1. Synthetic augmentation in ACL reconstruction: the evidence for and against

Wexham Cruciate Ligament Meeting, November 2026. Nick Smith, Consultant Knee Surgeon, University Hospitals Coventry and Warwickshire; Honorary Associate Professor, University of Warwick; Co-Chief Investigator, STRAP ACL.

ACL reconstruction outcomes are worse than patients are usually told: 28% return to sport at 18 months in the surgical arm of ACL SNNAP, 20–30% residual laxity in STABILITY, and graft rupture of 5–20% in young pivoting athletes. Reinforcing the graft with synthetic tape aims to protect it during ligamentisation. The idea dates to the Kennedy LAD in the 1970s; the synthetic replacements that followed (LARS, Dacron, carbon fibre) failed through fatigue, wear debris and synovitis. Current devices work in different ways, either sutured into and tensioned with the graft (LAD, BioBrace) or independently fixed (InternalBrace), so pooling them hides the signal.

Our meta-analysis with Warwick Clinical Trials Unit (Jiang et al., KSSTA 2025) included 47 studies and 4,289 patients, only 7 randomised. Return to sport improved (OR 1.58, moderate certainty). Graft failure was not significantly reduced across all devices; it was in the InternalBrace subgroup, but on only 218 patients. All 40 non-randomised studies were at moderate or serious risk of bias and no outcome reached high certainty. Non-randomised designs consistently flatter new treatments (Sacks et al. 1982; Ioannidis 2005), as subacromial decompression and degenerative meniscectomy showed.

Regulatory clearance requires safety and equivalence to existing devices, not better patient outcomes. Under the IDEAL framework augmentation sits at stage 2b, while uptake in the USA and UK is rising fast. That is genuine equipoise. STRAP ACL, a £1.9 million NIHR HTA trial, will randomise 318 patients across 20 UK sites to autograft ACL reconstruction with or without independently tensioned tape, with return to sport, graft failure, PROMs, cost-effectiveness and an MRI sub-study as outcomes. Recruitment opens November 2026.

2. Understanding medial and lateral tibial slope anatomy: why the two plateaux are not the same

Wexham Cruciate Ligament Meeting, November 2026. Nick Smith, Consultant Knee Surgeon, University Hospitals Coventry and Warwickshire; Honorary Associate Professor, University of Warwick.

The medial plateau is concave and acts as the stable pivot; the lateral plateau is flat or convex and allows rollback and rotation (Iwaki et al. 2000). ACL injury is rotational and happens laterally, yet most slope measurement and slope-correction decisions use medial slope. Murphy, Ollivier et al. (KSSTA 2026) pooled 24 studies and 6,335 knees: lateral slope was 2.1° higher in graft failures with a significant per-degree risk (aOR 1.15), while medial slope was 1.1° higher and not significant per degree.

Our UHCW cohort of 1,174 ACL reconstructions (2007–2018, minimum 5-year follow-up) found revision and contralateral-injury knees had lower medial and higher lateral slope than primaries, doubling the delta (lateral minus medial) from 3.1° to over 6°. Revision risk rose with lateral slope, but Delta was the strongest predictor. Measurement used a short tibial reference axis, so absolute medial values are not directly comparable with full-length radiograph studies.

With Andrew Amis and the Imperial College team (Nejima et al. 2026) we changed medial and lateral slope independently in 8 cadaveric knees under 500 N axial load. 10° more lateral slope increased anterior tibial translation by 1.7 mm; 10° more medial slope had no significant effect. Opposing combinations, lateral up and medial down, increased internal rotation by up to 13.5° at 20° flexion. Lateral slope drives anterior translation and delta drives rotation, the combined loading pattern that puts most force through the ACL.

In summary, lateral slope is the most important single measure. Medial slope is a reasonable surrogate when the lateral plateau is hard to read. Delta is a powerful risk factor, but for now not an indication for osteotomy on its own.

3. Gold standard multiligament knee injury management

Wexham Cruciate Ligament Meeting, November 2026. Nick Smith, Consultant Knee Surgeon, University Hospitals Coventry and Warwickshire; Honorary Associate Professor, University of Warwick.

A practical pathway for whoever is on call, in a major trauma centre or a district general hospital, from the front door to rehabilitation. Every multiligament knee injury should be treated as a knee dislocation: vascular injury occurs in about 18%, nerve injury, mostly common peroneal, in 25%, and around 2% end in amputation (Medina et al., CORR 2014). Most have reduced before arrival, including low-energy injuries in heavier patients.

In the first hour: reduce and splint, confirm reduction on a lateral X-ray, record a timed neurovascular examination, and get a CT angiogram for every suspected dislocation regardless of pulses, adding the leg to any trauma CT. Hard signs go straight to theatre with the vascular surgeons. A normal CTA still needs 24–48 hours of neurovascular observation, because intimal flaps occlude late. No ligament surgery until a vascular injury is excluded or repaired (BOAST arterial injuries guideline; Murray et al., BJSM 2024).

A hinged brace locked in extension holds most knees. A spanning external fixator is rarely needed and reserved for vascular repair, open injury, a knee that will not stay reduced, obesity or polytrauma, with pins a hand’s breadth clear of the joint and away from future tunnels and graft harvest sites, and off within 4–6 weeks.

Proposed referral thresholds: emergency transfer to the major trauma centre for vascular injury, irreducible, open or fracture-dislocation, and polytrauma; referral to an MLKI knee centre within 48 hours for bicruciate injury, PCL plus collateral, any posterolateral corner injury or peroneal palsy; ACL plus MCL can usually stay with a local knee surgeon. Before transfer, keep the options open: no graft harvest, no tunnels, no isolated ACL reconstruction.

At the MLKI centre: single-stage reconstruction of cruciates and corners within about 3 weeks, repair only for bony or peel-off avulsions, since corner repair alone fails about 3 times as often as reconstruction. Then early motion, because stiffness is the commonest complication.

4. Graft on the floor: ACL reconstruction when it goes wrong

Wexham Cruciate Ligament Meeting, November 2026. Nick Smith, Consultant Knee Surgeon, University Hospitals Coventry and Warwickshire; Honorary Associate Professor, University of Warwick.

A dropped graft is rare but most ligament surgeons will see one. Three messages: have a backup harvest site, consent for an alternative graft source before the day, and if it happens, laboratory evidence supports washing and using the graft.

The graft is not sterile to begin with. 96% of theatre floor swabs and 40% of dropped, unwashed hamstring segments culture positive (Barbier et al., Knee 2015), but so do 23% of hamstring segments taken straight after harvest that never touched the floor (Plante et al., KSSTA 2013). Molina et al. (Arthroscopy 2000) dropped ACL segments on the theatre floor for 15 s: 58% culture positive unwashed, 2% after 90 s in 4% chlorhexidine, 6% after neomycin-polymyxin and 24% after 10% povidone-iodine. In Barbier’s study washed segments had fewer positive cultures than segments that never left the table. Saline alone does not work. Whole tendon soaked in 4% chlorhexidine for 30 min keeps its failure load (Gurbuz 2025), twenty times the exposure needed; surface cells die, which is irrelevant for an autograft that ligamentises.

My protocol: retrieve and strip sutures; soak in 4% chlorhexidine scrub from a fresh sealed bottle for 90 s to 3 min; three saline rinses; vancomycin wrap as routine; re-suture and re-size; record the drop, protocol and reasoning in the operation note and tell the patient the same day; early review with a low threshold to aspirate; normal rehabilitation.

There were no infections in 16 documented washed and reused grafts (Pasque and Geib 2007; Chilean survey 2019), and 59–75% of surgeons who have dropped a graft report washing and reusing it. The one reported sanction I found, an NSW tribunal case involving a chin implant, was for not checking for a replacement, leaving the drop out of the operation note and telling the patient late, not for washing it. Surgeons should check with their own medical defence organisation.

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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.

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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.

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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

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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

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