I was delighted to be part of the organising faculty for ‘Sports Knee Surgery 2025’, one of the leading sports knee meetings in the UK calendar. The conference brought together many of the world’s foremost knee surgeons, researchers and therapists for two days of high-level discussion focused on the latest advances in sports knee surgery, ACL reconstruction, meniscal preservation, cartilage restoration and patellofemoral surgery.

Alongside Tim Spalding, Pete Thompson, Andy Metcalfe, Nicola Mackay and Feisal Shah, it was a privilege to help deliver a meeting that attracted an outstanding international faculty and excellent engagement throughout. The atmosphere across the conference reflected how rapidly the field of sports knee surgery continues to evolve, with increasing emphasis on personalised treatment, biomechanics and improving long-term patient outcomes.

A major highlight of the meeting was the exceptional international faculty, including Aaron Krych, David Dejour, Robert LaPrade, Laurie Hiemstra, Maria Tuca and Andy Williams. Their presentations and panel discussions generated outstanding debate across a wide range of complex sports knee topics.

ACL Revision Surgery, Tibial Slope and the “Delta Angle”

One of the presentations I delivered focused on slope-changing osteotomy in revision ACL reconstruction and the growing importance of tibial slope analysis when assessing patients with recurrent ACL failure.

Increasing evidence suggests that posterior tibial slope has a major influence on ACL graft loading and re-rupture risk. Modern ACL surgery is therefore moving beyond simply reconstructing the ligament itself and increasingly recognising the importance of underlying bony morphology and knee biomechanics.

My presentation focused particularly on the concept of the “delta angle” — the relationship between the lateral and medial posterior tibial slopes — and how slope asymmetry may help identify higher-risk patients in the revision setting. There was excellent discussion around surgical indications, thresholds for correction and how slope-reducing osteotomy can be integrated into complex revision ACL surgery in appropriately selected patients.

The session highlighted the continued movement towards truly personalised ACL surgery, tailoring treatment not only to the injury but also to the individual biomechanics of each patient.

Patellofemoral Session Highlights

The patellofemoral session was one of the standout parts of the conference and generated particularly strong engagement from delegates. With world-leading expertise from speakers including David Dejour and Laurie Hiemstra, discussions focused on the modern management of patellar instability and the increasing sophistication of contemporary patellofemoral surgery.

Topics included:

• Trochlear dysplasia
• Tibial tubercle osteotomy
• Rotational alignment
• Individualised treatment strategies
• The evolving role of bony correction procedures
• Decision-making around isolated soft tissue versus combined reconstruction techniques

As understanding of patellofemoral biomechanics continues to improve, treatment strategies are becoming increasingly tailored to the individual patient. The session provided excellent insight into current controversies and future directions within patellofemoral surgery.

AI, Innovation and the Future of Knee Surgery

Another major theme running throughout the meeting was the growing role of innovation, data science and artificial intelligence within sports knee surgery.

Discussions explored how AI may increasingly influence imaging analysis, surgical planning, outcome prediction, rehabilitation monitoring and research delivery in the future. There was considerable interest in how advanced data analysis and machine learning could help surgeons better identify patient-specific risk factors, refine decision-making and improve personalised treatment pathways.

The conference also highlighted the rapid pace of technological innovation across sports knee surgery, including developments in surgical techniques, biological augmentation, rehabilitation strategies and digital technologies designed to improve patient outcomes.

Collaboration, Innovation and Education

One of the most valuable aspects of Sports Knee Surgery 2025 was the opportunity for open discussion between surgeons, researchers, physiotherapists and industry partners. The meeting showcased not only cutting-edge surgical techniques, but also the importance of collaborative research, rehabilitation and outcome-driven care.

The programme covered a broad range of topics including:

• Primary and revision ACL reconstruction
• Meniscal repair and transplantation
• Cartilage restoration techniques
• Osteotomy
• Multi-ligament knee injuries
• Patellofemoral instability
• Rehabilitation and return to sport
• Emerging technologies and surgical innovation

A Fantastic Meeting

Sports Knee Surgery 2025 was a tremendous success and reflected the strength of the sports knee community both within the UK and internationally.

It was fantastic to see so many leading surgeons and enthusiastic delegates engaging in high-quality discussion around some of the most challenging areas of modern knee surgery. Meetings such as this are vital in continuing to improve standards, advance research and ultimately deliver better outcomes for patients.

Further information about the meeting can be found here:

Sports Knee Surgery 2025 Official Meeting Page

Nick Smith presented at the Imperial Sports Knee Meeting 2026 – an excellent meeting bringing together leading sports knee surgeons, researchers and therapists to discuss contemporary challenges and innovations in sports knee and joint preservation surgery.

The conference featured high-level discussion across ACL surgery, meniscal preservation, cartilage restoration, osteotomy and biologic augmentation, with a strong focus on practical surgical decision-making and the future direction of knee preservation techniques.

Meniscal Transplantation – Technique Tips and Tricks

Mr Smith’s presentation focused on meniscal transplantation, sharing practical surgical technique tips, graft preparation strategies and technical pearls developed through one of the largest meniscal transplant practices in Europe.

Meniscal transplantation remains an important treatment option for carefully selected patients with symptomatic meniscal deficiency, particularly younger and active individuals where preservation of the joint is the priority.

The presentation explored several key technical aspects of surgery, including:

• Graft preparation
• Portal positioning
• Soft tissue clearance
• Root tunnel creation
• Graft insertion techniques
• Optimising graft positioning and “fit”
• Fixation strategies and tensioning

A major theme of the talk was that successful meniscal transplantation is not simply about inserting the graft, but about restoring knee biomechanics as accurately as possible while minimising graft extrusion and overload.

The presentation also reviewed current evidence surrounding fixation methods and discussed the biomechanical advantages that may be associated with bone plug fixation techniques in selected cases.

Technical Pearls Discussed

Several practical intra-operative tips generated excellent discussion, including:

• Preparing the graft before patient preparation to improve theatre efficiency
• Using a lateral viewing portal to optimise visualisation
• Keeping anterior root sutures out of the working area until final graft seating
• Allowing graft “fit” to determine fixation order
• The importance of careful soft tissue clearance and trephination

The session generated excellent debate around graft fixation, root positioning, extrusion prevention and how technique refinement may improve longer-term graft function and survivorship.

Chairing the Cartilage Session

In addition to presenting, Mr Smith also chaired the cartilage restoration session, which was one of the standout parts of the meeting.

The session covered a broad range of topics surrounding the management of larger cartilage lesions and joint preservation surgery, including:

• Osteochondral allograft transplantation
• Autologous chondrocyte implantation (ACI)
• Biological augmentation
• Combined osteotomy and cartilage restoration
• Treatment strategies for complex and bipolar lesions
• The future of cartilage repair technologies

There was extensive discussion around patient selection, rehabilitation, biological enhancement and the increasing importance of treating the “whole knee environment” — including alignment, meniscal function and ligament stability — when managing complex cartilage pathology.

Innovation and the Future of Knee Preservation

A recurring theme throughout the meeting was how sports knee surgery continues to evolve towards increasingly personalised and biologically focused treatment strategies.

There was significant discussion around:

• AI and data-driven decision making
• Biological augmentation
• Advanced imaging and graft assessment
• Rehabilitation optimisation
• Earlier intervention to preserve joint health
• Improving long-term outcomes in younger active patients

The meeting highlighted the rapid pace of innovation within sports knee surgery and the growing emphasis on combining biomechanics, biologics and surgical precision to improve patient outcomes.

A Valuable Meeting

The Imperial Sports Knee Meeting 2026 provided an excellent forum for discussion, debate and shared learning among surgeons with a strong interest in sports knee and joint preservation surgery.

Mr Smith’s contribution to the programme through both his presentation on meniscal transplantation and chairing the cartilage session reflected the increasing international interest in advanced knee preservation techniques and contemporary meniscal surgery.

#ISKM 2026

The meeting brought together national and international experts to discuss the latest developments in ligament reconstruction, arthroplasty, cartilage restoration, osteotomy and knee preservation surgery. A major theme throughout the conference was how surgical techniques continue to evolve towards more personalised, biomechanically informed treatment strategies designed to improve patient outcomes and reduce re-injury risk.

Quadriceps Tendon ACL Reconstruction – Where Are We Now?

Mr Smith’s presentation focused on the rapidly increasing use of quadriceps tendon grafts in ACL reconstruction and the current evidence surrounding outcomes, biomechanics and graft selection.

Quadriceps tendon grafts have become one of the fastest-growing graft choices worldwide, particularly in younger athletic patients, revision surgery and complex ligament reconstruction.

Historically, hamstring tendon and bone-patellar tendon-bone (BTB) grafts have dominated ACL reconstruction. However, both grafts have recognised limitations:

• Hamstring grafts may lead to hamstring weakness and variable graft size
• BTB grafts are associated with anterior knee pain and kneeling discomfort

The quadriceps tendon has increasingly emerged as an attractive alternative, offering:

• A large and reliable graft diameter
• Strong biomechanical properties
• Lower donor-site morbidity than BTB in many studies
• Flexibility for use with or without a bone plug

Biomechanics and Graft Characteristics

The presentation reviewed the evolving biomechanical evidence surrounding quadriceps tendon grafts and how they compare with both hamstring and BTB grafts.

A key discussion point was that while hamstring grafts may demonstrate very high load-to-failure values in laboratory testing, quadriceps tendon grafts are structurally and biomechanically more similar to BTB grafts. Multi-strand hamstring constructs may also undergo elongation due to strand settling and interstitial motion.

The talk highlighted how quadriceps tendon grafts combine several of the advantages traditionally associated with both hamstring and BTB grafts, leading some surgeons to describe them as a potential “unicorn graft”.

Clinical Outcomes and Current Evidence

The presentation reviewed contemporary evidence comparing quadriceps tendon grafts with both hamstring and BTB grafts.

Current studies suggest:

• Similar stability and functional outcomes compared with BTB grafts
• Lower rates of anterior knee pain and kneeling discomfort compared with BTB
• Similar or potentially lower failure rates compared with hamstring grafts
• Larger and more reliable graft diameter

Mr Smith also discussed findings from randomised controlled trial meta-analysis data, which demonstrated no major differences in patient-reported outcomes, knee laxity or re-rupture rates compared with hamstring grafts, whilst potentially offering lower donor-site morbidity.

Challenges and Learning Curve

The presentation also addressed several important considerations surrounding quadriceps tendon ACL reconstruction, including:

• Learning curve issues
• Early quadriceps weakness
• Graft preparation complexity
• Rare complications such as patellar fracture when using bone-plug harvest techniques

Particular emphasis was placed on the importance of surgeon experience and volume. Registry data discussed during the presentation suggested higher failure rates in low-volume centres, reinforcing the need for careful adoption and appropriate rehabilitation protocols.

Where Does the Quad Graft Fit in Modern ACL Surgery?

A major discussion point was where quadriceps tendon grafts currently fit within modern ACL reconstruction practice.

The presentation suggested that quadriceps tendon grafts may be particularly useful:

• As an alternative to hamstring grafts
• In revision ACL reconstruction
• In multi-ligament knee injuries
• Where reliable graft size is important

However, discussion also focused on the need for longer-term high-quality data before completely replacing BTB grafts in the very highest-risk patients, where minimising re-rupture risk remains the overriding priority.

Innovation and the Future of ACL Surgery

The meeting also featured extensive discussion around:

• AI and data-driven surgical planning
• Individualised graft selection
• Biological augmentation
• Return-to-sport decision making
• Rehabilitation optimisation
• Prevention of ACL graft failure

The continued evolution of ACL surgery towards increasingly personalised and evidence-based treatment pathways was a recurring theme throughout the conference.

A Valuable National Meeting

BASK 2026 once again highlighted the strength of knee surgery research and innovation within the UK and internationally.

Mr Smith’s presentation contributed to excellent discussion surrounding modern ACL graft choice and the growing role of quadriceps tendon grafts within contemporary ligament reconstruction surgery.

Increasingly, surgeons are exploring whether synthetic augmentation, often referred to as “Internal Brace” augmentation, may help protect the graft during the early healing phase and improve return-to-sport outcomes.

What is ACL Augmentation/Internal Brace Surgery?

Augmentation involves reinforcing the ACL graft with a high-strength suture tape construct designed to provide additional stability during graft healing and maturation. Internal Brace refers specifically to Arthrex’s technique of using Fibertape fixed to a button on the femur, and separately tensioned with a Swivelock Anchor in the tibia.

The concept is not to replace the ACL graft itself, but to:

• Protect the graft during the early post-operative phase
• Reduce graft stretching or elongation
• Potentially lower re-rupture rates
• Allow greater confidence during rehabilitation and return to sport

Modern augmentation techniques differ significantly from older synthetic ligament replacements, which historically had poor outcomes due to mechanical failure and synovitis. Contemporary techniques use synthetic reinforcement alongside standard biological grafts rather than replacing them entirely.

Who Uses Them?

The majority of Internal Brace augmentations happen in the USA, but across the rest of the world, their use is increasing rapidly. Latest estimates in the UK are the approximately 15% of all ACL reconstructions are synthetically augmented.

What Does the Current Evidence Show?

Nick Smith recently co-authored a large systematic review and meta-analysis examining whether synthetic augmentation improves outcomes after ACL reconstruction.

The review analysed:

• 47 studies
• 4,289 patients
• Multiple augmentation techniques including Internal Brace augmentation, FiberTape and other synthetic reinforcement systems

The findings suggested that augmentation may improve return-to-sport rates, particularly with modern Internal Brace techniques.

Return to Sport

The meta-analysis demonstrated:

• Higher mid-term return-to-sport rates with augmentation
• Odds ratio (OR) 1.58 for improved return to sport overall
• Internal Brace subgroup OR 2.19 for return to sport improvement

This suggests much better return to sport rates for augmented ACL reconstructions. Several contemporary studies also reported very high return-to-sport rates following Internal Brace augmented ACL reconstruction.

What About Re-Rupture Rates?

One of the most interesting findings from the review was that Internal Brace augmentation appeared to reduce long-term graft re-rupture rates in some studies.

The Internal Brace subgroup demonstrated:

• OR 0.17 for graft failure reduction in long-term follow-up

This also suggests very low failure rates for augmented ACL reconstructions, compared to traditional ACL reconstruction. However, when all augmentation techniques were analysed together, the reduction in graft failure was not statistically significant.

This suggests that:

• Modern augmentation techniques may be more effective than older synthetic systems
• The type of augmentation used likely matters significantly
• We still need much higher-quality evidence before drawing definitive conclusions

The Problem with the Current Evidence

Although the early findings are encouraging, the current evidence base remains limited.

The systematic review concluded that:

• Most studies were low-quality or non-randomised
• Many studies had moderate-to-serious risk of bias
• Surgical techniques varied substantially
• Rehabilitation protocols were inconsistent
• Longer-term outcomes remain uncertain

Importantly, many of the currently available studies are relatively small and may be influenced by surgeon selection bias and evolving surgical techniques.

At present, there is still no definitive answer as to whether Internal Brace augmentation truly improves patient outcomes after ACL reconstruction.

STRAP ACL – A £1.9 Million NIHR Randomised Controlled Trial

To help answer this question properly, Mr Smith is Chief Investigator of the STRAP ACL trial — a major £1.9 million NIHR-funded randomised controlled trial designed to evaluate whether synthetic augmentation improves outcomes following ACL reconstruction.

The study will recruit patients between 2026 and 2028 across multiple centres and aims to provide the highest-quality evidence to date on this increasingly important topic.

The STRAP ACL trial will investigate:

• Return-to-sport outcomes
• ACL graft re-rupture rates
• Patient-reported outcome measures
• Rehabilitation progression
• Imaging and graft healing outcomes
• Safety and complications

The trial has been designed specifically to address many of the limitations identified within the current literature.

The Future of ACL Surgery

Modern ACL surgery continues to evolve rapidly towards increasingly personalised and biomechanically informed treatment strategies.

Potential future developments include:

• AI-driven risk prediction
• Individualised graft and augmentation selection
• Advanced rehabilitation monitoring
• Biological augmentation techniques
• Imaging-based graft maturation assessment

Internal Brace augmentation may ultimately prove to be an important advancement in ACL surgery — particularly for younger, higher-risk athletes — but definitive answers require high-quality randomised research.

The STRAP ACL trial aims to provide that evidence and help guide the future direction of ACL reconstruction surgery across the world.