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Chapter 228AbstractBackground: Tibial rotation is a hot topic in ACL surgery and many efforts are being made to address rotational stability. The exact role of the ACL in controlling tibial rotation in clinical studies is still unknown. Purpose: The purpose of this systematic review is to quantify the effect of ACL reconstruction on the amount of tibial rotation based on the current available literature.Study Design: Systematic reviewMethods: August 2019 a literature search was performed in the Pubmed and Embase databases. Two independent reviewers reviewed titles and abstracts as well as full text articles. A total of 2383 studies were screened for eligibility. After screening of title and abstracts 178 remained for full text assessment. Ultimately 13 studies were included for analysis. A quality assessment using the Risk of Bias in randomized trials (RoB 2.0) and the Risk Of Bias In Non-randomised Studies – of Interventions (ROBINS-1) was performed. Results: The included studies in this review report ACL reconstruction resulting in an average reduction of 17-32%. In current literature a gold standard for measuring tibial rotation is lacking. Major differences between the study protocols were found. Several techniques for measuring tibial rotation have been used, each with its own limitations. Most articles lack proper description of accompanying injuries. Conclusion: CAS studies showed that ACL reconstruction achieves a reduction of 17-32% of range of tibial rotation, when comparing pre- and postoperative individuals. Whether it returns to pre-injury levels remains unclear. Normal values for the range of tibial rotation in ACL deficient and ACL reconstructed patients cannot be provided based on the current available literature due to lack of a uniform measuring techniques and protocols. The authors therefore advocate uniformity in measuring tibial rotation.Mark Zee.indd 28 03-01-2024 08:56