Editorial Commentary: Are Adjustable-Length Loop Devices Adequate for Femoral Fixation of Anterior Cruciate Ligament Graft?

To date, there is no consensus regarding which type of cortical suspension device is biomechanically superior during anterior cruciate ligament reconstruction. Retensioning or knotting has been reported to improve the biomechanical profile of adjustable-length devices, although fixed-length devices demonstrated overall superior biomechanical properties. Intraoperative or postoperative loop slippage and graft displacement should be investigated in future clinical and radiographic studies including serial magnetic resonance imaging.     

Editorial Commentary: Triple-Bundle Anterior Cruciate Ligament Reconstruction: More Is More or Less Is More?

We need ambitious pioneers to explore the frontiers of surgical technique, but the surgeons that follow are wise to wait for independent and robust evidence of clinical benefit. Double-bundle anterior cruciate ligament reconstruction has struggled to establish its role, and triple-bundle reconstruction is perhaps even less likely to gain widespread acceptance, given that cadaveric research has shown only a small biomechanical advantage over a double-bundle or even a single-bundle technique and there is no convincing evidence of improved clinical outcomes.     

Editorial Commentary: Patellar Tendon or Hamstring: Which Kind of Anterior Cruciate Ligament Patient Are You?

The role of graft selection on clinical and functional outcomes following anterior cruciate ligament (ACL) reconstruction has gained significant attention in the orthopaedic sports medicine community in recent years. Bone–patellar tendon–bone (BPTB) and semitendinosus/gracilis hamstring tendon (HT) autografts are 2 of the most commonly used grafts, given their low failure rates, predictable outcomes, and ability to incorporate appropriately at the graft site. However, multiple studies have recently shown each of these graft options to have some potentially less-desirable characteristics in regards to outcomes in specific patient populations. More specifically, in 14- to 25-year-old athletes, HT autografts have been shown to result in decreased rotational stability, decreased return to sport rates, and increased graft failure rates. On the other hand, BPTB autografts can require a prolonged recovery period and have been associated with increased postoperative pain and long-term kneeling pain. HT and BPTB grafts are both excellent grafts; however, it is important to understand the differences in clinical and functional outcomes between these graft options for ACL reconstruction. The characteristics of the graft need to be considered and individualized for each patient who is being treated for an ACL injury.     

Editorial Commentary: Taking a Wider View During Anterior Cruciate Ligament Reconstruction? The Case for Doing More Than Just Reconstructing the Anterior Cruciate Ligament Itself

Anterior cruciate ligament reconstruction may leave a residual instability. If other pathology is identified, the surgeon should consider doing more than the isolated anterior cruciate ligament reconstruction to address peripheral lesions to the menisci, ligaments, and capsule in selected cases.     

Editorial Commentary: Back to the Past—Anterior Cruciate Ligament Repair Revisited

There has been increasing scientific interest in primary anterior cruciate ligament (ACL) repair in recent years. The results of these procedures have improved significantly compared with the 1970s and 1980s. Nevertheless, the overall rerupture rates after ACL repair are worse than after ACL reconstruction, and patient-reported outcome measures do not improve after ACL repair, in contrast to those after ACL reconstruction. However, because primary ACL repair is performed in the acute phase, improvement in patient-reported outcome measures after surgery is not expected. We believe that in the future, primary ACL repair will be established next to ACL reconstruction and nonsurgical therapy. One possible indication is a proximal ACL rupture. Which surgical technique will prevail—and whether orthobiological treatments such as platelet-rich plasma or stem cells will improve postoperative outcomes after ACL repair—will need further clarification by clinical trials.     

Editorial Commentary: Built to Last or Just a Trend? Hybrid Graft for Anterior Cruciate Ligament Reconstruction

The use of a hybrid autograft-allograft for primary anterior cruciate ligament reconstruction (ACLR) has gained significant attention in the orthopaedic sports medicine community in recent years. A hybrid graft is most often used to supplement a hamstring autograft with a small diameter, based on evidence that a graft size under a certain diameter (most often 8 mm) increases the risk for graft failure in younger patients. Multiple studies have been published comparing clinical outcomes of ACLR using a hybrid graft versus a hamstring autograft, with conflicting results. Although it is important to attempt to harvest a graft of sufficient size for this procedure, the indications for the use of a hybrid graft for primary ACLR are still unknown.     

Editorial Commentary: Anterior Cruciate Ligament Repair Revisited … Do We Need A Paradigm Shift?

This commentary discusses a brief history of anterior cruciate ligament (ACL) repair using a variety of techniques, including open primary repair, arthroscopic repair, and bridge-enhanced ACL repair. Concerns are raised about the current reported outcomes of primary ACL repair. There is a need for controlled prospective studies that assess the structural integrity of the repaired ligament using modern imaging techniques, physical examination, and KT-1000 testing. Caution should be used when interpreting published studies that rely solely on patient-reported outcome measures.     

Editorial Commentary: Use of Platelet-Rich Plasma in Anterior Cruciate Ligament Reconstruction: Should We Abandon?

The advantages of using platelet-rich plasma application in anterior cruciate ligament reconstruction remains controversial. However, I think further long-term and better design studies are needed to identify whether the administration of platelet-rich plasma could truly play a beneficial role during anterior cruciate ligament reconstruction.     

Editorial Commentary: Déjà Vu: Double-Bundle Anterior Cruciate Ligament Reconstruction Revisited

Regardless of the technique utilized, tunnel expansion following anterior cruciate ligament reconstruction remains a mystery and a clinical challenge. No procedure seems to be immune to this, even anatomic double-bundle reconstruction. This technique was introduced more than 20 years ago and showed great promise while also contributing significantly to our current knowledge of anterior cruciate ligament anatomy and biomechanics. However, we must remember that new techniques do carry with them new side effects that we must document and acknowledge if we hope to improve our surgical outcomes.     

Editorial Commentary: The Trend to Blend: Should We Be Using Hybrid Grafts in Adult Anterior Cruciate Ligament Reconstructions?

Hybrid anterior cruciate ligament grafts augmenting a small-diameter hamstring tendon autograft with nonirradiated allografts can be used with good results in adults. In teens, however, outcomes of hybrid grafts have not been well defined, and other solutions to small hamstring grafts including graft folding, contralateral autograft augmentation, or selection of a different autograft source could be considered.     

Editorial Commentary: Graft Orientation in Anterior Cruciate Ligament Reconstruction—Does It Really Matter?

The search for an isometric, anatomic, biomechanically optimal anterior cruciate ligament (ACL) reconstruction remains elusive. To better approximate the native ACL, surgeons have used a host of different graft options and repair techniques. Surgical techniques involving single-tunnel and double-tunnel (or even triple-tunnel!) fixation sites have been used in an attempt to re-create the “2 (or more) bundles” of the ACL. Transtibial and independent femoral drilling techniques are used in an effort to create a more “anatomic” femoral tunnel placement. Once the anatomic femoral attachment site is identified, there is then a debate on how best to “fill” the attachment site with the surgical graft. These are all important discussions and debates, but one question remains . . . Does any of it really matter?     

Editorial Commentary: All-Inside Anterior Cruciate Ligament Reconstruction: In Pursuit of Ideal Graft Fixation

With evolution of techniques in orthopaedic surgery, incremental improvements can be anticipated. All-inside anterior cruciate ligament (ACL) reconstruction represents a revolution in treatment of ACL injuries, and further technical modifications may result in gradual improvements. This process of continual optimization of our techniques is important for providing the best possible surgical outcomes. Supplemental fixation of the inner graft limbs may lead to improved time-zero biomechanical performance when all-inside ACL reconstruction is performed. However, in ACL surgery, optimal graft selection and fixation are still debated.     

Editorial Commentary: Anterior Cruciate Ligament Tibial Eminence Avulsion Fractures: Are They Trying to Tell Us Something?

Arthroscopic reduction and fixation of tibial eminence avulsion fractures has excellent clinical results and adequately restores anterior cruciate ligament function with a low rate of complications. Clinical outcomes are preserved at an average of 8 years, and the incidence of osteoarthritis is low at midterm follow up. These injuries may represent the best-case scenarios of anterior cruciate ligament injury because they represent lower energy injuries without significant associated meniscal or chondral pathologies. These findings may give us additional clues about which patients are the best candidates for primary anterior cruciate ligament repair in the setting of femoral-sided avulsions.     

Editorial Commentary: Anterolateral Ligament Augmentation for the Anterior Cruciate Ligament–Deficient Knee Debate—The Proof Is in the Pudding

The highly debatable and contentious anterolateral ligament (ALL) and its use as an augmentation for the anterior cruciate ligament (ACL)–deficient knee during ACL reconstruction continue to flourish in the literature, but the proof will be in the clinical outcome. Despite the ALL controversy, what clearly stands out from authors on either side of the debate is that there is much more going on than just the ACL in the ACL-deficient knee. Techniques of ALL augmentation or lateral extra-articular tenodesis continue to show promise that the lateral soft-tissue structures may provide the answer for the residual pivot and for better outcomes, higher return-to-sport rates, and lower rupture rates. Many authors and researchers believe that this may be a critical adjunct in high-risk situations during ACL reconstruction. But the proof of the pudding will be in the eating.     

Editorial Commentary: Anterior Cruciate Ligament Graft Fixation Strength: Do Ultimate Load and Cyclic Deformation Really Matter?

Surgeons, therapists, and industry are very focused on anterior cruciate ligament graft fixation strength, specifically ultimate load and cyclic deformation. Although many publications have focused on the importance of these values, no significant issues with early graft fixation failure or elongation have been recently been reported. Thus, instead of focusing on the absolute maximum values, it would be more helpful to define a minimum successful fixation strength, as well as determine how to test for physiologic cyclic elongation.     

Editorial Commentary: Ligamentous Hyperlaxity: A Decisive Factor for the Indication of a Combined Anterior Cruciate Ligament and Anterolateral Ligament Reconstruction?

Indications for combined anterior cruciate ligament (ACL) and anterolateral ligament (ALL) reconstruction are not well defined, and the role of ligamentous hyperlaxity on anterolateral rotatory instability in an ACL-deficient knee remains unclear. Possible indications for combine ACL and ALL reconstruction might be a high-grade pivot shift, revision ACL reconstruction, patients with proven anterolateral knee pathology on preoperative imaging, and young patients participating in high-demand sport, and perhaps, finally, patients with ligamentous hyperlaxity as above.     

Editorial Commentary: Single-Bundle Versus Double-Bundle Anterior Cruciate Ligament Reconstruction … Are We Barking up the Wrong Tree?

As techniques in anterior cruciate ligament reconstruction continue to evolve, studies comparing single bundle to double bundle continue to mount in numbers. Although there have been great strides in identifying anatomic tunnel placement, how many tunnels (bundles) are created, and how those tunnels are placed, we still seem to be stuck with grossly similar results with respect to both patient-related and objective outcome measures. It seems to me that we can do a very good job reproducing what we do to a cadaver in a lab. Unfortunately, that cadaver does not get up and walk after our job is done as surgeons. Nearly 20% of our athletes do not return to their prior level of sport, and 30% of our patients develop radiographic signs of osteoarthritis. There must be something we are neglecting.     

Editorial Commentary: Managing Excessive Posterior Slope in Anterior Cruciate Ligament Reconstruction: Where Do We Draw the Line?

When an anterior cruciate ligament (ACL) reconstruction fails, surgeons often rush to critique graft placement, graft choice, size, and fixation amongst other factors. One often-overlooked but important risk factor for noncontact failure of ACL reconstruction is tibial alignment. Although the deleterious effects of varus and valgus malalignment have been well established, recent research calls attention to excess posterior tibial slope as an underappreciated risk factor for failure of ACL reconstruction.