In this in vitro study of the hip joint we examined which soft tissues act as primary and secondary passive rotational restraints when the hip joint is functionally loaded. A total of nine cadaveric left hips were mounted in a testing rig that allowed the application of forces, torques and rotations in all six degrees of freedom. The hip was rotated throughout a complete range of movement (ROM) and the contributions of the iliofemoral (medial and lateral arms), pubofemoral and ischiofemoral ligaments and the ligamentum teres to rotational restraint was determined by resecting a ligament and measuring the reduced torque required to achieve the same angular position as before resection. The contribution from the acetabular labrum was also measured. Each of the capsular ligaments acted as the primary hip rotation restraint somewhere within the complete ROM, and the ligamentum teres acted as a secondary restraint in high flexion, adduction and external rotation. The iliofemoral lateral arm and the ischiofemoral ligaments were primary restraints in two-thirds of the positions tested. Appreciation of the importance of these structures in preventing excessive hip rotation and subsequent impingement/instability may be relevant for surgeons undertaking both hip joint preserving surgery and hip arthroplasty.

Cite this article: Bone Joint J 2015; 97-B:484–91.

Background. Lateral ankle instability is a common problem, but the precise role of the lateral ankle structures has not been accurately investigated. This study aimed to accurately investigate lateral ankle complex stability for the first time using a novel robotic testing platform. Method. A six degrees of freedom robot manipulator and a universal force/torque sensor were used to test 10 foot and ankle specimens. The system automatically defined the path of unloaded plantar/dorsi flexion. At four flexion angles: 20° dorsiflexion, neutral flexion, 20° and 40° of plantarflexion; anterior-posterior (90N), internal-external (5Nm) and inversion-eversion (8Nm) laxity were tested. The motion of the intact ankle was recorded first and then replayed following transection of the lateral retinaculum, Anterior Talofibular Ligament (ATFL) and Calcaneofibular Ligament (CFL). The decrease in force/torque reflected the contribution of the structure to restraining laxity. Data were analysed using repeated measures of variance and paired t-tests. Results. The ATFL was the primary restraint to anterior drawer (P< 0.01) and the CFL the primary restraint to inversion throughout range (P< 0.04), but with increased plantarflexion the ATFL's contribution increased. The ATFL had a significant role in resisting tibial external rotation, particularly at higher levels of plantarflexion, contributing 63% at 40° (P< 0.01). The CFL provided the greatest resistance to external tibial rotation, 22% at 40° plantarflexion (P< 0.01). The extensor retinaculum and skin did not offer significant restraint in any direction tested. Conclusion. This study shows accurately for the first time the significant role the ATFL and CFL have in rotational ankle stability. This significant loss in rotational stability may have implications in the aetiology of osteophyte formation and early degenerative changes in patients with chronic ankle instability. This is the first time the role of the lateral ankle complex has been quantified using a robotic testing platform

Abstract. Introduction. MCL injuries often occur concurrently with ACL rupture – most noncontact ACL injuries occur in valgus and external rotation (ER) - and conservative MCL treatment leads to increased rate of ACL reconstruction failure. There has been little work developing effective MCL reconstructions. Methods. Cadaveric work measured MCL attachments by digitisation and radiographically, relating them to anatomical landmarks. The isometry of the superficial and deep MCL (sMCL and dMCL) and posterior oblique ligament (POL) was measured using fine sutures led to displacement transducers. Contributions to stability (restraint) were measured in a robotic testing system. Two MCL reconstructions were designed and tested: 3-strand reconstruction (sMCL+dMCL+POL), and 2-strand method (sMCL+dMCL) addressing anteromedial rotatory instability (AMRI). The resulting stability was measured in a kinematics test rig, and compared to the ‘anatomic’ sMCL+POL reconstruction of LaPrade. Results. The sMCL was isometric, centred on the medial epicondyle, and the primary restraint of valgus. The dMCL elongated rapidly in ER, and was the primary restraint of ER near knee extension. The POL slackened rapidly with flexion and only stabilised the knee near extension. With sMCL+dMCL+POL deficiency (‘grade 3’), the 2-strand AM reconstruction restored all stability measures to native, apart from internal rotation. The 3-strand reconstruction restored all stability measures to native. The LaPrade reconstruction did not control ER, lacking a dMCL graft, or valgus in flexion, being anisometric. Conclusions. This work has revealed the importance of the dMCL in stabilising AMRI as part of anatomical MCL reconstruction, with the sMCL restraining valgus

Introduction. Anterior tibial translation (ATT) is assessed in the acutely injured knee to investigate for ligamentous injury and rotational laxity. Specifically, there is a growing recognition of the significance of anterior medial rotary laxity (AMRI) as a crucial element in assessing knee stability. Anterior cruciate ligament (ACL) injuries are often accompanied with medial collateral ligament (MCL) damage. It has been suggested that Deep MCL (dMCL) fibres are a primary restraint in rotational displacement. This research aims to quantify the difference in rotational laxity of patients with ACL and MCL injuries to deem if the Feagin-Thomas test can robustly capture metrics of AMRI. 2. Methods. AMRI was assessed using the Feagin-Thomas test in 7 isolated ACL (iACL) injured participants, 3 combined ACL and superficial fibre MCL (sMCL) injuries, 5 combined ACL and deep fibre MCL injuries, and 21 healthy controls. Displacement values were recorded using an optical motion capture (OMC) system and bespoke processing pipeline which map and model the knee's anterior displacement values relative to the medial compartment. Since absolute values (mm) of rotational laxity vary dependant on the person, values were recorded as a proportion of the rotational laxity obtained from the subject's contralateral leg. Values were compared between each patient group using an ANOVA test and Tukey's honesty significant difference post hoc test. 3. Results. The healthy control group had a median proportion of 0.97 (3SF), whilst the iACL was 1.12 (3SF), a 12% increase in rotational laxity in the injured leg. The sMCL group yielded a result of 1.64 (3SF), a 64% increase in rotational laxity in the injured leg; finally, dMCL resulted in a proportion of rotational laxity of 1.90 (3SF), a 90% increase in rotational laxity [table 1]. Whilst all groups showed differences in the increase of rotational laxity, dMCL was significantly different from the healthy control group (P value 0.0041). 4. Conclusion. ACL injuries with MCL involvement led to an increase in anterior medial rotary laxity and this is more evident in patients where deep MCL fibres are involved. The Feagin-Thomas test appears to be sensitive in detecting differences in AMRI and should be considered when performing comprehensive clinical knee examination. For any figures or tables, please contact authors directly

This in-vitro study finds which hip joint soft tissues act as primary and secondary passive internal and external rotation restraints so that informed decisions can be made about which soft tissues should be preserved or repaired during hip surgery. The capsular ligaments provide primary hip rotation restraint through a complete hip range of motion protecting the labrum from impingement. The labrum and ligamentum teres only provided secondary stability in a limited number of positions. Within the capsule, the iliofemoral lateral arm and ischiofemoral ligaments were primary restraints in two-thirds of the positions tested and so preservation/repair of these tissues should be a priority to prevent excessive hip rotation and subsequent impingement/instability for both the native hip and after hip arthroplasty

Introduction. There is little information available to surgeons regarding how the lateral soft-tissue structures prevent instability in knees implanted with total knee arthroplasty (TKA). The aim of this study was to quantify the lateral soft-tissue contributions to stability following cruciate retaining (CR) TKA. Methods. Nine cadaveric knees with CR TKA implants (PFC Sigma; DePuy Synthes Joint Reconstruction) were tested in a robotic system (Fig. 1) at full extension, 30°, 60°, and 90° flexion angles. ±90 N anterior-posterior force, ±8 Nm varus-valgus and ±5 Nm internal-external torque were applied at each flexion angle. The anterolateral structures (ALS, including the iliotibial band, anterolateral ligament and anterolateral capsule), the lateral collateral ligament (LCL), the popliteus tendon complex (Pop T) and the posterior cruciate ligament (PCL) were then sequentially transected. After each transection the kinematics obtained from the original loads were replayed, and the decrease in force / moment equated to the relative contributions of each soft-tissue to stabilising the applied loads. Results. In the CR TKA knee, the LCL was found to be the primary restraint to varus laxity (Fig. 2, an average 56% across all flexion angles), and was significant in internal-external rotational stability (28% and 26% respectively) and anterior drawer (16%). The ALS restrained 25% of internal rotation (Fig. 3), whilst the PCL was significant in posterior drawer only at 60° and 90° flexion. The Pop T was not found to be significant in any tests. Conclusion. This study has for the first time delineated the relative contributions of lateral structures to stability in the implanted knee. It was confirmed that the LCL is the major lateral structure in CR TKA stability throughout the arc of flexion. In the event of LCL deficiency, stability of the knee may only be restored by either changing to a more constrained implant or performing a reconstruction of the ligament. Furthermore, care should be taken when releasing the LCL to correct a valgus deformity as it may result in a combined rotational laxity pattern that cannot be overcome by the other passive lateral structures or the PCL. For figures, please contact authors directly

INTRODUCTION. Understanding the biomechanics of the anatomical knee is vital to innovations in implant design and surgical procedures. The anterior – posterior (AP) laxity is of particular importance in terms of functional outcomes. Most of the data on stability has been obtained on the unloaded knee, which does not relate to functional knee behavior. However, some studies have shown that AP laxity decreases under compression (1) (2). This implies that while the ligaments are the primary stabilizers under low loads, other mechanisms come into play in the loaded knee. It is hypothesized this decreased laxity with compressive loads is due to the following: the meniscus, which will restrain the femur in all directions; the cartilage, which will require energy as the femur displaces across the tibial surface in a plowing fashion; and the upwards slope of the anterior medial tibial plateau, which stabilizes the knee by a gravity mechanism. It is also hypothesized that the ACL will be the primary restraint for anterior tibial translation. METHODS. A test rig was designed where shear and compressive forces could be applied and the AP and vertical displacements measured (Figure 1). The AP motion was controlled by the air bearings and motor, allowing for the accurate application of the shear force. Position and force data were measured using load cells, potentiometers, and a linear variable differential transducer. Five knee specimens less than 60 years old and without osteoarthritis (OA), were evaluated at compressive loads of 0, 250, 500, 750 N, with the knee at 15° flexion. Three cycles of shear force at ±100 N constituted a test. The intact knee was tested, followed by testing after each of the following resections: LCL, MCL, PCL, ACL, medial meniscus, and lateral meniscus. RESULTS. The average displacement of the tibia without load was 6.17 mm anterior and −4.92 mm posterior. Under load the posterior translation of the tibia was reduced essentially to zero. After ACL resection, the anterior tibial displacement increased substantially, with a further increase after medial meniscus resection. Cartilage deformation had a minimal effect. DISCUSSION. The hypotheses that the ACL and the upwards tibial slope would provide stability under load were validated. The ACL was essential under all load conditions because the posterior tibial surface was flat (figure 2). The medial meniscus provided vertical stability, as a space buffer (figure 3), and in two specimens under load it provided the same restraint as the ACL (figure 2). The experiment was limited by lack of muscle action, the number of specimens, and a single flexion angle. SIGNIFICANCE. The test rig and methodology had capabilities exceeding those of previous work in determining the mechanisms of AP knee stability under load due to its frictionless air bearings. The results have application ranging from sports medicine to total knee design. The stabilizing effect of the tibial slope seen here validates tibial osteotomies for improved stability. The importance of reproducing ACL function in total knee design is emphasized. For figures/tables, please contact authors directly.

Recurrent patellar dislocation is a relatively common disorder in young patients. Historically, treatment options have been based on the underlying disorder predisposing the patient to the dislocation. This has resulted in various soft tissue reefing procedures, patella tendon realignment procedures and boney realignment procedures. Further research has shown that the medial patellofemoral ligament (MPFL) is the primary restraint to lateral patella subluxation and dislocation. Many authors have published their successful treatment of recurrent patella dislocation by reconstruction of the medial patellofemoral ligament. The most widely used is autologous semitendinosis tendon grafts, as well as synthetic materials, and MPFL reconstructions may be combined with boney procedures. Varieties of fixation techniques have been described involving both the patella and femoral sides. We present a technique of MPFL reconstruction using the autologous ipsilateral quadriceps tendon. Our technique avoids the morbidity associated with semitendinosis graft harvesting and the drill holes in, and potential resulting fracture of, the patella. The technique is also simple and is associated with decreased procedure costs. We present the technique and a series of 6 patients (7 knees) with follow up ranging from 8 months to 9 years. The average age of patients at the time of surgery 16–28 years (mean = 20years). There have been no redis-locations. The median Kujala patellofemoral knee score at follow up was 97 out of 100 (Range 69–100). The results compare very favourably to published results using other techniques. Our technique of reconstructing the MPFL is reliable, produces good results using an objective knee score, and is cost effective

Background and purpose of the study: the anterior cruciate ligament (ACL) is a continuum of fibres which are differently recruited through range of motion. Two main functional bundles can be identified: the postero-lateral bundle (PLB) which is taut exclusively towards extension and the anteromedial bundle (AMB) which is taut through full range of motion. The purpose of this investigation was to assess the relative contribution of the bundles to intact knee kinematics. Material and methods: fourteen intact cadaver knees were instrumented in a non-ferromagnetic rig and six degrees of freedom kinematics through flexion-extension was recorded with an electromagnetic device under the application of a 90N anterior force or a 5Nm internal rotation torque. The AMB and PLB were alternatively cut first in each knee and knee kinematics was recorded. The other bundle was then dissected and ACL deficient knee kinematics tested. Results: when the AMB was cut anterior tibial translation increased and no effects on rotations were recorded. When the PLB was first cut no significant effects on anterior laxity were observed. Different rotational responses were observed in different knees. After the section of both bundles a larger increase in anterior laxity was observed. The changes in rotation differed from knee to knee. Discussion: The AMB is a primary restraint against anterior tibial translation and has a small and variable effect on rotations. The PLB is a secondary restraint against anterior tibial translation in extension and maintains normal rotational laxity in AMB deficient knees. Therefore, reconstruction of both bundles is theoretically advantageous to restore both intact knee anteroposte-rior and rotational laxity

Controversies about the management of injuries to the soft tissue structures of the posteromedial corner of the knee and the contribution of such peripheral structures on rotational stability of the knee are of increasing interest and currently remain inadequately characterised. The posterior oblique ligament (POL) is a fibrous extension off the distal aspect of the semimembranosus that blends with and reinforces the posteromedial aspect of the joint capsule. The POL is reported to be a primary restraint to internal rotation and a secondary restraint to valgus translation and external rotation. Although its role as a static stabiliser to the medial knee has been previously described, the effect of the posterior oblique ligament (POL) injuries on tibiofemoral stability during Lachman and pivot shift examination in the setting of ACL injury is unknown. The objective of this study was to quantify the magnitude of tibiofemoral translation during the Lachman and pivot shift tests after serial sectioning of the ACL and POL. Eight knees were used for this study. Ligamentous constraints were sequentially sectioned in the following order: ACL first, followed by the POL. Navigated mechanised pivot shift and Lachman examinations were performed before and after each structure was sectioned, and tibiofemoral translation was recorded. Lachman test: There was a mean 6.0 mm of lateral compartment translation in the intact knee (SD = 3.3 mm). After sectioning the ACL, translation increased to 13.8 mm (SD = 4.6; P<0.05). There was a nonsignificant 0.7 mm increase in translation after sectioning the POL (mean = 14.5 mm; SD = 3.9 P>0.05). Mechanised pivot shift: Mean lateral compartment translation in the intact knee was −1.2 mm (SD = 3.2 mm). Sectioning the ACL caused an increase in anterior tibial translation (mean = 6.7 mm; SD = 3.0 mm; P<0.05). No significant change in translation was seen after sectioning the POL (mean = 7.0 mm, SD = 4.0 mm; P>0.05). Sectioning the POL did not significantly alter tibiofemoral translation in the ACL deficient knee during the Lachman and pivot shift tests. This study brings into question whether injuries to the POL require reconstruction in conjunction with ACL reconstruction. More studies are needed to further characterise the role of the injured POL in knee stability and its clinical relevance in the ACL deficient and reconstructed knee

Controversies about the management of injuries to the soft tissue structures of the posteromedial corner of the knee and the contribution of such peripheral structures on rotational stability of the knee are of increasing interest and currently remain inadequately characterised. The posterior oblique ligament (POL) is a fibrous extension off the distal aspect of the semimembranosus that blends with and reinforces the posteromedial aspect of the joint capsule. The POL is reported to be a primary restraint to internal rotation and a secondary restraint to valgus translation and external rotation. Although its role as a static stabiliser to the medial knee has been previously described, the effect of the posterior oblique ligament (POL) injuries on tibiofemoral stability during Lachman and pivot shift examination in the setting of ACL injury is unknown. The objective of this study was to quantify the magnitude of tibiofemoral translation during the Lachman and pivot shift tests after serial sectioning of the ACL and POL. Eight knees were used for this study. Ligamentous constraints were sequentially sectioned in the following order: ACL first, followed by the POL. Navigated mechanised pivot shift and Lachman examinations were performed before and after each structure was sectioned, and tibiofemoral translation was recorded. Lachman test: There was a mean 6.0 mm of lateral compartment translation in the intact knee (SD = 3.3 mm). After sectioning the ACL, translation increased to 13.8 mm (SD = 4.6; P<0.05). There was a nonsignificant 0.7 mm increase in translation after sectioning the POL (mean = 14.5 mm; SD = 3.9 P>0.05). Mechanised pivot shift: Mean lateral compartment translation in the intact knee was −1.2 mm (SD = 3.2 mm). Sectioning the ACL caused an increase in anterior tibial translation (mean = 6.7 mm; SD = 3.0 mm; P<0.05). No significant change in translation was seen after sectioning the POL (mean = 7.0 mm, SD = 4.0 mm; P>0.05). Sectioning the POL did not significantly alter tibiofemoral translation in the ACL deficient knee during the Lachman and pivot shift tests. This study brings into question whether injuries to the POL require reconstruction in conjunction with ACL reconstruction. More studies are needed to further characterise the role of the injured POL in knee stability and its clinical relevance in the ACL deficient and reconstructed knee

Recurrent patellar dislocation is a relatively common disorder in young patients. Historically, treatment options have been based on the underlying disorder predisposing the patient to the dislocation. This has resulted in various soft tissue reefing procedures, patella tendon realignment procedures and boney realignment procedures. Further research has shown that the medial patello-femoral ligament (MPFL) is the primary restraint to lateral patella subluxation and dislocation. Many authors have published their successful treatment of recurrent patella dislocation by reconstruction of the medial patellofemoral ligament. The most widely used is autologous semitendinosis tendon grafts, as well as synthetic materials, and MPFL reconstructions may be combined with boney procedures. Varieties of fixation techniques have been described involving both the patella and femoral sides. We present a technique of MPFL reconstruction using the autologous ipsilateral quadriceps tendon. Our technique avoids the morbidity associated with semitendinosis graft harvesting and the drill holes in, and potential resulting fracture of, the patella. The technique is also simple and is associated with decreased procedure costs. We present the technique and a series of six patients (seven knees) with follow up ranging from eight months to nine years. The average age of patients at the time of surgery 16 to 28 years (mean = 20 years). There have been no redislocations. The median Kujala patellofemoral knee score at follow up was 97 out of 100 (Range 69–100). The results compare very favorably to published results using other techniques. Our technique of reconstructing the MPFL is reliable, produces good results using an objective knee score, and is cost effective. Seventy staff members participated from a potential pool of approximately one hundred staff on duty at the time. Of the seventy staff who participated in this research project a total of three staff members were within 50 mls of the correct amount for each of the three samples. Overall staff were very poor at estimating blood loss. Staff working in the operating theatre, no matter what their affiliation or years of experience, are not accurate when estimating blood loss spilt into a patients bed. A tool that aids in blood loss estimation is a valuable addition to the theatre resource manual

The supporting structures on the medial side of the knee consist of:. - Layer I, the superficial fascia. - Layer II, the superficial Medial Collateral Ligament (sMCL) with parallel fibers running from the femoral epicondyle to the anteromedial tibial crest 5–7 cm below the joint line. - Layer III, the deep capsular layer. The pes tendons are situated between Layer I and II–III. Beneath the sMCL Layer III thickens and forms the deep MCL (dMCL) from femur condyle to meniscus and from meniscus to tibia. More dorsally Layer II and III fuse and form the Postero Medial Capsule (PMC) which is connected to the meniscus and tibia. The PMC is augmented by the semimembranosus tendon. The sMCL is the primary restraint against valgus and transsection causes 2–5 degrees laxity in flexion or approximately 3–5 mm joint opening. Additional cutting of the PMC gives additional laxity of 7–8 degrees up to 10 degrees. An isolated sMCL lesion causes more laxity in flexion and a combination of sMCL with a PMC lesion causes also laxity in extension. The dMCL does provide some stability in 45 dg. of flexion but is not very strong. The goal of MCL-PMC reconstruction should be functional anatomical repair of the pathology and retention of the meniscus. After treating the pathology the medial side of the knee should be stable in extension (by repair PMC) and in flexion (by repair sMCL). The PMC – meniscus – semimembranosus complex should be refixated at the posteromedial tibia corner if it is loose. Bony avulsions should be fixed with washer and screw or anchors. Ligamentous avulsions can be fixed at the anatomical insertion site with trans-osseous non-resorbable sutures or bone anchors or screws with toothed washers. A distalisation of a ligament insertion (sMCL) with its bony attachment is also an elegant solution in chronic cases. If the surgeon wants to tension the SMCL at the femoral side, the bony insertion with the ligament attached to it can be recessed at its original position. Allografts and double stranded hamstring autografts can be used when native tissue is lacking

Aims

Mid-level constraint designs for total knee arthroplasty (TKA) are intended to reduce coronal plane laxity. Our aims were to compare kinematics and ligament forces of the Zimmer Biomet Persona posterior-stabilized (PS) and mid-level designs in the coronal, sagittal, and axial planes under loads simulating clinical exams of the knee in a cadaver model.

Aims

Unicompartmental knee arthroplasty (UKA) has become a popular method of treating knee localized osteoarthritis (OA). Additionally, the posterior cruciate ligament (PCL) is essential to maintaining the physiological kinematics and functions of the knee joint. Considering these factors, the purpose of this study was to investigate the biomechanical effects on PCL-deficient knees in medial UKA.

Recent literature suggests MPFL is the primary medial restraint in lateral patellar dislocation and supports acute repair in first lateral dislocations. Objective: To evaluate the results of patients who underwent acute surgical repair of MPFL in our unit. Materials and Methods: Nine patients with mean age of 25(12–41) were evaluated in a dedicated clinic. The mean follow-up was 15.7 months (6–22). All patients had MRI scan preoperatively and were operated within two weeks of injury. Patients were evaluated clinically and Kujala and Lysholm scores were recorded. Results: None of these patients had further dislocations of patella and patellar apprehension test was negative on examination. The mean Kujala score was 78(74–100) and mean Lysholm score was 92(85–100). All patients had returned to sporting activities at clinic review. All but one mentioned that they would choose surgical repair if the injury occurred in the other knee. Conclusion: Our results confirm in selective patients acute repair of MPFL is the ideal treatment to prevent recurrent dislocations and early return to sports

Objectives

The use of the haptically bounded saw blades in robotic-assisted total knee arthroplasty (RTKA) can potentially help to limit surrounding soft-tissue injuries. However, there are limited data characterizing these injuries for cruciate-retaining (CR) TKA with the use of this technique. The objective of this cadaver study was to compare the extent of soft-tissue damage sustained through a robotic-assisted, haptically guided TKA (RATKA) versus a manual TKA (MTKA) approach.

The June 2015 Research Roundup360 looks at: Tranexamic acid: just give it – it’s not important how!; The anterolateral ligament re-examined; Warfarin a poor post-operative agent; Passive exoskeleton the orthosis of the future?; Musculoskeletal medicine: a dark art to UK medical students?; Alendronic acid and bone density post arthroplasty; Apples with oranges? Knee functional scores revisited

Objectives

The injured anterior cruciate ligament (ACL) is thought to exhibit an impaired healing response, and attempts at surgical repair have not been successful. Connective tissue growth factor (CTGF) is reported to be associated with wound healing, probably through transforming growth factor beta 1 (TGF-β1).

Injury to the anterior cruciate ligament (ACL) is one of the most devastating and frequent injuries of the knee. Surgical reconstruction is the current standard of care for treatment of ACL injuries in active patients. The widespread adoption of ACL reconstruction over primary repair was based on early perception of the limited healing capacity of the ACL. Although the majority of ACL reconstruction surgeries successfully restore gross joint stability, post-traumatic osteoarthritis is commonplace following these injuries, even with ACL reconstruction. The development of new techniques to limit the long-term clinical sequelae associated with ACL reconstruction has been the main focus of research over the past decades. The improved knowledge of healing, along with recent advances in tissue engineering and regenerative medicine, has resulted in the discovery of novel biologically augmented ACL-repair techniques that have satisfactory outcomes in preclinical studies. This instructional review provides a summary of the latest advances made in ACL repair.

Cite this article: Bone Joint Res 2014;3:20–31.