PURPOSE:The purpose of this study was to reproducibly measure computed tomography (CT) tibial tunnel features in failed anterior cruciate ligament reconstructions (ACLRs) and to propose a CT classification system for tibial tunnel morphology in the setting of evaluation for a one- versus two-stage revision ACLR surgery. METHODS:A retrospective study was performed on 75 patients presenting for ACLR graft failure between July 2019 and April 2023. Inclusion criteria comprised patients who underwent a revision ACLR by a single surgeon with preoperative knee CT imaging. The centre of the anatomic tibial ACL footprint and the centre and size of the previously drilled ACLR tibial tunnel were used for axial classification. The size of the tibial tunnel on sagittal images was used to develop the sagittal classification system. RESULTS:Five tibial tunnel sagittal CT morphologies were categorized according to uniform dilation, 'tubular' (Type A; n = 39); distal dilation, 'shovel' (Type B; n = 4); midpoint dilation, 'balloon' (Type C; n = 16); dual tunnel (Type D; n = 3) and proximal dilation, 'mushroom' (Type E; n = 13). On axial CT slices, tunnels were classified as Type I (< 2.5 mm between anatomic footprint and ACLR tunnel), Type II (2.5-12.5 mm) and Type III (>12.5 mm). The average distance between the tibial tunnel and the centre of the ACL footprint measured 4.4 ± 2.7 mm (interrater correlation coefficient [ICC] = 0.84; confidence interval [CI] = 4.0-4.8 mm). Overall, 56 (74.7%) were classified as Type I, 18 (24.0%) as Type II and 1 (1.3%) as Type III. CONCLUSIONS:This study found that there was a reproducible categorization of CT tibial tunnels by five sagittal CT morphologies and three axial CT scan categories. The study also found that relative offset of ACLR tibial tunnels to their native footprint can be reproducibly identified using CT, which may assist in the future diagnosis and identification of ACLR knees that are at greater risk of revision. LEVEL OF EVIDENCE:Level IV, retrospective cross-sectional study.
PURPOSE:To establish evidence-based consensus recommendations regarding the diagnosis and treatment of partial-thickness posterosuperior rotator cuff tears (PT-PS-RCTs). This part addresses the definition, classification, natural history and diagnosis of these controversial conditions in shoulder surgery. METHODS:This official European Society of Sports Medicine, Knee Surgery and Arthroscopy-European Shoulder Associates (ESSKA-ESA) Formal Consensus was conducted according to the ESSKA Formal Consensus Methodology. A Steering Group developed 33 questions, followed by a standardized literature search and evidence review. For each question, a consensus statement was drafted and assigned recommendation grades (A-D) according to the level of evidence. An independent Rating Group evaluated all statements until strong agreement was achieved. RESULTS:Twelve recommendations were generated with three Grade A, three Grade B, two Grade C, five Grade D and strong agreement. Grade A was found for the use of multiple classification systems in unison to characterize these injuries and for the distinction between acute and chronic tears. Scientific presumption level (Grade B) was found for the increased incidence of articular injuries in overhead and contact athletes and for the absence of a link between calcifying tendinitis and PT-PS-RCTs. Grade C was found to define the risk and timeframe of tear progression and the ideal imaging modality. CONCLUSION:This ESSKA-ESA Formal Consensus recommends that PT-PS-RCTs should be classified according to tear location, depth and tendon involvement. The aetiology of these injuries is multifactorial, and their progression is unpredictable. Current imaging modalities have limitations in characterizing these lesions. The present consensus provides clinicians with a practical evidence-based framework for the diagnosis and classification of PT-PS-RCTs while identifying key priorities for future clinical research. LEVEL OF EVIDENCE:Level I, formal consensus.
PURPOSE:Artificial intelligence (AI) is increasingly utilized in medical education and clinical contexts, yet few studies compare the performance of large language models (LLMs) to subspecialized experts in providing guideline-based medical information on hip preservation. The purpose of this study was to evaluate the performance of three LLMs compared to a panel of international hip preservation experts in answering guideline-based questions related to femoroacetabular impingement syndrome, hip dysplasia and microinstability of the hip. METHODS:A 21-item questionnaire was developed based on published consensus guidelines. The survey was distributed to a panel of hip preservation specialists identified through the professional network of the senior author. Ten experts responded and were included in the analysis. Three LLMs (ChatGPT 5.2, Gemini 3 and Claude 4.5 Sonnet) were prompted using the same questionnaire, with each LLM performing three runs per item. Outcomes included overall accuracy, percent agreement, Fleiss' κ, generalized linear mixed-effects modelling and qualitative assessment of AI answer justifications. RESULTS:Expert accuracy was 90.5% (95% confidence interval [CI] 87.1-93.9), compared to 100% (p = 0.004) for Gemini, 98.4% (p = 0.016) for ChatGPT and 96.8% (p = 0.053) for Claude. Expert percent agreement was 42.9% and Fleiss' κ was 0.769; alternatively, AI intra-item percent agreement was 100% (Gemini) and 95.2% (ChatGPT and Claude). ChatGPT and Claude provided thorough justifications for even incorrect responses, and Gemini demonstrated formatting deviations despite 100% accuracy. CONCLUSION:The three LLMs demonstrated high accuracy and consistency when answering the hip preservation questionnaire, with two of the LLMs statistically outperforming the expert panel. In structured, verifiable question sets, the ability of newer LLMs to accurately and consistently respond to consensus-based questions is improving compared to prior reports. LLMs are likely to serve as an adjunct in orthopaedic education and practice, and limitations to AI's implementation into practice should be continuously and rigorously explored. LEVEL OF EVIDENCE:Level V.
Progress in surgery has never been driven by technical innovation alone. Advancing patient care extends far beyond the operating room, relying on the research and academic engagement of orthopaedic surgeons. Every improvement in surgical practice, from refined indications to optimised rehabilitation protocols, has been built on rigorous research and critical evaluation of evidence. Among academic activities, peer review is perhaps one of the most undervalued. It is time-consuming, often performed after long clinical hours, and offers little personal recognition. Yet, it remains the cornerstone of scientific integrity, strengthening manuscripts by challenging unsupported conclusions, refining methodology, and improving the quality of evidence that informs clinical decision-making. The benefits of peer review extend beyond the published article. Critically evaluating the work of others enhances reviewers' analytical skills, keeps them current with emerging evidence, and fosters more critical interpretation of the literature. The future of orthopaedic surgery is shaped not only by those who operate, but by those who question, investigate, review, and train future generations. Our patients deserve surgeons who are not merely skilled technicians but thoughtful towards scientific progress.
PURPOSE:This European Society of Sports Traumatology, Knee Surgery and Arthroscopy-European Hip Preservation Associates-European Sports Medicine Association (ESSKA-EHPA-ESMA) formal consensus aims to provide evidence- and expert opinion-based recommendations for the terminology, clinical examination and imaging concerning the assessment of athletes and physically active adults with hip and groin pain. METHODS:The 'ESSKA Formal Consensus' methodology, involving a rigorous, iterative peer review process, was utilized. A multidisciplinary group of 57 experts from 22 countries formed a steering group (15 experts), rating group (20 experts) and reader group (22 experts). The steering group developed 13 questions, including four conclusive questions, across three domains: terminology, clinical examination and imaging. Statements were graded A (high-level scientific evidence) to D (expert opinion) and scored 1-9 according to the level of agreement by the rating group. The reader group assessed statements for clarity and geographic adaptability. RESULTS:Median ratings for the 13 statements ranged from 8 to 9 out of 9. Strong agreement was recorded for five questions, relative agreement for five questions, and three questions remained uncertain. All statements were graded C. Recommended terminology includes adductor, iliopsoas, inguinal, pubic and hip joint-related groin pain. Clinical examination should include gait assessment, Trendelenburg's test, palpation and resistance testing of relevant muscle groups, hip range of motion and the flexion, adduction, internal rotation (FADIR) test. Imaging examinations are neither fully sensitive or specific and should always be used in conjunction with history and examination. Depending on the suspected pathology, plain radiographs or ultrasonography should be used as first-line investigations, with magnetic resonance imaging, computed tomography and diagnostic hip injections reserved as second-line investigations. CONCLUSION:This consensus provides a structured reference frame for the terminology, examination and imaging for athletes and physically active adults with hip and groin pain. Different and combined aetiologies for hip and groin pain exist, and therefore consistent terminology and systematic clinical examination are essential. Red flags must not be ignored, and imaging must be interpreted alongside history and examination findings. LEVEL OF EVIDENCE:Level I.
PURPOSE:The purpose of this scoping review was to map the existing literature describing revision anterior cruciate ligament reconstruction (ACLR) following failure of combined ACLR with lateral extra-articular procedures (LEAPs), characterize reported surgical strategies, summarize available clinical outcomes and identify gaps in the current evidence base. METHODS:A scoping review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines. Ovid MEDLINE, Embase and PubMed were searched from inception to February 2026. Eligible studies included technical notes and clinical studies describing revision of failed combined ACLR with LEAPs, including lateral extra-articular tenodesis (LET) or anterolateral ligament reconstruction (ALLR). Studies were included irrespective of outcome reporting, provided revision strategies were described. Single-revision or re-revision cases and adult and paediatric populations were included. Review articles, editorials and letters were excluded. Data were extracted and synthesized descriptively. RESULTS:Nine studies were included. Three studies described detailed revision strategies, including single-stage revision ACLR with ALLR, double-bundle revision ACLR with LET preservation and all-epiphyseal revision ACLR following failed LET. Six clinical studies included 594 patients within broader primary or revision ACLR cohorts, of whom 23 were explicitly identified as undergoing revision or re-revision following failure of a combined ACLR with LEAP. Revision strategies were heterogeneous in graft selection and management of the LEAP, including LET preservation, LET revision or conversion to ALLR. Clinical outcomes were reported in two case reports, both demonstrating satisfactory short-term stability and functional outcomes following revision ACLR with LET preservation. CONCLUSIONS:The current literature on the revision of failed combined ACLR with LEAPs is limited and heterogeneous. Revision strategies vary widely, and reporting of both technique and clinical outcomes is inconsistent. Based on the limited evidence and expert opinion, revision ACLR in this context should be individualized according to surgeon experience and patient-specific factors, such as prior ACL graft harvest, tunnel interactions and the status of the prior LEAP. LEVEL OF EVIDENCE:Level V.
PURPOSE:Achilles tendon rupture (ATR) is a serious lower limb injury that may result in persistent deficits in strength and endurance of the calf muscles. Compensatory mechanisms at proximal joints are known, but the effects of fatigue are less studied. The aim was therefore to evaluate the effect of a fatigue protocol on lower limb kinetics during performance of single-limb drop countermovement jumps (CMJ) in individuals with a history of a unilateral ATR. METHODS:Thirty participants were recruited on average 2 years after ATR. Drop CMJs were performed on each side before and after a fatigue protocol, and peak power values for the hip, knee and ankle joints were calculated, as well as jump height and duration. A mixed model analysis of variance was used to evaluate inter-limb differences pre- and post-fatigue during the landing (eccentric) and push-off (concentric) phases of the involved (INV) and uninvolved (UNinv) side. RESULTS:The fatigue protocol had a greater effect on peak ankle joint power of the UNinv side across both phases (by a mean [95% confidence interval, CI] of 1.06 [0.58-1.54] W/kg) compared to the INV side (0.51 [0.03-1.00] W/kg; p = 0.039). Moreover, greater fatigue-induced changes in ankle joint power were found during landing (by a mean [95% CI] of 1.13 [0.64-1.61] W/kg) compared to push-off (0.45 [0.04-0.93] W/kg; p = 0.011), across both sides. A trend towards increased knee joint power was seen as a response to fatigue across both sides and phases (p = 0.062), with no change at the hip. CONCLUSIONS:Rehabilitation following ATR should emphasize progressive reliance on the INV side across the rehabilitation continuum by incorporating strength, endurance and training under fatigued conditions. This approach may help reduce compensatory reliance on the UNinv side, potentially lowering the risk of overuse‑related injuries. LEVEL OF EVIDENCE:Level III.
Despite 14 systematic reviews and meta-analyses published between 2018 and 2026, the role of capsular closure after hip arthroscopy for femoroacetabular impingement syndrome remains controversial. While several studies report superior outcomes following capsular repair, others demonstrate little or no clinically meaningful benefit. This persistent inconsistency raises the possibility that current meta-analyses may be addressing the wrong question. Most published studies compare different capsular management strategies, including non-closure, partial (T-capsule) repair and complete capsular closure, across highly heterogeneous patient populations while largely ignoring baseline hip stability characteristics. Patients with BDDH, generalized ligamentous laxity, increased femoral version, and other manifestations of microinstability are frequently analysed together with mechanically stable hips. Consequently, pooled estimates may represent averages across fundamentally different biomechanical phenotypes. The common hidden thread running through all the studies might simply be that capsular closure is likely dependent on the underlying stability profile of the hip rather than being universally beneficial or universally unnecessary. Future studies and meta-analyses should move beyond simple comparisons of closure versus non-closure and instead focus on stability phenotype-based analyses. The key question may no longer be whether capsular closure works, but rather in which hips capsular closure matters.
PURPOSE:The purpose of this study was to report minimum 10-year survivorship, patient-reported outcomes (PROs), clinically significant outcome achievement and predictors of outcomes and failure in patients with structurally stable femoroacetabular impingement syndrome (FAIS) who underwent primary hip arthroscopy with interportal capsulotomy without capsular repair. METHODS:A retrospective review was conducted of patients undergoing primary hip arthroscopy for FAIS from 2010 to 2013 with a minimum 10-year follow-up. Exclusion criteria included hip dysplasia, Tönnis Grade >1, prior ipsilateral hip surgery and unavailable preoperative radiographs. All patients underwent interportal capsulotomy without capsular repair. Outcomes included modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), minimal clinically important difference (MCID) achievement, survivorship and predictors of PROs and failure. RESULTS:A total of 150 patients were included (62.7% female), with mean follow-up of 11.7 ± 1.1 years and mean age of 38.3 ± 12.1 years. Ten-year survivorship was 90.7%; 7 patients (4.7%) underwent total hip arthroplasty and 7 (4.7%) underwent revision arthroscopy. mHHS improved from 52.0 ± 11.7 to 87.9 ± 16.7 (p < 0.001), and NAHS improved from 49.5 ± 11.4 to 86.2 ± 18.0 (p < 0.001). Patient Acceptable Symptom State (PASS) was achieved by 76.0% of patients for mHHS and 65.3% for NAHS. Female sex and higher body mass index (BMI) were associated with worse 10-year PROs, whereas Tönnis Grade 1 (p = 0.003) and lower preoperative NAHS (p = 0.034) were associated with failure. CONCLUSION:Primary hip arthroscopy for structurally stable FAIS performed with interportal capsulotomy and without capsular repair demonstrated favourable 10-year outcomes, high PASS achievement and 90.7% survivorship. Clinically, these findings provide long-term benchmarking data for counselling appropriately selected patients with structurally stable hips. Higher BMI and female sex were associated with worse 10-year PROs, while Tönnis Grade 1 and lower preoperative NAHS were associated with increased failure risk, supporting their use in preoperative risk stratification and shared decision-making. LEVEL OF EVIDENCE:Level IV, retrospective case series (single-surgeon, without comparison group).
PURPOSE:Introduction of new components in total knee arthroplasty (TKA) should be assessed for long-term stability. The primary objective was to determine whether migration of a new cementless tibial baseplate in kinematically aligned (KA) TKA is below the 6-month threshold where baseplates have a low incidence of long-term loosening. Other objectives were to determine when stability occurred, whether stability was associated with varus angles in knee and limb alignments, and whether a recut of the tibia affected migration. METHODS:New cementless components were implanted in 45 patients, of which 38% had a tibial recut. Baseplate migration was assessed using model-based radiostereometric analysis with radiographs obtained post-operatively and at 6 weeks, 3 months and 6 months. Mean maximum total point motion (MTPM) at 6 months was compared to a 6-month threshold where baseplates have low incidence of long-term loosening. An equivalence analysis determined when stability occurred. Correlation analyses related MTPM at 6 months to the medial proximal tibial angle (MPTA) and the hip-knee-ankle angle (HKAA). A two-sample t test determined whether mean MTPM differed between recut and non-recut groups. RESULTS:Mean 6-month MTPM of 0.93 mm was significantly below the 6-month stability threshold of 1.15 mm (p = 0.015), and stability was achieved by 3 months. There was no significant relationship between MTPM and MPTA (ρ = 0.050, p = 0.77) or HKAA (ρ = 0.060, p = 0.72). Mean MTPM did not differ between recut (0.85 ± 0.56 mm) and non-recut (0.97 ± 0.64 mm) groups (p = 0.57). CONCLUSION:The new cementless tibial baseplate has migration significantly below the 6-month threshold where baseplates have a low incidence of long-term loosening and migration stabilizes early at 3 months. Varus alignment of the baseplate and the limb as well as tibial recuts were not associated with increased migration. LEVEL OF EVIDENCE:N/A.
PURPOSE:This study aimed to compare strength recovery, functional and clinical outcomes between full- and partial-thickness quadriceps tendon autografts for 12 months post-operatively and to examine the clinical implications of graft thickness in anterior cruciate ligament reconstruction among non-professional competitive soccer players. METHODS:42 non-professional competitive Spanish federal soccer players who underwent primary anterior cruciate ligament reconstruction using either full- or partial-thickness quadriceps tendon grafts were included in this retrospective cohort study. Both groups followed standardised surgical and rehabilitation protocols. Evaluations were assessed preoperatively and at 3, 6 and 12 months post-operatively, with the reinjury rates recorded at 24 months. Quadriceps index, measured by isokinetic dynamometry was the primary outcome. Hamstring index, extension and flexion peak torque, single leg hop test, patient-reported outcome measures (Lysholm and Cincinnati Knee Rating System scores) and reinjury rate were evaluated as secondary outcomes. Statistical analysis was performed using repeated-measures ANCOVA with a Bonferroni adjustment, and the significance level was set at 5%. RESULTS:During the first 6 months, faster recovery of quadriceps symmetry was observed in partial-thickness group compared to the full-thickness group at 300°/s (mean difference: -26.5, 95% confidence interval [CI] [-51.4, -1.7], p = 0.037), 180°/s (mean difference: -31.0, 95% CI [-56.0, -6.0], p = 0.017), and 60°/s (mean difference: -31.2, 95% CI [-55.4, -7.0], p = 0.013), as well as greater improvement in extension peak torque. No statistical differences (p > 0.05) remained between groups at 12 months, with both groups achieving similar recovery. Hop test and clinical outcomes improved significantly over time in both groups, without significant between-group differences (p > 0.05). Reinjury rate was similar between groups (p = 0.634). CONCLUSIONS:Earlier strength recovery was observed with partial-thickness graft after ACL reconstruction, highlighting the clinical relevance of graft choice in early rehabilitation in competitive soccer players. LEVEL OF EVIDENCE:Level II.
PURPOSE:Anterior cruciate ligament (ACL) injuries are increasing in children and adolescents and reconstruction (ACLR) is now frequently performed in this population. Paediatric patients remain at higher risk of reinjury, possibly due to delayed graft remodelling. The current study aims to compare magnetic resonance imaging (MRI)-based graft remodelling between paediatric and adult populations at 1 year postoperatively. METHODS:We conducted a single-centre comparative pilot study including a prospectively collected cohort of 52 paediatric and 59 adult patients undergoing ACLR with a semitendinosus autograft folded in four (ST4) without additional lateral extra-articular tenodesis (LET). MRI was performed at 12 months postoperatively. Graft maturation was assessed using the signal-to-noise quotient (SNQ) and Howell scores. Tibial tunnel widening (TTW) and patient-reported outcome measures (PROMs) were also collected. RESULTS:The mean adjusted SNQ was significantly higher (p < 0.001) in paediatric patients (5.1; 95% confidence interval [CI] [4.3-5.9]) than in adults (1.5; 95% CI [0.9-2.2]), indicating slower remodelling. The Howell classification confirmed less mature grafts in children, with a predominance of Grade II. TTW was observed in similar proportions in both groups. PROMs were favourable and comparable in both groups. One paediatric patient experienced a graft rupture at 6 months, following premature return to pivoting sport. CONCLUSION:At 1-year post-ACLR, paediatric patients show delayed graft remodelling compared to adults. This slower biological incorporation may contribute to higher reinjury rates in young athletes and supports the need for prolonged rehabilitation and careful return to high-risk sports. LEVEL OF EVIDENCE:Level II.
PURPOSE:To provide a state-of-the-art technical review of complications associated with anterior closing-wedge high tibial osteotomy (ACWHTO) performed in the setting of anterior cruciate ligament reconstruction (ACLR). The review focuses on mechanisms, risk factors, prevention strategies and management principles rather than pooled complication-rate estimation. METHODS:A targeted literature search was performed in PubMed/MEDLINE, Ovid and Scopus, supplemented by manual review of references from key clinical series, technical reports, biomechanical studies and systematic reviews. Publications addressing ACWHTO, slope-reducing tibial osteotomy, ACL-deficient knees, primary or revision ACLR, or technical aspects relevant to complication prevention were considered. Evidence was synthesized qualitatively. Clinical cohort data were distinguished from biomechanical studies, technical reports, systematic reviews and expert-opinion-based recommendations. Pooled complication rates were not calculated because of heterogeneity in indications, osteotomy techniques, fixation constructs, follow-up, reporting definitions and potential cohort overlap. RESULTS:ACWHTO may be performed using supratubercle, transtubercle, infratubercle or retrotubercle techniques, each with distinct implications for sagittal correction, fixation strategy, tibial tunnel planning, patellar height, bone healing and complication risk. Reported overall complication rates ranged from 0% to 56.5%, although definitions varied substantially across studies. Reported or potential complications include hinge fracture, unintended coronal alignment modification, knee hyperextension or genu recurvatum, patellar height changes, over- or undercorrection of posterior tibial slope, delayed union or nonunion, ACLR failure, infection and hardware removal when symptomatic. Available evidence suggests favourable clinical and radiographic outcomes in appropriately selected patients, but complication reporting remains inconsistent, and secondary procedures are variably defined. CONCLUSION:ACWHTO is an effective adjunctive procedure for selected patients undergoing ACLR in the presence of increased posterior tibial slope. However, its true safety profile remains difficult to define. Patient selection, individualized planning, precise hinge and wedge control and stable fixation are essential to minimize complications. Prospective studies with standardized complication definitions and stratified reporting are required. LEVEL OF EVIDENCE:Level V.
PURPOSE:The goal of this systematic review with meta-regression was to investigate the influence of different platelet-rich plasma (PRP) composition and administration characteristics on the clinical results of intra-articular PRP injections in patients with knee osteoarthritis (KOA) as compared to placebo. METHODS:Three databases were searched until 25 May 2025, to identify randomised placebo-controlled trials of PRP injections in KOA. Population, PRP composition and administration characteristics and clinical scores data were collected. Clinical data were categorised into functional and pain scores and recorded at 6- and 12-month follow-up. Meta-analysis comparing PRP to placebo was conducted using random-effects model and summarised as standardised mean differences and 95% confidence intervals. Meta-regression was conducted using patient-related and PRP-specific covariates. RESULTS:Twenty studies including 26 unique groups of PRP (n = 1774) and 20 groups of placebo (n = 1518). The PRP group showed statistically significant improved knee function and pain at 6 months and at 12 months (large effect, very low certainty). Higher platelet increase factor and activation with CaCl2 were significantly associated with superior PRP results in knee function and pain at 6 months. Younger age and leucocyte-rich PRP were significantly associated with improved knee function. However, PRP type and concentration factor were significantly correlated. No other moderator explained the superior PRP results at 6 months, and none at the 12-month follow-up. CONCLUSIONS:Younger age, higher platelet increase factor, LR-PRP and CaCl2 activation were associated with greater short-term improvements in meta-regression analyses. Intra-articular PRP injections appeared to be more effective than placebo in reducing pain and improving knee function at 6 and 12 months. However, the certainty of evidence was very low and due to interrelated PRP characteristics and limited reporting across studies, the independent contribution of individual factors remains uncertain, and these findings are still hypothesis-generating rather than definitive evidence supporting specific PRP formulations. LEVEL OF EVIDENCE:Level I.
PURPOSE:The purpose of this study was to describe current arthroscopic diagnostic and repair practices for ramp lesions during anterior cruciate ligament reconstruction and to evaluate the association between the Thaunat classification, meniscal mobility and surgical repair strategy. METHODS:A multicenter descriptive study was performed using data from the prospective French Arthroscopy Society registry. Patients undergoing anterior cruciate ligament reconstruction with an associated ramp lesion were included. Demographic data, mechanism of injury, delay to surgery, arthroscopic diagnostic technique, lesion type (Thaunat classification), meniscal mobility, lesion length, repair technique, number of sutures and surgical approach were recorded. Associations between lesion type, meniscal mobility and number of sutures were analysed. RESULTS:A total of 449 patients were included (69.3% male, mean age 25.4 ± 8.4 years). Sports trauma accounted for 91.5% of cases. Ramp lesion diagnosis was achieved primarily through intercondylar view alone (46.5%) or intercondylar view combined with posteromedial probing (41.9%). Lesion type according Thaunat were Type 1 (43.0%), Type 2 (7.8%), Type 3 (20.7%), Type 4 (21.2%) and Type 5 (7.3%). Meniscal mobility was pathological (defined as abnormal displacement of the posterior horn during probing without or with condylar overpass) in 79.7% of cases and a significant association was found between lesion type and pathological meniscal mobility (p < 0.01). Repair was with a posteromedial hook technique in 77.7%. Lesion type was significantly associated with the number of sutures (p < 0.01). CONCLUSION:Ramp lesions demonstrate substantial morphological variability associated with different patterns of meniscal mobility. The Thaunat classification correlates with meniscal mobility and surgical strategy in this univariate analysis. Repair using a suture hook through a posteromedial portal remains the predominant technique in France. These findings may contribute to a more standardised, lesion-specific approach to the diagnosis and repair of ramp lesions during ACL reconstruction. LEVEL OF EVIDENCE:Level III.
PURPOSE:Efficient and reliable magnetic resonance imaging (MRI)-based diagnosis of early avascular necrosis of the femoral head (AVNFH) is essential for guiding treatment but remains challenging due to variability in clinician experience. Deep learning (DL) models offer a promising solution. This review evaluates and summarizes the performance of DL models in the early detection and staging of AVNFH and compares their diagnostic performance with that of physicians. METHODS:Three databases (PubMed, Embase, Medline [Ovid]) were searched from database inception to 25 February 2026, for articles evaluating the use of MRI-based DL models in early detection or staging of AVNFH. Studies that used only non-DL methods, did not apply DL to MRI, were not full-text, or focused on paediatric or non-human populations were excluded. Signed differences in diagnostic performance between DL models and physicians were calculated to directly compare their effectiveness. RESULTS:Of 1494 records, 10 studies met the inclusion criteria, comprising 1054 patients and 1958 femoral heads for early detection, 1573 patients and 2293 femoral heads for staging, and 276 patients and 533 femoral heads for both. For internal validation, average accuracy was 94.5%, sensitivity 93.2%, specificity 96.5% and AUROC 95.1%. For external validation, average accuracy was 91.4%, sensitivity 87.8%, specificity 93.3% and AUROC 91.8%. In five studies directly comparing DL models to physicians, DL models outperformed or matched physicians across most metrics, with signed differences in accuracy ranging from -10.58% to -0.43%. Among the five studies reporting statistical comparisons, the DL model significantly outperformed six of seven less experienced physicians (p < 0.05), but only two of 13 experienced physicians. CONCLUSION:DL models demonstrate promising performance, performing comparably to experienced physicians while frequently outperforming less experienced physicians. Their high diagnostic accuracy and efficiency highlight their promise as valuable, objective tools to support clinical decision-making in this challenging area of musculoskeletal imaging. LEVEL OF EVIDENCE:Level IV, systematic review.
PURPOSE:To compare anterior cruciate ligament (ACL) graft survivorship and clinical outcomes after isolated anterior cruciate ligament reconstruction (ACLR) versus ACLR combined with all-inside lateral meniscus posterior root (LMPR) repair. METHODS:This single-centre, single-surgeon retrospective comparative cohort study included consecutive patients undergoing ACLR between January 2017 and December 2023 with a minimum 24-month follow-up. Patients underwent isolated ACLR or ACLR with all-inside LMPR repair according to intraoperative findings. A standardised anatomic single-bundle ACLR with a three-strand pedicled hamstring tendon autograft was used in all cases. The primary endpoint was graft rerupture-free survival. Secondary endpoints included return to sport (RTS), return to work (RTW), contralateral ACL rupture and simple knee value (SKV) at 12 months. Survival was assessed using Kaplan-Meier estimates and adjusted Cox regression. RESULTS:Overall, 841 knees were analysed: 786 isolated ACLR and 55 ACLR + LMPR repair, with a median follow-up of 46.0 months. ACL graft rerupture occurred in 41 isolated ACLR patients and 5 ACLR + LMPR repair patients (5.2% vs. 9.1%; p = 0.216), with no significant difference in graft rerupture-free survival (log-rank p = 0.209). In adjusted Cox analysis, ACLR + LMPR repair was not independently associated with graft rerupture-free survival (hazard ratio [HR] 1.5; 95% confidence interval [CI] 0.6-3.9; p = 0.407), whereas professional athlete status increased rerupture risk (HR 2.8; 95% CI 1.3-6.1; p = 0.010). Contralateral ACL rupture, RTS, RTW and postoperative SKV were comparable between groups. CONCLUSIONS:Concomitant all-inside LMPR repair during ACLR was not independently associated with decreased graft rerupture-free survival and showed comparable clinical outcomes to isolated ACLR at short- to mid-term follow-up. LEVEL OF EVIDENCE:Level III, retrospective comparative cohort study.
PURPOSE:The reliability and efficiency of a dedicated 3D planning software were evaluated for magnetic resonance imaging (MRI)-based measurement of femoral torsion, tibial torsion, knee version and whole-lower extremity torsion compared with manual assessment. METHODS:In this retrospective observational reliability study, torsional MRI scans of both lower extremities from 100 healthy volunteers were analysed. Measurements were performed according to Strecker and Waidelich using manual and digital assessment with mediCAD® 3D. One manual and two digital measurement rounds were performed by one experienced orthopaedic surgeon and one inexperienced orthopaedic resident. Inter and intraobserver reliability was assessed using intraclass correlation coefficients with 95% confidence intervals. Agreement was evaluated using Bland-Altman plots and equivalence testing with a predefined ±3° margin. Measurement times of the first and last 10 measurements of each series were compared. RESULTS:The cohort included 50 males and 50 females, with a mean age of 26.7 ± 5.8 years. All parameters demonstrated good to very good reliability. Manual interobserver reliability was highest for femoral torsion (ICC: 0.99; 95% CI: 0.98-0.99; p < 0.001). Digital interobserver reliability ranged from ICC 0.94 to 0.98 in the first digital round and from ICC 0.89 to 0.98 in the second digital round, all p < 0.001. Manual-to-digital agreement ranged from ICC 0.90 to 0.98 for both observers. Bland-Altman analysis showed mean digital interobserver bias within approximately 2°. All comparisons were equivalent within the predefined ±3° margin. The largest efficiency gain occurred in the inexperienced observer, with median time decreasing from 200 to 150 s, corresponding to a 25% reduction (p < 0.001). CONCLUSION:The 3D planning software demonstrated good to very good inter and intraobserver reliability for MRI-based lower extremity torsional assessment. It improved efficiency, particularly for the inexperienced observer, and, through automated calculations and guided workflow, supports standardised preoperative planning. LEVEL OF EVIDENCE:Level III.
PURPOSE:To compare clinical outcomes, strength, donor-site morbidity, complications and graft failure after primary or revision anterior cruciate ligament reconstruction (ACLR) using rectus femoris tendon (RT) versus hamstring tendon (HT) autografts. METHODS:A systematic review was conducted in accordance with preferred reporting items for systematic reviews and meta-analyses 2020. Comparative clinical studies of RT and HT autografts in primary or revision ACLR were included. Outcomes were synthesised narratively because of the small number of studies and clinical and methodological heterogeneity. RESULTS:Four comparative studies enrolled 324 patients, of whom 299 were available for final comparative analysis (RT, n = 142; HT, n = 157). Two studies evaluated primary and two evaluated revision ACLR. Three studies reported patient-reported outcomes. One revision study found higher International Knee Documentation Committee scores (83.8 ± 12.2 vs. 78.6 ± 16.8; p = 0.037) and Tegner scores (5.8 ± 1.8 vs. 5.6 ± 1.5; p = 0.043) with RT; however, the absolute differences were small, and attainment of a minimal clinically important difference was not reported. The other two studies found no significant between-group differences. At approximately 6 months, quadriceps peak torque did not differ between RT and HT (173.0 ± 62.0 vs. 167.7 ± 45.7 Nm; p = 0.689). Failure rates were 2.3% versus 17.4% (p = 0.031) in one revision study and 7.1% versus 7.4% in another. Donor-site morbidity was reported quantitatively in one study and did not differ significantly (4.7% vs. 13.0%; p = 0.268). CONCLUSION:RT autografts produced early clinical outcomes broadly comparable to HT autografts, but the evidence base comprises only four heterogeneous comparative studies with short and unequal follow-up. RT may be considered when established autografts are unavailable, particularly in revision ACLR; routine use in primary ACLR cannot yet be recommended. LEVEL OF EVIDENCE:Level IV.
PURPOSE:To systematically review randomized controlled trials and quantitatively evaluate the efficacy and safety of injections of autologous adipose-derived mesenchymal stromal cells (AD-MSCs) in patients with knee osteoarthritis (OA). METHODS:Multiple electronic databases were searched with no date restrictions for randomized controlled trials evaluating intra-articular autologous adipose-derived cell products for knee OA. The stromal vascular fraction was considered biologically distinct and was not pooled for the same intervention. The primary efficacy outcomes were the pain visual analogue scale (VAS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total scores. Safety outcomes were defined by the occurrence of any adverse events (AEs) and serious AEs (SAEs). A random-effects meta-analysis was performed. RESULTS:Of the 1178 identified records, six randomized controlled trials, including 551 patients, were included. Compared with control, AD-MSC treatment was associated with lower WOMAC total scores at 3 months (mean difference [MD], -8.14; 95% confidence interval [CI], -13.33 to -2.95) and 6 months (MD, -8.07; 95% CI, -13.60 to -2.54), and lower pain VAS scores at 3 months (MD, -1.49; 95% CI, -2.45 to -0.54), 6 months (MD, -1.40; 95% CI, -2.08 to -0.73) and 12 months (MD, -1.80; 95% CI, -3.20 to -0.41). The pooled risk of any AEs was not significantly increased (risk ratio [RR], 1.12; 95% CI, 0.99-1.27), and SAEs were rare (RR, 0.48; 95% CI, 0.10-2.18). CONCLUSIONS:Intra-articular autologous AD-MSC injections for knee OA were associated with improvements in pain and WOMAC outcomes without a significant increase in AEs. However, given the heterogeneity in comparator type, blinding and cell-product characteristics and the limited long-term and structural evidence, these findings suggest symptomatic benefit across heterogeneous AD-MSC products but do not establish the efficacy of a specific standardized product or structural disease modification. LEVEL OF EVIDENCE:Level I, systematic review and meta-analysis of randomized controlled trials.
