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Background and Hypothesis: Anterior shoulder instability is a common problem affecting young, athletic populations that results in potential career-altering functional limitations. However, little is known regarding the differences in clinical outcomes after operative management of overhead vs. non-overhead athletes presenting with first-time anterior shoulder instability. We hypothesized that overhead athletes would have milder clinical presentations, similar surgical characteristics, and diminished postoperative outcomes when compared with non-overhead athletes after surgical stabilization following first-time anterior shoulder instability episodes., Methods: Patients with first-time anterior shoulder instability events (subluxations and dislocations) undergoing operative management between 2013 and 2020 were included. The exclusion criteria included multiple dislocations and multidirectional shoulder instability. Baseline demographic characteristics, imaging data, examination findings, and intraoperative findings were retrospectively collected. Patients were contacted to collect postoperative patient-reported outcomes including American Shoulder and Elbow Surgeons score, Western Ontario Shoulder Instability Index score, Brophy activity index score, and Subjective Shoulder Value, in addition to return-to-work and -sport, recurrent dislocation, and revision rates., Results: A total of 256 patients met the inclusion criteria, of whom 178 (70%) were non-overhead athletes. The mean age of the entire population was 23.1 years. There was no significant difference in concomitant shoulder pathology, preoperative range of motion, or preoperative strength between cohorts. A greater proportion of overhead athletes presented with instability events not requiring manual reduction (defined as subluxations; 64.1% vs. 50.6%; P < .001) and underwent arthroscopic surgery (97% vs. 76%, P < .001) compared with non-overhead athletes. A smaller proportion of overhead athletes underwent open soft-tissue stabilization compared with non-overhead athletes (1% vs. 19%, P < .001). Outcome data were available for 60 patients with an average follow-up period of 6.7 years. No significant differences were found between groups with respect to recurrent postoperative instability event rate (13.0% for overhead athletes vs. 16.8% for non-overhead athletes), revision rate (13.0% for overhead athletes vs. 11.1% for non-overhead athletes), American Shoulder and Elbow Surgeons score, Western Ontario Shoulder Instability Index score, Brophy score, Subjective Shoulder Value, or rates of return to work or sport., Conclusion: Overhead athletes who underwent surgery after an initial instability event were more likely to present with subluxations compared with non-overhead athletes. With limited follow-up subject to biases, this study found no differences in recurrence or revision rates, postoperative patient-reported outcomes, or return-to-work or -sport rates between overhead and non-overhead athletes undergoing shoulder stabilization surgery following first-time instability events. Although larger prospective studies are necessary to draw firmer conclusions, the findings of this study suggest that overhead athletes can be considered in the same treatment pathway for first-time dislocation as non-overhead athletes., (Copyright © 2023 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: The glenoid track concept for shoulder instability primarily describes the medial-lateral relationship between a Hill-Sachs lesion and the glenoid. However, the Hill-Sachs position in the craniocaudal dimension has not been thoroughly studied., Hypothesis: Hill-Sachs lesions with greater inferior extension are associated with increased risk of recurrent instability after primary arthroscopic Bankart repair., Study Design: Case-control study; Level of evidence, 3., Methods: The authors performed a retrospective analysis of patients with on-track Hill-Sachs lesions who underwent primary arthroscopic Bankart repair (without remplissage) between 2007 and 2019 and had a minimum 2-year follow-up. Recurrent instability was defined as recurrent dislocation or subluxation after the index procedure. The craniocaudal position of the Hill-Sachs lesion was measured against the midhumeral axis on sagittal magnetic resonance imaging (MRI) using either a Hill-Sachs bisecting line through the humeral head center (sagittal midpoint angle [SMA], a measure of Hill-Sachs craniocaudal position) or a line tangent to the inferior Hill-Sachs edge (lower-edge angle [LEA], a measure of Hill-Sachs caudal extension). Univariate and multivariate regression were used to determine the predictive value of both SMA and LEA for recurrent instability., Results: In total, 176 patients were included with a mean age of 20.6 years, mean follow-up of 5.9 years, and contact sport participation of 69.3%. Of these patients, 42 (23.9%) experienced recurrent instability (30 dislocations, 12 subluxations) at a mean time of 1.7 years after surgery. Recurrent instability was found to be significantly associated with LEA >90° (ie, Hill-Sachs lesions extending below the humeral head equator), with an OR of 3.29 ( P = .022). SMA predicted recurrent instability to a lesser degree (OR, 2.22; P = .052). Post hoc evaluation demonstrated that LEA >90° predicted recurrent dislocations (subset of recurrent instability) with an OR of 4.80 ( P = .003). LEA and SMA were found to be collinear with Hill-Sachs interval and distance to dislocation, suggesting that greater LEA and SMA proportionally reflect lesion severity in both the craniocaudal and medial-lateral dimensions., Conclusion: Inferior extension of an otherwise on-track Hill-Sachs lesion is a highly predictive risk factor for recurrent instability after primary arthroscopic Bankart repair. Evaluation of Hill-Sachs extension below the humeral equator (inferior equatorial extension) on sagittal MRI is a clinically facile screening tool for higher-risk lesions with subcritical glenoid bone loss. This threshold for critical humeral bone loss may inform surgical stratification for procedures such as remplissage or other approaches for at-risk on-track lesions., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: T.C. has received a grant from Arthrex and support for education from Mid-Atlantic Surgical Systems. M.F. has received support for education from Mid-Atlantic Surgical Systems. A.B. has received support for education from CGG Medical, Mid-Atlantic Surgical Systems, Smith + Nephew, Fortis Surgical, Supreme Orthopedic Systems, and Arthrex; grants from Encore Medical and Arthrex; and hospitality payments from Stryker. B.L. has received support for education from Mid-Atlantic Surgical Systems. M.R. has received support for education from Mid-Atlantic Surgical Systems. A.L. has received consulting fees from Arthrex, Tornier, Stryker, and Wright Medical Technology; and support for education from Mid-Atlantic Surgical Systems. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Purpose: Quantitative pivot shift (QPS) testing using PIVOT technology can detect high- and low-grade rotatory knee instability following anterior cruciate ligament injury or reconstruction (ACLR). The aim of this project was to determine if preoperative QPS correlates with postoperative knee kinematics in the operative and contralateral, healthy extremity following ACLR with or without lateral extraarticular tenodesis (LET) using a highly precise in vivo analysis system. A positive correlation between preoperative QPS and postoperative tibial translation and rotation following ACLR with or without LET in the operative and healthy, contralateral extremity was hypothesized., Methods: Twenty patients with ACL injury and high-grade rotatory knee instability were randomized to undergo anatomic ACLR with or without LET as part of a prospective randomized trial. At 6 and 12 months postoperatively, in vivo kinematic data were collected using dynamic biplanar radiography superimposed with high-resolution computed tomography scans of patients' knees during downhill running. Total anterior-posterior (AP) tibial translation and internal-external tibial rotation were measured during the gait cycle. Spearman's rho was calculated for preoperative QPS and postoperative kinematics., Results: In the contralateral, healthy extremity, a significant positive correlation was seen between preoperative QPS and total AP tibial translation at 12 months postoperatively (r s  = 0.6, p < 0.05). There were no additional significant correlations observed between preoperative QPS and postoperative knee kinematics at 6 and 12 months postoperatively in the operative and contralateral, healthy extremity for combined isolated ACLR and ACLR with LET patients as well as isolated ACLR patients or ACLR with LET patients analyzed separately., Discussion: The main finding of this study was that there was a significant positive correlation between preoperative QPS and total AP tibial translation at 12 months postoperatively in the contralateral, healthy extremity. There were no significant correlations between preoperative QPS and postoperative in vivo kinematics at 6 and 12 months following ACLR with or without LET. This suggests that QPS as measured with PIVOT technology does correlate with healthy in vivo knee kinematics, but QPS does not correlate with in vivo kinematics following ACLR with or without LET., (© 2022. The Author(s) under exclusive licence to European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA).)

Background: The purpose of this study was to compare recurrent instability rates between patients with on-track Hill-Sachs lesions who underwent arthroscopic labral repair (ALR) alone and those who underwent ALR with remplissage (ALR-R). Our hypothesis was that ALR-R would decrease the rate of recurrent instability, especially among patients at high risk of recurrent instability after ALR, such as contact athletes with near-track Hill-Sachs lesions., Methods: We performed a multicenter, retrospective analysis of patients aged 14-50 years with on-track Hill-Sachs lesions who underwent ALR-R or ALR without remplissage between January 2014 and December 2019 with minimum 2-year follow-up. The exclusion criteria included prior ipsilateral shoulder surgery, >15% glenoid bone loss (GBL), off-track Hill-Sachs lesion, concomitant shoulder procedure, and connective tissue disorder. Age, sex, follow-up, and contact sports participation were recorded. GBL, Hills-Sachs interval (HSI), glenoid track, and distance to dislocation (DTD) were determined from preoperative magnetic resonance imaging scans. Affected-shoulder range of motion, Western Ontario Shoulder Instability Index scores, Subjective Shoulder Value scores, and recurrent dislocation and/or revision surgery status were also collected. A subgroup analysis was performed on "high-risk" patients (defined as participants in contact sports with DTD <10 mm) from each cohort., Results: The ALR-R cohort included 56 patients, and the ALR cohort included 127. ALR-R patients had greater GBL (P = .004) and a greater HSI (P < .001). In the ALR-R cohort, only 1 patient (1.8%) had a recurrent dislocation and there were no revision operations. In comparison, in the ALR cohort, 14 patients (11.0%) had recurrent dislocations (P = .040) and 8 (6.3%) underwent revision operations (P = .11). Univariate analysis showed that remplissage protected against recurrent dislocation (P = .040) whereas younger age (P = .004), contact sports participation (P = .001), and increased GBL (P = .048) were associated with recurrent dislocation. Multivariate analysis showed that HSI (P = .001) and contact sports participation (P = .002) predicted recurrent dislocation. Among high-risk patients, only 1 patient (4.2%) in the ALR-R group had a recurrent instability event vs. 6 (66.7%) in the ALR group (P < .001). The high-risk ALR-R subgroup also had significantly better final Western Ontario Shoulder Instability Index (P = .008) and Subjective Shoulder Value (P = .001) scores than the high-risk ALR subgroup., Conclusions: Anterior shoulder instability patients with on-track Hill-Sachs lesions have lower recurrent dislocation rates after ALR plus remplissage when compared with ALR alone. This is especially true for high-risk patients, such as contact athletes with a DTD <10 mm., (Copyright © 2023 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Purpose: The purpose of this study was to compare rates of recurrent dislocation and postsurgical outcomes in patients undergoing arthroscopic Bankart repair for anterior shoulder instability immediately after a first-time traumatic anterior dislocation versus patients who sustained a second dislocation event after initial nonoperative management., Methods: A retrospective chart review was performed of patients undergoing primary arthroscopic stabilization for anterior shoulder instability without concomitant procedures and minimum 2-year clinical follow-up. Primary outcome was documentation of a recurrent shoulder dislocation. Secondary clinical outcomes included range of motion, Visual Analog Scale (VAS), American Shoulder and Elbow Surgeons Shoulder Score (ASES), and Shoulder Activity Scale (SAS)., Results: Seventy-seven patients (mean age 21.3 years ± 7.3 years) met inclusion criteria. Sixty-three shoulders underwent surgical stabilization after a single shoulder dislocation, and 14 underwent surgery after 2 dislocations. Average follow-up was 35.9 months. The rate of recurrent dislocation was significantly higher in the 2-dislocation group compared to single dislocations (42.8% vs 14.2%, P = .03). No significant difference was present in range of motion, VAS, ASES, and SAS scores. The minimal clinically important difference (MCID) was 1.4 for VAS and 1.8 for SAS scores. The MCID was met or exceeded in the primary dislocation group in 31/38 (81.6%) patients for VAS, 23/31 (74.1%) for ASES, and 24/31 for SES (77.4%) scores. For the second dislocation cohort, MCID was met or exceeded in 7/9 (77.8%) for VAS, 4/7 (57.1%) for ASES, and 5/7 for SES (71.4%) scores., Conclusion: Immediate arthroscopic surgical stabilization after a first-time anterior shoulder dislocation significantly decreases the risk of recurrent dislocation in comparison to those who undergo surgery after 2 dislocation events, with comparable clinical outcome scores. These findings suggest that patients who return to activities after a primary anterior shoulder dislocation and sustain just 1 additional dislocation event are at increased risk of a failing arthroscopic repair., Study Design: Retrospective comparative study; Level of evidence, 3., (Copyright © 2022 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

In recent years, an appreciation for the dynamic relationship between glenoid and humeral-sided bone loss and its importance to the pathomechanics of glenohumeral instability has substantially affected modern treatment algorithms. However, comparatively less attention has been paid to the influence of glenoid version on glenohumeral instability. Limited biomechanical data suggest that alterations in glenoid version may affect the forces necessary to destabilize the glenohumeral joint. However, this phenomenon has not been consistently corroborated by the results of clinical studies. Although increased glenoid retroversion may represent an independent risk factor for posterior glenohumeral instability, this relationship has not been reliably observed in the setting of anterior glenohumeral instability. Similarly, the effect of glenoid version on the failure rates of surgical stabilization procedures remains poorly understood., (Copyright © 2022 by the American Academy of Orthopaedic Surgeons.)

Purpose: To determine if anterior cruciate ligament (ACL) reconstruction (ACLR) with lateral extraarticular tenodesis (LET) is beneficial for restoring knee kinematics with concomitant meniscal pathology causing rotatory knee instability., Methods: Twenty patients with an ACL tear were randomized to either isolated ACLR or ACLR with LET. Patients were divided into four groups based on the surgery performed and the presence of meniscal tear (MT): ACLR without MT, ACLR with MT, ACLR with LET without MT, and ACLR with LET with MT. Kinematic data normalized to the contralateral, healthy knee were collected using dynamic biplanar radiography superimposed with high-resolution computed tomography scans of patients' knees during downhill running. Anterior tibial translation (ATT) and tibial rotation (TR) as well as patient-reported outcome measures (PROMs) were analyzed at 6- and 12-months postoperatively., Results: At 6 months, ACLR with LET resulted in significantly decreased ATT at heel strike compared to ACLR (ACLR without MT: 0.3 ± 0.8 mm and ACLR with MT: 1.4 ± 3.1 mm vs. ACLR with LET without MT: - 2.5 ± 3.4 mm and ACLR with LET with MT: - 1.5 ± 1.2 mm ATT, p = 0.02). At 6 months, at toe off ACLR with LET better restored ATT to that of the contralateral, healthy knee in patients with meniscal pathology, while in patients without meniscal pathology, ACLR with LET resulted in significantly decreased ATT (1.0 ± 2.6 mm ATT vs. - 2.6 ± 1.7 mm ATT, p = 0.04). There were no significant differences in kinematics or PROMs between groups at 12 months., Conclusion: For combined ACL and meniscus injury, ACLR with LET restores native knee kinematics at toe off but excessively decreases ATT at heel strike in the early post-operative period (6 months) without altering knee kinematics in the long term. Future large-scale clinical studies are needed to better understand the function of LET and ultimately improve patient outcomes., Level of Evidence: III., (© 2021. European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA).)

Background: Off-track lesions are strongly associated with failure after arthroscopic Bankart repair. However, on-track lesions with a small distance-to-dislocation (DTD) value, or "near-track lesions," also may be at risk for failure. The purpose of the present study was to determine the association of DTD with failure after arthroscopic Bankart repair., Methods: We performed a retrospective analysis of 173 individuals who underwent primary arthroscopic Bankart repair between 2007 and 2015. Glenoid bone loss and Hill-Sachs lesion size were measured with use of previously reported methods. Patients with failure were defined as those who sustained a dislocation after the index procedure, whereas controls were defined as individuals who did not. DTD was defined as the distance from the medial edge of the Hill-Sachs lesion to the medial edge of the glenoid track. Receiver operating characteristic (ROC) curves were constructed for DTD to determine the critical threshold that would best predict failure. The study population was subdivided into individuals ≥20 years old and <20 years old., Results: Twenty-eight patients (16%) sustained a recurrent dislocation following Bankart repair. Increased glenoid bone loss (p < 0.001), longer Hill-Sachs lesion length (p < 0.001), and decreased DTD (p < 0.001) were independent predictors of failure. ROC curve analysis of DTD alone demonstrated that a threshold value of 8 mm could best predict failure (area under the curve [AUC] = 0.73). DTD had strong predictive power (AUC = 0.84) among individuals ≥20 years old and moderate predictive power (AUC = 0.69) among individuals <20 years old. Decreasing values of DTD were associated with a stepwise increase in the failure rate., Conclusions: A "near-track" lesion with a DTD of <8 mm, particularly in individuals ≥20 years old, may be predictive of failure following arthroscopic Bankart repair. When using the glenoid track concept as the basis for surgical decision-making, clinicians may need to consider the DTD value as a continuous variable to estimate failure instead of using a binary on-track/off-track designation., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of Levels of Evidence., Competing Interests: Disclosure: The authors indicated that no external funding was received for any aspect of this work. On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version of the article, one or more of the authors checked “yes” to indicate that the author had a relevant financial relationship in the biomedical arena outside the submitted work (http://links.lww.com/JBJS/G432)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Lateral extra-articular tenodesis (LET) in combination with anterior cruciate ligament (ACL) reconstruction (ACLR) has been proposed to improve residual rotatory knee instability in patients having ACL deficiency., Purpose/hypothesis: The purpose was to compare the effects of isolated ACLR (iACLR) versus LET in combination with ACLR (ACLR+LET) on in vivo kinematics during downhill running. It was hypothesized that ACLR+LET would reduce the internal rotation of the reconstructed knee in comparison with iACLR., Study Design: Controlled laboratory study., Methods: A total of 18 patients with ACL deficiency were included. All participants were randomly assigned to receive ACLR+ LET or iACLR during surgery. Six months and 12 months after surgery, knee joint motion during downhill running was measured using dynamic biplane radiography and a validated registration process that matched patient-specific 3-dimensional bone models to synchronized biplane radiographs. Anterior tibial translation (ATT; positive value means "anterior translation") and tibial rotation (TR) relative to the femur were calculated for both knees. The side-to-side differences (SSDs) in kinematics were also calculated (operated knee-contralateral healthy knee). The SSD value was compared between ACLR+LET and iACLR groups using a Mann-Whitney U test., Results: At 6 months after surgery, the SSD of ATT in patients who had undergone ACLR+LET (-1.9 ± 2.0 mm) was significantly greater than that in patients who had undergone iACLR (0.9 ± 2.3 mm) at 0% of the gait cycle (foot strike) ( P = .031). There was no difference in ATT 12 months after surgery. Regarding TR, there were no differences between ACLR+LET and iACLR at either 6 months ( P value range, .161-.605) or 12 months ( P value range, .083-.279) after surgery., Conclusion: LET in combination with ACLR significantly reduced ATT at the instant of foot strike during downhill running at 6 months after surgery. However, this effect was not significant at 12 months after surgery. The addition of LET to ACLR had no effect on TR at both 6 and 12 months after surgery., Clinical Relevance: LET in combination with ACLR may stabilize sagittal knee motion during downhill running in the early postoperation phase, but according to this study, it has no effect on 12-month in vivo kinematics., Registration: NCT02913404 (ClinicalTrials.gov identifier).

Background: The pivot-shift test is used to assess for rotatory knee laxity in the anterior cruciate ligament (ACL)-deficient knee and ACL-reconstructed knee; however, the pivot shift uses a subjective grading system that is limited by variability between examiners. Consequently, quantified pivot shift (QPS) test software (PIVOT iPad application) has been developed and validated to measure the magnitude of rotatory knee laxity during the positive pivot-shift test., Purpose: To employ intraoperative QPS (iQPS) to assess for differences in residual rotatory knee laxity after ACL reconstruction (ACLR) versus ACLR augmented with lateral extra-articular tenodesis (ACLR + LET), and to employ iQPS to determine if ACLR and/or ACLR + LET result in overconstrained knee kinematics when compared with the contralateral knee., Study Design: Cohort study; Level of evidence, 2., Methods: iQPS was performed in 20 patients by a single surgeon on both the operative and contralateral knees before ACLR. ACLR was augmented with a LET if the lateral compartment tibial translation measured during QPS was greater than or equal to double the amount of lateral tibial compartment translation measured for the contralateral knee. After each reconstruction (ACLR or ACLR + LET), iQPS measurements were performed. iQPS data were compared with the preoperative QPS measurements of the operative and contralateral knees. Postoperative iQPS data were compared with both the preoperative QPS measurements of the operative and contralateral knees with paired samples t tests. Categorical variables were compared using the Fisher exact test., Results: The mean age in the cohort was 17.3 years (range, 15-24 years). There were no significant differences between the groups in terms of the proportion of male patients (ACLR: 5 male, 5 female vs ACLR + LET: 4 male, 6 female) or age (ACLR: 17.7 ± 3.3 years; 95% CI, 15.4-24.0 vs ACLR + LET: 16.8 ± 2.8 years, 95% CI, 14.8-22.0; P = .999). There were no significant differences between the groups with respect to preoperative QPS performed during examination under anesthesia (ACLR: 4.7 ± 2.0 mm; 95% CI, 3.3-6.1 vs ACLR + LET: 3.6 ± 1.8 mm; 95% CI, 2.3-4.9; P = .2). Both ACLR and ACLR + LET resulted in significant decreases in rotatory knee laxity when compared with preoperative QPS measurements (ACLR: -3.4 ± 1.7 mm; 95% CI, -4.6 to -2.2; P < .001: ACLR + LET: -2.6 ± 1.9 mm; 95% CI, -3.9 to -1.3; P < .002). Moreover, when compared with isolated ACLR, ACLR + LET did not result in a significantly smaller magnitude of change in iQPS between the pre- and postoperative states ( P = .3)., Conclusion: Both ACLR and ACLR + LET resulted in significant decreases in rotatory knee laxity. The augmentation of ACLR with LET did not change the constraint of the knee with respect to lateral compartment translation as measured during iQPS.

Purpose: To systematically review patient and technical risk factors for anterior glenoid rim fractures through suture anchor points (i.e. "postage stamp") after arthroscopic Bankart repair., Methods: An independent, duplicate search of Embase, Medline, and Web of Science databases, in addition to the past 5-year annual meeting abstracts of several prominent shoulder meetings, was conducted according to R-AMSTAR and Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines to identify English-language studies reporting this complication., Results: A screen of 2,833 studies yielded 6 for inclusion herein. Data across 43 patients, aged 14 to 61 years (mean 24.4), 5% female, and who were followed for 4 to 108 months postoperatively, were reviewed. Only 1 of 6 studies (n = 2) reported postage stamp fracture in female patients. Median time from initial surgery to fracture ranged from 12 to 24 months. Five of 6 studies (n = 32) reported a median age at initial surgery of 25 years or younger (range 17-35). Four of 6 studies (n = 30) reported fracture mostly after sport involvement. All studies (n = 35) reported initial fixation with a median of 3 anchors or more, 3 of 5 studies (n = 26) reported fracture entirely after conventional knot-tying anchors, and 5 of 6 studies (n = 24) reported more fractures after absorbable suture anchor use. Fractures occurred entirely through anchor holes in 5 of 6 studies (n = 29) and mostly after osteolysis in 3 of 4 studies (n = 19). Management strategies after fracture included revision arthroscopic Bankart repair or open Bristow/Latarjet procedures., Conclusion: Postage stamp fractures were reported frequently in patients who were male, age 25 years or younger, and participants in sporting activities and in fractures initially stabilized with 3 or more anchors or conventional knot-tying anchors or that experienced osteolysis around anchor sites., Level of Evidence: Level IV, systematic review of level III and IV studies., (Copyright © 2019 Arthroscopy Association of North America. All rights reserved.)

Anatomy is the foundation of orthopaedic surgery, and the advancing knowledge of the anterior cruciate ligament (ACL) anatomy has led to the development of improved modern reconstruction techniques that approach the anatomy of the native ACL. Current literature on the anatomy of the ACL and its reconstruction techniques, as well as our surgical experience, was used to develop a flowchart that can aid the surgeon in performing anatomic ACL reconstruction. We define anatomic ACL reconstruction as the functional restoration of the ACL to its native dimensions, collagen orientation, and insertion sites. A guideline was written to accompany this flowchart with more detailed information on anatomic ACL reconstruction and its pitfalls, all accompanied by relevant literature and helpful figures. Although there is still much to learn about anatomic ACL reconstruction methods, we believe this is a helpful document for surgeons. We continue to modify the flowchart as more information about the anatomy of the ACL, and how to more closely reproduce it, becomes available., ((c) 2010 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)