This study aimed to evaluate anterior cruciate ligament (ACL) graft rupture in a selective approach to lateral extra-articular tenodesis (LET), with a focus on the impact of posterior tibial slope (PTS) and static anterior tibial translation (SATT) on graft rupture rate. This retrospective study included patients who underwent primary ACL reconstruction (ACLR) using hamstrings autograft between 2014 and 2018, with a minimum follow-up of 6 years. LET was performed based on specific indications (pivot shift grade 2-3, hyperlaxity and genu recurvatum) in adult patients and systematically in those under 18 years of age. Demographic variables, associated procedures, ACL graft rupture and time to rupture were recorded. Preoperative radiographs were used to measure PTS and SATT. Univariate and multivariate analyses were performed to identify risk factors for graft rupture. A total of 839 patients were eligible. Follow-up was obtained for 705 patients (mean age 30.5 ± 10.9 years; 38% female). Forty-one ACL graft ruptures were identified (5.8%). Among adult patients (≥18 years), the graft rupture rate was 4.5% in the ACLR + LET group versus 5.4% in the isolated ACLR group (p = 0.673). Risk factors significantly associated with graft rupture included PTS ≥ 12° (odds ratio [OR] = 3.0; 95% confidence interval [CI] = 1.5-6.2; p = 0.001), SATT ≥ 5 mm (OR = 2.7; 95% CI = 1.3-5.5; p = 0.006), age < 18 years (OR = 2.3; 95% CI = 1.0-3.9; p = 0.017) and lateral meniscal injuries (OR = 2.3; 95% CI = 1.1-5.0; p = 0.041). The highest graft rupture rate occurred in patients <18 years with both PTS ≥ 12° and SATT ≥ 5 mm (2/7; 29%). A selective, indication-based approach to LET in patients ≥18 years and systematic LET in patients under 18 years of age was associated with low ACL graft rupture rates. Higher PTS, SATT, younger age and lateral meniscal injury were associated with an increased risk of graft rupture. These findings should be interpreted within the limitations of the study design. Level III, retrospective case-control study.

Lateral Extra-Articular Procedures Reduce Anterior Cruciate Ligament Graft Failure in Patients Younger than 21 Years Undergoing Primary Anterior Cruciate Ligament Reconstruction: A Systematic Review.

Female athletes have a greater risk of anterior cruciate ligament (ACL) injuries, a disparity partly attributed to hormonal influences on ligament biomechanics and collagen metabolism. Oral contraceptives (OCs) may stabilize hormonal fluctuations and have been associated with a reduced risk of ACL injury; however, their potential effect on biological healing after ACL reconstruction (ACLR) remains unclear. To investigate whether the use of OCs affects graft maturation, assessed by the signal-to-noise quotient (SNQ) of postoperative magnetic resonance imaging (MRI), in female patients who have undergone ACLR with hamstring tendon autograft and associated lateral extra-articular tenodesis (LET). Cohort study; Level of evidence, 3. This retrospective comparative cohort study included a series of female patients with an active menstrual cycle, aged 16 to 45 years, who underwent anatomic ACLR with hamstring tendon autograft and LET between January 2022 and December 2023. Patients were stratified based on OC use at the time of surgery and postoperatively. Thus, the study included patients who underwent ACLR+LET with and without OC treatment. The 2 groups were comparable based on all the criteria analyzed. Follow-up MRI (3.0 T) was performed at a mean of 7 months postoperatively to analyze graft maturity using circular region of interest measurements in the proximal, midsubstance, and distal ACL graft regions, by measuring the SNQ. Lower SNQ ratios indicate less water content and better graft maturity and healing. A total of 55 patients with ACLR+LET were included (30 without OC use [R group] and 25 with OC use [R+OC group]). There were no significant demographic differences between the 2 groups. The median global graft SNQ was significantly lower in the R+OC group (1.8 [IQR, 0.6-3.3]) in comparison to the group in which no OC was used (3.7 [IQR, 2.0-6.0]) (P = .001). All graft regions-distal, midsubstance, and proximal-also showed significantly lower SNQ values in patients using OCs (R+OC group) compared to those not using them: distal (1.2 [IQR, 0.3-2.6] vs 3.2 [IQR, 1.5-6.0], P = .007), midsubstance (1.3 [IQR, 0.5-3.3] vs 3.7 [IQR, 2.1-7.8], P = .002), and proximal (1.3 [IQR, 0.7-3.3] vs 3.5 [IQR, 2.0-4.9], P = .006). OC use in female patients undergoing ACLR with hamstring tendon autograft and concomitant LET is associated with lower MRI-based SNQ values.

There is ongoing controversy regarding whether the addition of anterolateral tenodesis (ALT) affects the maturation process of anterior cruciate ligament (ACL) grafts. Some authors argue that patients undergoing ACL reconstruction with ALT demonstrate delayed graft maturation on MRI, while others report no improvement or delay in graft maturation with the addition of ALT. The aim of this study was to analyze whether the addition of anterolateral tenodesis (ALT) affects ACL graft maturation and to evaluate interobserver agreement in MRI analysis, given the lack of consensus in the literature. This study included 168 patients: 117 underwent isolated ACL reconstruction, and 51 underwent ACL reconstruction with associated ALT between 2018 and 2021. Radiological evaluation was performed to assess graft maturation and integration. Two orthopedic surgeons and two radiologists independently assessed MRI findings to determine interobserver variability. Radiological evaluation showed no significant differences between groups in the Howell ligamentization scale (p > 0.5) or signal-to-noise quotient (SNQ). Similarly, there were no differences in tendon-bone healing at the fibrous interzone (p > 0.5). Interobserver evaluation revealed only slight agreement between the four observers. The addition of anterolateral tenodesis to ACL reconstruction does not affect ACL graft maturation as assessed by MRI.

Purpose Intra-operative anterior cruciate ligament (ACL) graft contamination is a rare but recognised complication.There are no guidelines or consensus on the management of this occurrence. Our aim was to survey trauma and orthopaedic surgeons with a knee subspecialty interest in the United Kingdom (UK) who perform ACL reconstruction (ACLR) to explore the preferred strategy when there is intra-operative graft contamination. Methods An online questionnaire was sent to UK ACLR surgeons. The survey included the year of training completion, the average number of ACLs per year, whether they have experienced any intra-operative graft contamination, the strategies implemented, and whether they are aware of any literature and how it has influenced their strategies. Results Twenty-eight responses were received, with an average of 11 years of experience in ACLR, totalling an estimated of more than 15,000 ACLR. Three surgeons surveyed had experienced a single intra-operative ACL graft contamination, all of which were soaked in chlorhexidine gluconate (CG) solution. Of those surgeons who had not encountered a contaminated graft, 11 (44%) would use CG, 7 (28%) would soak in saline and vancomycin solution, and 7 (28%) would harvest a new graft. Conclusions There is significant variation in management strategy for an intra-operative contaminated graft in ACLR. This variation highlights the need for further work to develop a consensus for guidance for ACLR surgeons.

Antero Lateral Ligament Reconstruction by Modified Sonnery Cottet Technique

Background and Aims: Lateral extra-articular tenodesis (LET) is increasingly used as an adjunct to anterior cruciate ligament reconstruction (ACLR) to reduce graft failure, particularly in high-risk patients. Multiple femoral fixation techniques for LET have been described; however, their relative effectiveness in improving graft survivorship and associated complications remains unclear. Materials and Methods: A systematic review and meta-analysis were performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Electronic databases were searched for studies comparing ACLR with and without LET using the modified Lemaire technique. Subgroup analyses were conducted based on femoral fixation method, graft type, reconstruction setting (primary vs. revision), and level of evidence. The primary outcome was anterior cruciate ligament (ACL) graft failure. Pooled odd ratios (ORs) were calculated using a random-effects model. Results: Eleven studies encompassing 2208 knees were included. Overall, ACLR augmented with LET significantly reduced graft failure compared with isolated ACLR (OR, 0.45; 95% confidence interval [CI], 0.30–0.68; P = 0.0002). Subgroup analysis demonstrated a significant reduction in failure rates with anchor fixation (OR, 0.31; 95% CI, 0.13–0.75) and staple fixation (OR, 0.43; 95% CI, 0.23–0.79). Screw, button, and suture fixation did not demonstrate statistically significant reductions in graft failure. No significant heterogeneity was observed across analyses. Conclusion: LET augmentation significantly improves ACL graft survivorship compared with ACLR alone. Anchor and staple femoral fixation methods demonstrate the greatest clinical benefit; however, overlapping confidence intervals preclude definitive superiority of one technique.

Posterior tibial slope (PTS) is a well-established anatomic risk factor for anterior cruciate ligament (ACL) graft failure. Lateral extra-articular tenodesis (LET) is increasingly used as an adjunctive procedure in high-risk patients to reduce rerupture rates; however, how its protective effect varies across the continuum of slope values remains insufficiently characterized. To determine how PTS modifies the protective effect of LET in high-risk patients and to evaluate the influence of PTS on graft failure across different risk profiles. Cohort study; Level of evidence, 3. A retrospective cohort of 585 patients who underwent primary ACL reconstruction (ACLR) with hamstring tendon autografts between 2014 and 2017 was analyzed at a minimum follow-up of 6 years. Patients were nonrandomly allocated according to predefined clinical risk criteria into a low-risk group (isolated ACLR) and a high-risk group (ACLR + LET). A graft rerupture was defined clinically and confirmed by imaging. Multivariable logistic regression was used to assess the association between PTS and graft failure. Restricted cubic spline regression was also used to explore nonlinear relationships and identify slope ranges associated with low and high failure probabilities. PTS independently predicted a graft rerupture in both groups, with a stronger effect in the high-risk group (adjusted odds ratio, 1.63; P = .005) compared with the low-risk group (adjusted odds ratio, 1.21; P = .029). The relationship between PTS and graft failure was nonlinear. In the high-risk group, the lowest failure probabilities were observed within a PTS range of 5° to 9°, below which the risk of failure plateaued. In contrast, PTS values exceeding 11° to 12° were associated with high failure probabilities in both groups. PTS was independently associated with graft failure in both groups. Although LET was associated with lower failure probabilities within a moderate slope range, increasing PTS values were linked to a progressively higher risk of reruptures in both groups. The association between a steeper slope and failure observed in the ACLR with LET group suggests that an elevated PTS may attenuate the relative protective effect of LET.

Background/Objectives: Objective, non-invasive biomarkers are needed to track anterior cruciate ligament (ACL) graft maturation and support individualized return-to-sport decisions. This study evaluated a single-session multiparametric quantitative MRI (qMRI) protocol for longitudinal assessment of ACL graft microstructural evolution and its association with patient-reported outcomes. Methods: Twenty-eight patients undergoing primary ACL reconstruction with hamstring autografts underwent multiparametric qMRI (T1, T2*, R2*, and PD mapping) at 1, 3, 6, and 12 months. The contralateral native ACL served as a within-subject control. IKDC, Lysholm, and VAS scores were recorded at each visit. Linear mixed-effects models were used to test longitudinal changes. Correlations of baseline-normalized changes between adjacent visits were used to evaluate imaging-clinical associations. Results: All qMRI parameters changed significantly over time (all p < 0.001). At 1 month, T1, PD, and T2* were lower and R2* higher than the contralateral native ACL (all p < 0.001). Thereafter, T1, PD, and T2* increased and R2* decreased, with most metrics approaching contralateral values by 3-6 months (all p < 0.05), and changes entered a plateau after 6 months (all p > 0.05). IKDC, Lysholm, and VAS improved over time (all p < 0.001), mainly before 6 months. Greater early T2* increases and R2* decreases (1-3 months) were associated with less pain relief and smaller Lysholm improvement (p < 0.05); no significant associations were observed from 6-12 months. Conclusions: Single-session multiparametric qMRI sensitively captures ACL graft maturation and highlights 3-6 months as a critical remodeling window, providing objective biomarkers to complement clinical assessment for individualized rehabilitation monitoring and return-to-sport timing.

Posterior tibial slope (PTS) and static anterior tibial translation (SATT) are established risk factors for anterior cruciate ligament (ACL) graft rupture and may also be associated with cyclops syndrome. This study aimed to assess whether these anatomical parameters influence the prevalence of cyclops syndrome after ACL reconstruction (ACLR). The hypothesis of the present study was that increased PTS and SATT would facilitate the development of cyclops syndrome. Patients aged ≥14 years with a minimum follow-up of 6 years who underwent primary ACLR with hamstring autograft between January 2015 and December 2017 were included. Demographic data, PTS, SATT, concomitant lateral extra-articular tenodesis (LET) and reoperation for cyclops syndrome were recorded. Time from index surgery to arthrolysis was documented, with a minimum follow-up of 6 years. Subgroup analysis regarding PTS, SATT and gender was performed. Univariate and multivariate logistic regression analyses were conducted to identify independent risk factors. Of 530 patients included for analysis, 18 (3.4%) developed cyclops syndrome at a mean of 14 ± 9 months postoperatively (range, 6-33 months). Patients with a PTS ≥ 12° had a 4.3% rate of cyclops syndrome compared with 3.2% in those with a PTS < 12° (p = 0.536). Patients with a SATT ≥ 5 mm had a 5.6% rate compared with 2.7% for SATT < 5 mm (p = 0.154). Female patients presented a statistically significant higher prevalence (5.9%) compared with males (1.8%, p = 0.024). Concomitant LET did not demonstrate a protective effect (p = 0.807). Female sex was the only independent predictor of cyclops syndrome (OR, 3.3; 95% CI, 1.2-9.1; p = 0.018). This study found no evidence that increased PTS or SATT predisposes to cyclops syndrome after ACLR with hamstring autograft. These preoperative parameters should not alert clinicians to an increased risk of postoperative cyclops syndrome. Level III, retrospective case-control study.

Higher body mass index, postoperative bracing, narrower femoral notch, and anterior tibial tunnel positioning are independent risk factors for cyclops syndrome following anterior cruciate ligament reconstruction.

To evaluate short-term anterior cruciate ligament (ACL) graft maturity in skeletally immature patients undergoing ACL reconstruction (ACLR) with physeal-sparing over-the-top (OTT) technique using hamstring tendon (HT) autograft with preserved tibial insertion, and to compare the results with adult patients operated using an OTT technique with similar features. Skeletally immature patients who underwent primary ACLR with OTT between February 2022 and January 2025 with post-operative Magnetic Resonance Imaging (MRI) performed between 10 weeks and 6 months were retrospectively reviewed. Graft maturation was evaluated via the Howell grading system and ACL signal/noise quotient (SNQ) on MRI. Additionally, graft continuity, tunnel widening, fluid collection within the graft, and bone oedema of the tibial tunnel wall were assessed. Skeletally immature patients were propensity-matched at a 1:1 ratio to adult patients, and comparisons were performed. A total of 22 skeletally immature patients (average skeletal age 12.9 ± 2.3 years) out of 79 patients were included. MRI assessment of graft maturity was performed at an average of 4.0 ± 1.3 months postoperatively. All patients presented graft continuity, with Grade I or II Howell grade in 86% of cases. For the comparative analysis, a subset of 10 skeletally immature patients (those with a tibial tunnel) was matched with 10 adult patients (90% males, mean age 25.9 ± 10.0 years) who underwent MRI 4.0 ± 1.2 and 18.0 ± 2.1 months after surgery. No significant differences were reported for all individual items, such as the Howell graft score, SNQ, and tunnel features, between skeletally immature and adult patients at the 4-month assessment (p > 0.05). ACLR with OTT technique via HT autograft with preserved tibial insertion may provide satisfactory ligamentization in skeletally immature patients. Graft maturity was comparable to that of the adult population. These data suggest that graft maturation using this specific surgical approach is satisfactory in skeletally immature patients and is comparable to adults. Level IV, retrospective study.

The lateral meniscus (LM) controls anterolateral rotatory instability (ALRI) and is considered a secondary restraint. However, how the anterior cruciate ligament (ACL) and LM contribute to ALRI control remains unclear. This study investigated the degree to which ACL and LM contribute to ALRI control and examined factors contributing to ALRI during anterior cruciate ligament reconstruction (ACLR). Twenty-six patients in ACL and LM-injured knees were enroled. Tibial acceleration in pivot shift was measured using a triaxial accelerometer by adjusting ACL graft tension before and after LM repair. ACL graft tension required for below-healthy-side pivot shift acceleration (minimum required tension [MRT]) was measured before and after LM repair. Patient factors for a larger contribution of LM to ALRI were determined by univariate linear regression analysis between changes in pivot shift acceleration before and after LM repair, and explanatory variables included patient and morphological factors. Furthermore, multiple regression analysis was conducted to identify independent factors significantly associated with the change. LM repair reduced the pivot shift acceleration in most cases, even following ACLR fixed at 10 N for each bundle (20 N in total) and pivot shift acceleration decreased significantly from 4.3 ± 1.2 to 2.9 ± 0.9 m/s2 by LM repair (p < 0.001). The MRT was 10 N without LM repair in 13 patients (50%). LM repair reduced MRT to 10 N in 11 of the remaining 13 patients. Only the lateral posterior tibial slope (PTS) significantly correlated with changes in pivot shift acceleration (r = 0.60, p = 0.001). In the multiple regression analysis as well, lateral PTS was the only factor identified as a significant predictor. LM repair decreased pivot shift acceleration and MRT, indicating the importance of LM repair in force-sharing with the ACL. LM contributes significantly to ALRI in patients with a larger lateral PTS. During ACLR, the LM should be repaired as much as possible. Level III, diagnostic study.

Knee stability can be conferred passively by ligaments and menisci and actively by the neuromuscular system. We sought to determine the relationship between passive tibiofemoral alignment and dynamic constraint in patients undergoing anterior cruciate ligament (ACL) reconstruction (ACLR) and matched control participants who have been followed for more than a decade. It was hypothesized that (1) anterior tibial position would be greater in the surgical knee compared to the contralateral knee and when compared to knees of control participants, and (2) the surgical limb differences would be greater in the dynamic state during a 1-leg hop-for-distance landing task. Controlled laboratory study. A total of 21 participants were recruited from a recently completed longitudinal clinical trial (NCT00434837): 10 patients who had undergone ACLR 10 to 15 years earlier and 11 matched control participants without knee injury. The 3-dimensional (3D) tibiofemoral position was extracted from each participant's computed tomography images as a measure of passive alignment. Dynamic 3D knee kinematics were recorded using biplane videoradiography during the landing of a 1-leg hop-for-distance activity. Side-to-side differences in knee kinematics between limbs were used as a measure of dynamic constraint. Peak anterior tibial position was the primary outcome measure, and peak anterior tibial position as a function of flexion angle was the secondary outcome measure. The passive tibial position of patients with ACLR was 7.5 ± 2.3 mm more anterior compared to that of uninjured participants and 3.1 ± 1.1 mm more anterior than their contralateral limb (P < .05). The mean peak dynamic anterior position was not different between surgical and contralateral limbs in ACLR patients (P = .83). When anterior position was explored as a function of flexion angle, peak anterior tibial position was up to 10.3 mm greater in the ACLR surgical limbs (P = .01) and 7.5 mm in the contralateral limbs (P = .001) compared to the limbs of control participants. Passive alignment is abnormal long after ACLR, whereas side-to-side dynamic constraint is largely restored, but with a persistent bias toward greater anterior tibial position that is present bilaterally. Compared with similar studies at earlier postoperative time points, the results at long-term follow-up suggest that ACL graft function deteriorates with time, which can be compensated for to some degree by the neuromuscular system.

Editorial Commentary: Ratio of Anterior to Posterior Distances of Lateral-to-Medial Tibial Plateau Is Associated With Increased Anterior Cruciate Ligament Rupture Risk and Graft Failure and Can Be Considered in Individualized Surgical Plan for Anterior Cruciate Ligament Reconstruction.

Trends in arthroscopic meniscus and anterior cruciate ligament surgery in Japan: Review of a 3-year registry of the Japan Sports Orthopaedic Association.

Experimental modelling is required to test novel anterior cruciate ligament (ACL) grafts. Porcine ACLs resemble human ACLs regarding in situ force distribution and anatomic characteristics. However, their essential properties remain unclear. This study describes essential baseline porcine ACL properties and determines the impact of standardised cyclic loading. Twenty mature porcine cadaver knee joints were used for standardised biomechanical testing. Axial tensile loading was performed, and force to failure (Fmax), elongation, stiffness, yield point, and absorbed energy by ACL ligament were determined. Baseline values were compared with samples exposed to cyclic loading (10.000 runs). Dimensions were determined by computed tomography (CT) scanning. ACLs showed a mean Fmax of 720.5 N ± 108.6 N, whereas a mean Fmax of 614.9 N ± 98.1 N was found upon cyclic loading, p = 0.07. Stiffness did not differ between groups (baseline: 76.9 N/mm ± 8.9 N/mm vs. after cyclical loading: 76.1 N/mm ± 9.5 N/mm, p = 0.8). Furthermore, sample elongation during cyclic loading was unaltered. A biphasic pattern of ACL rupturing, reflecting two separate porcine bundles, was identified. Two separate porcine bundles have been identified as being in line with humans. The robust results of this study underline the applicability of this model to the human condition. Moreover, specific features of porcine ACL may form a template for developing synthetic ligaments and tailored treatment protocols.

Abstract Purpose To map and synthesise current evidence on machine learning (ML) applications for anterior cruciate ligament (ACL) injury risk estimation, rehabilitation monitoring and return‐to‐sport (RTS) decision support, with emphasis on clinical relevance and methodological quality. Study Design Scoping review with descriptive evidence synthesis. Methods The review was conducted in accordance with PRISMA‐ScR guidelines. Four electronic databases ( n = 4) (PubMed, Scopus, IEEE Xplore and Web of Science) were searched for peer‐reviewed studies published between 2016 and 2025. Eligible studies applied ML models to ACL injury prediction, postoperative recovery assessment, or RTS evaluation. Data were extracted on study design, participant characteristics, data modalities, ML algorithms and clinical endpoints. Reporting quality, risk of bias and certainty of evidence were assessed using TRIPOD‐AI, PROBAST‐AI and an adapted GRADE framework. Quantitative results were summarised descriptively rather than pooled meta‐analytically. Results Forty studies ( n = 40) met the inclusion criteria. Tree‐based ensemble models, particularly Random Forest and Extreme Gradient Boosting, were most frequently applied and showed consistent performance across clinical, biomechanical and wearable datasets. Deep learning models were predominantly used for imaging‐based tasks such as ACL tear detection and graft assessment. Wearable and sensor‐integrated approaches supported continuous functional monitoring and RTS readiness estimation. Methodological quality was generally acceptable, although external validation and standardised outcome definitions were inconsistently reported. Conclusion ML approaches demonstrate growing potential as adjunctive clinical decision‐support tools in ACL rehabilitation and RTS assessment. Wider clinical adoption will require standardised multimodal datasets, external validation and explainable modelling to ensure safe, interpretable and context‐appropriate implementation. Level of Evidence Level II, high‐quality scoping review with structured synthesis of cohort‐based prognostic and predictive modelling studies.

Ten-year risk of graft re-rupture and contralateral anterior cruciate ligament injury after primary anterior cruciate ligament reconstruction: A systematic review and meta-analysis.

Despite surgical reconstruction, some patients develop persistent residual rotatory laxity following anterior cruciate ligament (ACL) reconstruction (ACLR). Lateral extra-articular tenodesis (LET) has been shown to be a successful adjunctive procedure to address anterolateral instability in high-risk patients with ACL tears. It is often performed during ACLR; however, there is growing interest in understanding possible indications for the LET as an isolated procedure. To consolidate the current evidence on isolated LET (iLET) following ACLR, explore its indications, and evaluate outcomes such as laxity, patient-reported outcome (PRO) measures (PROMs), and complication rates. Systematic review; Level of evidence, 4. This systematic review was conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A comprehensive literature search was performed across Ovid MEDLINE, Embase, EBM Reviews, and Emcare from inception to April 2025. Studies were eligible if they reported outcomes in patients undergoing iLET for residual laxity following ACLR with evidence of an intact ACL graft. Biomechanical, cadaveric, and non-English studies were excluded. Two reviewers independently screened studies, extracted data, and assessed methodological quality. A narrative synthesis was conducted, with descriptive statistics (frequencies, percentages, or weighted means with measures of variability) reported where appropriate. Four studies (N = 69 patients, 70 knees) were included, with a mean ± SD patient age of 25.3 ± 2.9) and follow-up period of 26.3 ± 3.6 months. Patients demonstrated significant reductions in rotatory laxity following iLET, with only 6 patients reporting positive postoperative pivot shift (grade ≥1). Reported PROMs improved across all studies. Complication rates ranged from 15.8% to 36.8% while failure rates ranged from 0% to 10.5%. This review demonstrated that iLET may provide favorable PROs, reduction in laxity, and low failure rates in patients with residual laxity following ACLR. These findings suggest that the use of iLET may be a viable option for residual laxity following ACLR with evidence of an intact ACL graft; however, a limited number of reporting studies and small sample size require these results to be interpreted with caution.