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General Discussion1819exhibit compensatory patterns. Given that over 91% of patients expect to return to sports within one year of ACL reconstruction,11 measuring range of tibial rotation at that moment should be considered a sensible and valuable adjunct to ACL rehabilitation, as this may reveal persistent compensatory muscle activity. As time passes, some subjects may display more rotational laxity as a consequence of depletion of the compensatory mechanisms. It is plausible that within one year of reconstruction, patients use compensatory muscle activation patterns to stabilise the knee, but that those compensatory mechanisms fail to protect the graft in the long term. This is supported by the new (and recently popularised) insight that lateral extra-articular tenodesis as an adjunct to ACL reconstruction can reduce the incidence of a positive pivot shift after ACL reconstruction and foremostly can reduce the graft failure rate.14The finding that one year after ACL reconstruction compensatory mechanisms are still present, supports the theory that ACL reconstruction and rehabilitation are individual processes that are not time-driven but rather need to be guided by individual patient characteristics and rates of progression. This is relevant as patients need to be counselled preoperatively to ensure that expectations are realistic. Recreational athletes may mirror themselves against professional athletes who generate a lot of media attention, and may recover more quickly thanks to highintensity, professional guidance and money-driven goals. It needs to be emphasised in preoperative counselling that this may not be realistic for the average recreational athlete, which still covers the majority of patients.The findings of this thesis support the theory that we need to aim for an individualised approach in which the most biomechanically accurate reconstruction is created, combined with an individualised rehabilitation protocol with attention for neuromodulation strategies. Based on the knowledge gained in the first part of this thesis we conclude that we must improve the surgical treatment of ACL-injured patients in order to better recreate native knee kinematics and restore the ‘biology, neurology and psychology of the knee’. The necessity to match the patient’s pre-injury state in the best possible way is pertinent from a surgical perspective.Mark Zee.indd 181 03-01-2024 08:56