Conclusion: With an annual incidence of 68.6 per 100,000 person-years, isolated ACL tears remain a common orthopaedic injury. Differences in age-specific incidence trends in male and female patients may potentially reflect differences in sports participation patterns through the high school and college years. The significant increase in the rate of ACL reconstruction over time may reflect changing surgical indications or an increasing desire among patients to return to high levels of activity after ACL injury.

Conclusions: The increasing incidence of ACL reconstructions in young Australians over 15 years is worrying. The individuals at greatest risk are men aged 20-24 years and women aged 15-19 years; the rate of reconstruction is increasing most rapidly among those aged 5-14 years. Revision rates are increasing more rapidly than those of primary reconstructions.

Conclusions: The ACL surgery has evolved considerably over the past 50 years. At first, this involved an awareness of the inadequacy of extra articular procedures and the need to reconstruct the ACL. The use of PT is at first difficult and reconstruction using fascia lata or extensor mechanisms becomes popular. The use of a free PT graft disrupts the hierarchy and becomes the “gold standard”. For reasons relating to frequent secondary pain problems, some surgeons gradually move towards the hamstrings. The transition to a double bundle technique is an evolution linked to a better understanding of ACL anatomy. All this evolution is based on the biomechanics of the ACL. Beginning in 2000, a biological and mechanical concept emerges. It is on track to be evaluated and under an interesting evolutionary path that will provide food for thought for young surgeons for many years to come.

Conclusion: This is a detailed anatomical study describing the ribbon-like structure of the ACL from its femoral insertion to midsubstance. A key point was to carefully remove the surface fibrous membrane of the ACL. A total of 2-3 mm from its bony femoral insertion, the ACL formed a flat ribbon without a clear separation between AM and PL bundles. The ribbon was in exact continuity of the posterior femoral cortex. The findings of a flat ligament may change the future approach to femoral ACL footprint and midsubstance ACL reconstruction and to graft selection.

Conclusion: The tibial ACL midsubstance and tibial "C"-shaped insertion are flat and are resembling a "ribbon". The centre of the "C" is the bony insertion of the anterior root of the lateral meniscus. There are no central or PL inserting ACL fibres. Anatomical ACL reconstruction may therefore require a flat graft and a "C"-shaped tibial footprint reconstruction with an anteromedial bone tunnel for single bundle and an additional posteromedial bone tunnel for double bundle.

Conclusion: The present study clarified anatomic and histologic character of the mid-substance fibres and fan-like extension fibres, and provided critical information for future clinical and biomechanical studies concerning both two different fibres. Specifically for ACL reconstruction, it is difficult to reconstruct the natural fan-like extension fibres by creating a tunnel at the femoral and tibial ends of each fibre bundle, although the mid-substance fibres can be reconstructed by such procedures.

Conclusion: Over the past 10 years, a renewed interest in the native anatomy of the ACL has facilitated the progression of reconstruction techniques from non-anatomic to more anatomic techniques. Furthermore, double-bundle ACL reconstruction has also become popular as a potential means of more closely restoring the native anatomy and function of the ACL. To date, numerous studies comparing single- and double-bundle reconstruction techniques have been performed, but there is little evidence to suggest a superiority of one technique over another.25 More recent work has focused on individualizing ACL reconstruction based on each patient’s distinct anatomical characteristics such as native insertion site size, as well as notch size and shape. Finally, investigators have turned to objective outcome measurement tools, such as in vivo kinematics, to provide a precise assessment of knee joint motion and contact mechanics. Continued investigation in ACL surgery and factors affecting the potential progression to osteoarthritis in the long term is essential in furthering the understanding to prevent this possible risk in the future.

Conclusions: This article presents an ACL reconstruction technique using oval dilatators and medial portal aimers to create oval tunnels. These oval tunnels match the insertion site anatomy much closer than round tunnels do.

Abstract: Anterior cruciate ligament (ACL) reconstruction is commonly performed and has been for many years. Despite this, the technical details related to ACL anatomy, such as tunnel placement, are still a topic for debate. In this paper, we introduce the flat ribbon concept of the anatomy of the ACL, and its relevance to clinical practice.

Conclusion: This study confirms macroscopically the C-shaped tibial insertion of the ACL and shows histologically that synovial tissue is an indirect insertion filling the major part of the footprint.