantly reduced ACL graft rupture rates at a minimum follow-up of 2 years: a prospective comparative study of 502 patients from the SANTI Study Group. Am J Sports Med. 45:1547–57. DOI: 10.1177/0363546516686057. PMID: 28151693.

93. Lee DW, Kim JG, Cho SI, Kim DH. 2019; Clinical outcomes of isolated revision anterior cruciate ligament reconstruction or in combination with anatomic anterolateral ligament reconstruction. Am J Sports Med. 47:324–33. DOI: 10.1177/0363546518815888. PMID: 30640514.

94. Kittl C, Halewood C, Stephen JM, et al. 2015; Length change patterns in the lateral extra-articular structures of the knee and related reconstructions. Am J Sports Med. 43:354–62. DOI: 10.1177/0363546514560993. PMID: 25540293.

95. Devitt BM, Bell SW, Ardern CL, et al. 2017; The role of lateral extra-articular tenodesis in primary anterior cruciate ligament reconstruction: a systematic review with meta-analysis and best-evidence synthesis. Orthop J Sports Med. 5:2325967117731767. DOI: 10.1177/2325967117731767. PMID: 29124075. PMCID: PMC5661757.

96. Hewison CE, Tran MN, Kaniki N, Remtulla A, Bryant D, Getgood AM. 2015; Lateral extra-articular tenodesis reduces rotational laxity when combined with anterior cruciate ligament reconstruction: a systematic review of the literature. Arthroscopy. 31:2022–34. DOI: 10.1016/j.arthro.2015.04.089. PMID: 26116497.

97. Song GY, Hong L, Zhang H, Zhang J, Li Y, Feng H. 2016; Clinical outcomes of combined lateral extra-articular tenodesis and intra-articular anterior cruciate ligament reconstruction in add-ressing high-grade pivot-shift phenomenon. Arthroscopy. 32:898–905. DOI: 10.1016/j.arthro.2015.08.038. PMID: 26524939.

98. Xu J, Han K, Lee TQ, et al. 2022; Anterolateral structure reconstruction similarly improves the stability and causes less over-constraint in anterior cruciate ligament-reconstructed knees compared with modified Lemaire lateral extra-articular tenodesis: a biomechanical study. Arthroscopy. 38:911–24. DOI: 10.1016/j.arthro.2021.06.023. PMID: 34358641.