Acute, traumatic meniscus tears are common and should be repaired whenever possible. However, the biological age of the patient, along with the specific tear morphology, may significantly influence the selection of the repair technique, expected clinical outcomes and the postoperative rehabilitation protocol. Risk factors for failure of meniscus repair, such as ligament laxity, need to be addressed to improve the healing potential of the meniscus. Biologic augmentation strategies, including bone marrow stimulation, platelet-rich plasma, fibrin clot, mesenchymal stem cells or meniscal wrapping, can be used to enhance healing and reduce failure of meniscus repair rates. However, the clinical evidence remains limited and of low quality. As such, the routine use of biologic augmentation in meniscus repair warrants critical evaluation. In patients with post-meniscectomy syndrome, meniscus allograft transplantation (MAT) may be a viable option to reduce pain and joint degeneration and improve knee function. Meniscus implants provide alternatives to traditional MAT; however, their long-term efficacy, chondroprotective effects and integration within the knee joint require further research. Meniscus reconstruction using tendon autografts has been described as an alternative treatment option in patients with meniscus loss. Emerging methods, such as gene therapy and repurposed drugs, demonstrate in vitro potential for advancing meniscal repair, although their clinical applications are still in their infancy. Future research is necessary to optimize meniscal repair techniques, enhance clinical efficacy, and ultimately, improve outcomes in patients. Level of Evidence Level V.

PURPOSE:Multiple versions of the Knee Injury and Osteoarthritis Outcome Score (KOOS) are used in anterior cruciate ligament (ACL) populations, but their responsiveness and ceiling effects remain uncertain. This study aimed to evaluate the floor and ceiling effects, responsiveness and minimal important difference (MID) using the United Kingdom's National Ligament Registry (NLR). It was hypothesised that ceiling effects would increase over time, but would vary by KOOS version. METHODS:A secondary analysis of the NLR (2012-2024) was performed including patients undergoing ACL reconstruction. We quantified floor and ceiling effects for KOOS5, KOOS4, KOOS-ACL, KOOSglobal. Responsiveness was assessed using Cohen's d and standardised response mean comparing pre-operative scores and follow-up scores (6 months, 1 year, 2 years and 5 years). MIDs were estimated using a distribution-based method (half of the baseline standard deviation). RESULTS:14,660 participants completed baseline scores and were followed up. Large improvements were observed from baseline to 12 months (KOOS5 1.44 [95% confidence interval, CI, 1.40-1.48], KOOS4 1.54 [95% CI 1.50-1.59], KOOS-ACL 1.45 [95% CI 1.42-1.49] and KOOSglobal 1.81 [95% CI 1.74-1.87], followed by increased ceiling effects). At 12 months, ceiling effects (90-100 definition) were present for KOOS5 (30.46%), KOOS4 (24.60%) and KOOS-ACL composite (44.01%), and increased at 24 and 60 months. KOOSglobal demonstrated lower ceiling effects: 5.37% at 12 months and 13.38% at 60 months. Pre-operative floor effects were highest for sport/recreation (20.32%) and KOOS-ACL sport (19.68%). Estimated MIDs were 9.0 for KOOS5, 9.0 for KOOS4, 9.6 for pain, 9.7 for symptoms, 10.3 for activities, 13.6 for sport/recreation, 9.5 for quality of life, 10.1 for KOOS-ACL composite, 10.0 for KOOS-ACL function, 12.5 for KOOS-ACL sport, and 5.1 for KOOSglobal. CONCLUSIONS:Ceiling effects were observed for KOOS5, KOOS4 and KOOS-ACL from 12 months, suggesting a limited ability to distinguish between higher-functioning patients. KOOSglobal appears less susceptible to ceiling effects. LEVEL OF EVIDENCE:Level III, cohort study.

The incidence of anterior cruciate ligament (ACL) injuries is increasing in the UK, with a particularly sharp increase among young female athletes participating in sport. ACL injuries result in significant morbidity, with a profound impact on the physical, mental and social health of individuals, alongside lengthy rehabilitation. Therefore, primary prevention of ACL injuries is desirable. The intrinsic and extrinsic risk factors associated with ACL injury, such as deficits in neuromuscular control, impaired movement quality, fatigue, strength imbalances, and suboptimal load management, are shared with a spectrum of other lower-limb musculoskeletal injuries. This overlap supports the concept that ACL injury prevention may not be best considered a condition-specific endeavour, but rather as a component of a comprehensive lower-limb injury prevention strategy. ACL prevention interventions typically include multi-component training methods designed to improve neuromuscular control, functional performance, balance, strength and power. while often framed around ACL injury reduction, their effects extend beyond the knee, conveying protection against other lower-limb injuries and improving overall performance. Despite a growing body of evidence demonstrating the efficacy of neuromuscular injury prevention programmes, their translation into routine practice has been inconsistent. This annotation outlines the current best evidence relating to ACL injury epidemiology and the effectiveness of injury prevention strategies, supporting a transition to integrate ACL injury prevention into wider, sport-specific lower-limb injury prevention programmes. In doing so, it highlights key stakeholders and barriers relevant to large-scale implementation of injury prevention programmes.

Anterior cruciate ligament revision (ACLRev) remains a complex and demanding procedure. Although an increasing number of studies identified factors associated with graft failure and revision outcomes, clear and practical guidelines are still limited. To address these gaps, the European Society for Sports Traumatology, Knee Surgery and Arthroscopy developed a consensus aimed at standardizing indications for ACLRev. Although this initiative provided important guidance, some questions remain unresolved, such as the optimal graft choice and the management of associated procedures. The aim of this review is to provide an updated overview of current literature regarding preoperative planning, surgical techniques and ACLRev management. ACLRev is currently indicated after previous anterior cruciate ligament reconstruction resulting in knee instability, particularly in younger patients with high-functional demands. ACLRev may be performed as a one- or two-stage procedure. A two-stage approach is appropriate in case of infection, arthrofibrosis or insufficient bone stock that precludes secure and anatomical graft fixation. Autografts are generally preferred, particularly in young active patients, due to lower reported failure rates. Increasing attention has been directed to treatment of associated pathologies, such as ramp and root lesions, associated ligamentous instabilities (medial and lateral) or bony malalignment. Additional extraarticular anterolateral procedures are frequently used to reduce failure rates and improve rotational stability. Conversely, the role of slope-reducing osteotomies in ACLRev remains less defined, with good outcomes reported in small case series. Despite the growing body of clinical research, several issues remain unresolved, including the optimal individualized graft selection and indications for combined procedures. This manuscript summarizes the most recent evidence on ACLRev management, with emphasis on graft selection, indications for extraarticular anterolateral procedures, management of medial instability and principles of slope correction. Future high-level studies are needed, particularly addressing peripheral soft-tissue management and osseous corrections, to establish guidelines and enhance clinical outcomes for patients undergoing ACLRev. LEVEL OF EVIDENCE: Level V, expert opinion.

Background:Partial anterior cruciate ligament (ACL) tears, particularly injuries detected with magnetic resonance imaging (MRI) but stable on ligamentous examination, appear to be recognized more frequently; however, there remains no consensus management for this complex pathology. Purpose:To present the results of a survey of a group of international ACL experts on the management of partial ACL injuries. Study Design:Survey study; Level of evidence, 5. Methods:The ACL Study Group is an international group of orthopaedic surgeons with a special interest in the ACL. There are 169 members overall, with 135 clinically active surgeons. A branching logic survey was developed and circulated to members of the ACL Study Group via electronic mail. Categories included member demographics as well as recommended management strategies of partial ACL injuries, including recommendations on return to play. Results:Of the 135 clinically active surgeon members, 113 responded to the survey (84%). Nonoperative management of partial ACL injuries was selected by 92% of respondents. Of those who managed nonoperatively, 75% indicated they would not restrict weightbearing and 59% would not recommend a knee brace. When those who managed the patient nonoperatively determined criteria for return to sports (RTS), 33% would use differential knee laxity, 87% would assess functional testing, 26% would utilize imaging, and 40% selected time from injury. When using time as a guide for RTS, 13% chose RTS between 7 and 11 weeks postinjury, 56% selected no sport before 3 months, and 22% favored waiting 4 to 6 months before allowing an athlete with a partial ACL injury to RTS. With regard to function as a tool to determine RTS, painless Lachman, strength, swelling, and functional performance tests were all chosen by a majority of respondents. Conclusion:This study presented the results of a survey on partial ACL injury management administered to ACL Study Group active surgical members. The majority favored nonoperative management for partial ACL injuries (stable ligament examination but MRI changes in the ligament). Nonoperative treatment and RTS protocols varied and must be customized to the patient.

PURPOSE:To define expert consensus on whether and how lateral extra-articular procedures (LEAPs) should accompany anterior cruciate ligament (ACL) reconstruction to optimize outcomes in ACL-deficient knees. METHODS:Fifty-five knee surgeons from 17 countries on 5 continents completed a 3-round modified Delphi process. Twenty-one statements on patient selection for combined ACL reconstruction (ACLR) + LEAPs were graded on 5-point Likert scales; ≥75% "agree/strongly agree" signified consensus. Strength of recommendation was ranked, and statements failing the threshold were revised or discarded after discussion. RESULTS:One statement achieved unanimous agreement (100%): it is strongly recommended to add a LEAP for active patients ≤25 years receiving hamstring-autograft ACLR to reduce graft failure. Strong consensus (≥90%) supported LEAPs in primary ACLR when grade 3 pivot shift (97.9%), knee hyperextension (97.9%), skeletally immature status (79.5%), revision ACLR (91.5%), return to pivoting sports (93.2%), active patients ≤25 years using nonhamstring grafts (90.7%), grade 3 Lachman test (90%), and when multiple relative risk factors coexist (statement 36, 97.1%). Consensus (75%-89.9%) favored LEAPs for chronic symptomatic ACL deficiency (86.1%), posterior tibial slope >12° (85.7%), and a history of contralateral ACL injury (88.9%). Eight statements did not reach consensus regarding small-diameter autografts, female athletes, imaging signs of anterolateral injury (e.g., Segond fracture, lateral femoral-notch sign), and concomitant meniscal procedures. One statement on LEAPs with primary ACL repair was withdrawn because the project focused on reconstruction. CONCLUSIONS:International experts strongly recommend adding a LEAP in young active patients undergoing hamstring-autograft ACLR and in cases of high-grade rotational or anterior laxity, knee hyperextension, revision surgery, or returning to pivoting sports. Unresolved issues include small graft size, female athletes, imaging findings of rotational instability, and concurrent meniscal procedures, highlighting priorities for future research. LEVEL OF EVIDENCE:Level V, expert opinion.

INTRODUCTION/OBJECTIVES:Anterior cruciate ligament reconstruction (ACLR) has been a highly active area in orthopaedic research in the past several decades, which has been associated with changing surgical practices. The purpose of this study is to present survey data over 25 years from members of the ACL Study Group (ACL SG) and to evaluate trends in expert opinion over time. METHODS:From 1998 to 2023, an electronic questionnaire was distributed to members of the ACL SG every two years. The questions explore ACLR topics including graft preferences, tunnel drilling techniques, graft fixation techniques, role for ACL repair, meniscal repair aggressiveness, return to sport timelines, and osteoarthritis risk as it relates to ACLR. RESULTS:Between 1998 and 2023, preferences for graft choice for primary ACLR showed a trend toward decreasing bone-patellar tendon-bone (BTB) autograft usage, increasing hamstring autograft usage, low allograft usage, and a recent rise in quadriceps autograft usage. For revision ACLR, hamstring autograft usage initially predominated but sharply declined in 2016, concurrent with a sharp rise in BTB autograft use and a steadier rise in quadriceps autograft usage. Anteromedial femoral tunnel drilling technique showed a dominant and increasing utilization, antegrade full-tunnel tibial drilling consistently predominated, metallic interference screw use has declined with a rise in cortical suspensory constructs for femoral fixation, and absorbable interference screws use for tibial fixation has been the most common technique. There has been a trend of increasing aggressiveness for concurrent extra-articular augmentation and meniscus repair over time, and a recent trend toward 9-month return to cutting sport timelines compared to 6 months. CONCLUSION:This study reveals trends in opinions and preferences of the ACL SG over the past 25 years, which dynamically both drive and respond to important scientific evidence in ACLR. LEVEL OF EVIDENCE:Level V, Expert Opinion.

PURPOSE:Meniscal allograft transplantation (MAT) aims to restore function without pain. Guidance on return-to-sport remains unclear due to concerns about re-injury. This study compared failure rates, outcomes, and complications in patients who resumed competitive sport after MAT with those who did not. METHODS:A retrospective review of a prospectively maintained MAT cohort was performed. Patients achieving a postoperative Tegner score ≥8 were classified as return-to-sport. Kaplan-Meier analysis assessed failure rates. Postoperative International Knee Documentation Committee (IKDC), Tegner, Knee Injury and Osteoarthritis Outcome Score, and Lysholm scores were compared between groups. RESULTS:Data from 422 patients were analysed; 51 returned to competitive sport. Mean age was 28.0 (8.1) in the return group and 30.1 (9.4) in the non-return group (p = 0.09). Five-year survival probability was higher in the return to sport group (94.1% vs. 88.6%, p < 0.001). Patient-reported outcomes were consistently superior, with mean IKDC at 10 years of 79.7 (8.2) versus 61.0 (20.8) (p < 0.001). CONCLUSIONS:Return to competitive sport after MAT is associated with excellent graft survival and superior long-term outcomes, with no evidence of increased failure. These results support safe return to high-level sport and provide important counselling information for postmeniscectomy patients considering transplantation. LEVEL OF EVIDENCE:Level IV.

Aims The aim of this study was to compare patient-reported outcomes (PROMs) following isolated anterior cruciate ligament reconstruction (ACLR), with those following ACLR and concomitant meniscal resection or repair. Methods We reviewed prospectively collected data from the UK National Ligament Registry for patients who underwent primary ACLR between January 2013 and December 2022. Patients were categorized into five groups: isolated ACLR, ACLR with medial meniscus (MM) repair, ACLR with MM resection, ACLR with lateral meniscus (LM) repair, and ACLR with LM resection. Linear regression analysis, with isolated ACLR as the reference, was performed after adjusting for confounders. Results From 14,895 ACLR patients, 4,400 had two- or five-year Knee injury and Osteoarthritis Outcome Scores (KOOS) available. At two years postoperatively, the MM repair group demonstrated inferior scores in KOOS pain (beta = -3.63, p < 0.001), symptoms (beta = - 4.88, p < 0.001), ADL (beta = - 2.43, p = 0.002), sport and recreation (beta = - 5.23, p < 0.001), quality of life (QoL) (beta = - 5.73, p < 0.001), and International Knee Documentation Committee (beta = - 4.1, p < 0.001) compared with the isolated ACLR group. The LM repair group was associated with worse KOOS sports and recreation scores at two years (beta = - 4.264, p < 0.001). At five years, PROMs were comparable between the groups. At five years, PROMs were comparable between the groups. Participants undergoing ACLR surgery within 12 weeks from index injury demonstrated superior PROMs at two and five years. Conclusion Our study showed that MM repair, and to a lesser extent LM repairs in combination with ACLR, were associated with inferior patient-reported outcome measures (PROMs) compared to isolated ACLR at two years postoperatively, while meniscal resection groups exhibited comparable outcomes. However, by five years postoperation, no significant differences in PROMs were evident. Further longer-term, cross-sectional studies are warranted to investigate the outcomes of ACLR and concomitant meniscal surgery.

Aims:The aim of this study was to compare patient-reported outcomes (PROMs) following isolated anterior cruciate ligament reconstruction (ACLR), with those following ACLR and concomitant meniscal resection or repair. Methods:We reviewed prospectively collected data from the UK National Ligament Registry for patients who underwent primary ACLR between January 2013 and December 2022. Patients were categorized into five groups: isolated ACLR, ACLR with medial meniscus (MM) repair, ACLR with MM resection, ACLR with lateral meniscus (LM) repair, and ACLR with LM resection. Linear regression analysis, with isolated ACLR as the reference, was performed after adjusting for confounders. Results:From 14,895 ACLR patients, 4,400 had two- or five-year Knee injury and Osteoarthritis Outcome Scores (KOOS) available. At two years postoperatively, the MM repair group demonstrated inferior scores in KOOS pain (β = -3.63, p < 0.001), symptoms (β = - 4.88, p < 0.001), ADL (β = - 2.43, p = 0.002), sport and recreation (β = - 5.23, p < 0.001), quality of life (QoL) (β = - 5.73, p < 0.001), and International Knee Documentation Committee (β = - 4.1, p < 0.001) compared with the isolated ACLR group. The LM repair group was associated with worse KOOS sports and recreation scores at two years (β = - 4.264, p < 0.001). At five years, PROMs were comparable between the groups. At five years, PROMs were comparable between the groups. Participants undergoing ACLR surgery within 12 weeks from index injury demonstrated superior PROMs at two and five years. Conclusion:Our study showed that MM repair, and to a lesser extent LM repairs in combination with ACLR, were associated with inferior patient-reported outcome measures (PROMs) compared to isolated ACLR at two years postoperatively, while meniscal resection groups exhibited comparable outcomes. However, by five years postoperation, no significant differences in PROMs were evident. Further longer-term, cross-sectional studies are warranted to investigate the outcomes of ACLR and concomitant meniscal surgery.

PURPOSE:Due to a lack of consensus regarding effective treatment options in young patients, the indications of meniscal allograft transplantation (MAT) have widened to include those with substantial cartilage disease. The aim of this study was to report the long-term patient-reported outcome measures (PROMs) and allograft survival rates for patients with substantial cartilage disease. METHODS:A review of the prospectively maintained database was performed. Patients with International Cartilage Repair Society 3b or above cartilage grading in either their femur or tibia were classified as having substantial cartilage disease. Postoperative International Knee Documentation Committee, Tegner, Knee Injury and Osteoarthritis Outcome Score and Lysholm were compared between those with and without substantial cartilage disease. Kaplan-Meir analysis was used to assess the survival rates. Survival was defined as revision or removal of allograft or conversion to arthroplasty. RESULTS:Data from 422 patients were included in the analysis with 129 patients found to have full-thickness chondral lesions and 281 patients without full-thickness chondral lesions. The mean follow-up was 6.33 (SD 3.48) years for the cohort. The mean age for the entire cohort was 30 (SD 9.23). Patients in substantial cartilage disease group underwent meniscal transplantation at an older age (32 [standard deviation {SD} 8.47] years vs. 29 [SD 9.35] years [p < 0.001]). There was no significant difference in PROMs between the two groups up to 10 years postoperatively (p > 0.05). The substantial cartilage disease group had significantly lower survival rates compared to those without (80.62% vs. 94.32%). CONCLUSIONS:MAT in the context of substantial cartilage disease was associated with an improvement in PROMs up to 10 years with no difference to the group without substantial cartilage disease. The PROMs in combination with the long-term survival rates in this study can be used to counsel patients preoperatively. LEVEL OF EVIDENCE:Level IV.

Purpose: The aim of this study was to report the demographic and mechanism of injury data in the UK National Ligament Registry (NLR) at 10 years and determine factors leading to poor compliance with completion of Patient-Reported Outcome Scores (PROMs). Methods: A retrospective review was performed for prospectively collected data on the NLR between January 2013 and December 2022. All patients who underwent primary anterior cruciate ligament reconstruction (ACLR) were included. Patient demographics, mechanism of injury and patient compliance with completing PROMs were analysed. Patient characteristics were further analysed in relation to compliance with completing the different PROMs at the predefined time points. Patients were identified as nonresponders if they had not completed either 1- or 2-year postoperative Knee injury and Osteoarthritis Outcome Score (KOOS). Results: A total of 17,492 patients were included in this study. The average age for patients undergoing ACLR between 2013 and 2022 was 29.4 (SD, 10.3). Seventy percent were men and 30% women. Football was the most common activity associated with an ACL injury. Patient compliance with recording PROMs was 55% preoperatively and 37%, 32% and 24% at 1-, 2- and 5-year postoperative follow-up, respectively. Nonresponders represented 54% of eligible patients. Multivariate analyses showed that sex, age, smoking, time interval between injury and surgery and low socioeconomic status were associated with low compliance with postoperative PROM completion (p < 0.001). Conclusion: This study reports the demographic characteristics for patients on the NLR since 2013. Male sex, young age, increased waiting time between injury and surgery, smoking and lower socioeconomic class were predictors of low compliance with completion of postoperative PROMs on the UK NLR. Understanding the factors that affect patient compliance with PROMs improves our ability to provide targeted interventions and information to specific patient populations with the aim of enhancing inclusiveness and representation of population in the registry. Level of EvidenceLevel III.

PURPOSEThe purpose of this study was to establish consensus statements via a Delphi process on the management of failed knee cartilage surgery.METHODSA consensus process on knee cartilage injuries utilizing a modified Delphi technique was conducted. Seventy-nine surgeons across 17 countries participated in these consensus statements. Eleven questions were generated on the management of failed knee cartilage surgery, with three rounds of questionnaires and final voting occurring. Consensus was defined as achieving 80-89% agreement, whereas strong consensus was defined as 90-99% agreement, and unanimous consensus was defined as 100% agreement with a proposed statement.RESULTSOf the 11 total questions and consensus statements on the management of failed knee cartilage surgery developed from three rounds of voting, none achieved unanimous consensus, 10 achieved strong consensus, and one achieved consensus.CONCLUSIONThe statements that achieved strong consensus related to revision cartilage indications, contraindications, lesion size, prior procedures, unipolar/bipolar lesions, and salvage procedures. The statement that did not achieve strong consensus was related to the management of a failed osteochondral autograft/allograft.Level of EvidenceLevel V Expert Opinion.

PURPOSE:The aim of this study was to describe the 10-year findings from the UK National Ligament Registry (NLR). METHODS:A retrospective review was performed for prospectively collected data on the NLR between January 2013 and December 2022. All patients who underwent primary ACL reconstruction (ACLR) on the registry were included. Surgical characteristics were analysed, including surgeon grade and case volume, concomitant knee procedures, venous thromboembolic prophylaxis, graft characteristics, femoral and tibial tunnel drilling, and fixation methods. Clinical outcomes were collected preoperatively and at 6 months, 1 year, 2 years and 5 years following the index procedure. RESULTS:During the study period, 17,492 unilateral ACLR procedures were recorded. Autograft was used in 98%, most commonly a combined semitendinosus and gracilis graft (77%) or patella tendon graft (31%). Allograft was used in only 1% of the patients. In 52% of cases, ACLR was associated with an additional procedure, with isolated medial meniscal surgery being the most common (21%). Femoral tunnel drilling was mostly performed through an anteromedial portal (73%) and tibial tunnel drilling using an outside-in technique (92%). The most common method of femoral graft fixation was with an Endobutton fixed loop suspensory device (77%), while interference screws predominated for tibial tunnel fixation (86%). Patients who underwent ACLR surgery showed significant improvement in their functional outcome scores at six months, 1 year, 2 years and 5 years postoperatively. CONCLUSION:Data from the NLR shows a detailed description of the current trends and evolution of ACLR in the United Kingdom over the last 10 years. Satisfactory functional outcomes were observed 5 years postoperatively. This study provides useful information on the prevalence of ACL-associated injuries and current surgical techniques with the aim of improving the quality of clinical care and patients' outcomes. Moreover, it provides surgeons with a benchmark against which to compare current practices and functional outcomes following ACLR across the United Kingdom. LEVEL OF EVIDENCE:Level III.

Background: The overall revision rate for primary anterior cruciate ligament reconstruction (ACLR) has increased over the past decade, with the commonest mode of failure being a combination of traumatic, technical, and biological factors. The challenge in revision ACLR is the need to address malpositioned or widened tunnels with the ideal scenario being single-stage revision, with widened and type 2 tunnels being the most difficult scenarios to deal with. Tunnels can be filled using autograft, allograft, and more recently described bone graft substitute (BGS). In this video, we describe a technique using fast-setting BGS to fill the problem of malpositioned tunnel or tunnels to allow single-stage revision ACLR. Indications: This technique is indicated in patients undergoing revision ACLR where tunnels are nearly right (type 2) with no widening at the joint surface aperture. Technique Description: Following preparation of the notch, the femoral tunnels are prepared in the normal fashion to remove all the previous graft and to create fresh bleeding surfaces. The fluid in the knee is completely drained, and the femoral tunnel is repeatedly dried with ribbon gauze that is left in place until ready to inject. The BGS, genex (Biocomposites Ltd), is mixed and loaded into the delivery syringe before injecting arthroscopically. After 15 minutes, the new anatomic femoral tunnel is then prepared in routine fashion. The same steps are repeated for the tibial tunnel. Results: Twenty patients underwent single-stage revision ACLR using this technique. There have been no reruptures in this series. All eligible patients at the 12-month follow-up had grade 0 or 1 laxity on clinical examination and full incorporation of the BGS on radiographs. There were no complications related to the BGS during the intra- or postoperative period. Discussion/Conclusion: We describe a technique that allows revision ACLR to be performed as single stage in a subset of patients with type 2 tunnels with successful short- to mid-term results. We have found this to be a safe and effective way to avoid 2-stage surgery in a subgroup of cases who have a challenging problem for surgeons to manage. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Background: Anterior cruciate ligament (ACL) tunnel placement has been long debated for many years. Femoral tunnel mal-position is the commonest technical error resulting in early ACL laxity and failure. There are many different methods to achieve accurate femoral tunnel position. In this video, we describe use of a novel femoral jig aiming device to drill a reliably and easily reproducible femoral tunnel for primary ACL reconstruction (ACLR). Indications: This femoral jig aiming device is indicated for all patients undergoing primary ACLR with any graft chosen by the surgeon. This jig is particularly useful for the inexperienced and low volume ACLR surgeon. Technique Description: An appropriate graft is harvested and prepared according to preferred techniques and the diameter of the graft to be inserted in the femoral tunnel is measured. The femoral notch is prepared, ensuring appropriate tissue is cleared to view the apex of the deep cartilage (ADC). The Infinity anteromedial (AM) femoral guide (Conmed), is inserted through the AM portal and hooked onto the notch just proximal to the ADC. In deep flexion, the guide wire is advanced and the tunnel reamed, aiming to preserve 2.0 to 2.5 mm of bone. Results: 19 consecutive patients were operated on. There were no complications during the intra- and postoperative period. There have been no reported failures or graft ruptures. All tunnels (100%) were centered in the footprint. The mean tunnel position was 25:20 on the superimposed Bernard-Hertel grid with tight grouping. Discussion/Conclusion: We have shown that this new femoral guide accurately locates the femoral tunnel close to the AM bundle position and gives a reliable and reproducible femoral tunnel position, thereby reducing the risk of intra-operative error. This may assist accuracy of tunnel position for surgeons starting out performing ACLR or for low-volume surgeons. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

AbstractBackgroundOsteochondral allograft (OCA) transplantation is a clinically and cost-effective option for symptomatic cartilage defects. In 2017 we initiated a program for OCA transplantation for complex chondral and osteochondral defects as a UK tertiary referral centre.AimTo characterise the complications, re-operation rate, graft survivorship and clinical outcomes of knee OCA transplantation.MethodologyAnalysis of a prospectively maintained database of patients treated with primary OCA transplantation from 2017 to 2021 with a minimum of one-year follow-up. Patient reported outcome measures (PROMs), complications, re-operations and failures were evaluated.Results37 patients with 37 knee OCA procedures were included (mean age 31.6 years [16–49 years]). Mean BMI 26.6 kg/m2 (19.1–35.9 kg/m2). The mean chondral defect size was 3cm2 (1.2–7.3 cm2). Mean duration of follow-up was 3.1 years (1–5.3 years). 16 patients underwent meniscal allograft transplantation (MAT), 6 underwent osteotomy and 4 underwent ligament reconstruction as concurrent procedures. Significant improvements in mean PROMs were noted at 12 months. 16 patients had reoperations of which 5 had more than one surgery. Of these patients 6 were related to OCA (mainly debridement and revision OCA in one patient), and the remainder were related to additional procedures including removal of plate in 2 patients. The overall failure rate was 1 in 37 patients (3%).ConclusionsEarly experience of OCA as a treatment option for complex chondral and osteochondral lesions in the knee shows satisfactory results. The reoperation rate is high but at mean follow-up of 3.1 years the survival rate was 97%.