Purpose:The aim of this study was to identify preoperative determinants of postoperative change in joint line convergence angle (JLCA) after closing-wedge high tibial osteotomy (CWHTO), comparing standing- and supine-based radiographic references for preoperative planning. Methods:Consecutive patients with medial compartmental knee disorders who underwent CWHTO between February 2009 and September 2017 were retrospectively reviewed. Patients with anterior cruciate ligament reconstruction, unavailable radiographs or non-measurable radiographs were excluded. JLCA was measured on standing, supine and valgus/varus stress radiographs. Postoperative change in JLCA (cJLCA) was calculated from preoperative supine to postoperative standing JLCA (cJLCA [pre-supine to post-stand]) and from preoperative standing to postoperative standing JLCA (cJLCA [pre-stand to post-stand]). The preoperative standing-supine difference in JLCA (dJLCA) was also calculated. Associations between cJLCA and demographic and radiographic variables were evaluated using univariate and multivariable analyses. Results:After excluding patients with anterior cruciate ligament reconstruction (n = 1), unavailable radiographs (n = 7) or non-measurable radiographs (n = 4), 40 patients were included. The cohort included 29 women and 11 men, with a mean age of 60.3 years (range, 39-77 years); postoperative radiographs were obtained at a mean of 9.9 months (range, 2-14 months). Univariate analysis showed that dJLCA was positively correlated with cJLCA (pre-supine to post-stand) (ρ = 0.52, p = 0.001) and negatively correlated with cJLCA (pre-stand to post-stand) (ρ = -0.43, p = 0.007). In multivariable analysis, dJLCA remained independently associated with both outcomes (B = 0.51, p = 0.006; B = -0.49, p = 0.008, respectively). Conclusions:The preoperative standing-supine difference in JLCA was the primary determinant of postoperative change in JLCA after CWHTO. A greater standing-supine difference was associated with greater undercorrection when supine radiographs were used as the planning reference, but with greater overcorrection when standing radiographs were used as the planning reference. Level of Evidence:Level IV.
Purpose:Meniscal injuries are among the most common knee disorders and a major risk factor for osteoarthritis. Although meniscectomy provides short-term symptom relief, it irreversibly alters joint biomechanics, underscoring the need for regenerative strategies. Advances in additive manufacturing and biomaterials science have enabled three-dimensional (3D)-printed meniscal scaffolds with controlled architecture, tunable anisotropy and tailored biological functionality. This systematic review critically evaluates preclinical in vivo evidence on these strategies and identifies key factors influencing their functional integration and translational potential. Methods:A systematic literature search was conducted in PubMed, Web of Knowledge and Scopus up to September 2025, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Included studies involved preclinical in vivo models of meniscectomy evaluating 3D-printed meniscal scaffolds with reported mechanical and biological outcomes. Data extraction focused on biomaterials, fabrication techniques, scaffold design, mechanical performance and regenerative outcomes. Results:Twenty-three studies met the inclusion criteria. Resorbable polymer-based scaffolds, predominantly polycaprolactone, were most frequently investigated. Biofunctionalisation strategies-including cellularisation, biochemical cues and hydrogel-polymer composites-were widely employed. Most studies used rabbit models. Outcomes revealed a dynamic interplay between material composition, architecture, degradation kinetics and biological integration. An initial decline in mechanical properties was followed by progressive maturation, in some cases approaching native anisotropic behaviour and correlating with cellular infiltration and matrix deposition. Biofunctionalised scaffolds consistently demonstrated improved cartilage preservation compared with meniscectomy alone. However, heterogeneity in experimental design and reporting standards limited cross-study comparability. Conclusion:3D-printed meniscal scaffolds show promising preclinical potential for promoting tissue regeneration and preserving joint integrity. To bridge the gap between experimental findings and clinical application, this review introduces a structured reporting checklist identifying key material, structural and biological determinants of successful scaffold integration. By promoting methodological harmonization and standardized outcome assessment, this framework aims to enhance cross-study comparability and support the stepwise clinical translation of next-generation bioactive scaffolds for meniscal injuries. Level of Evidence:N/A.
While robotic-assisted total knee arthroplasty (rTKA) has been proven to achieve highly precise and reproducible radiographic results, its accuracy remains highly dependent on correct intraoperative landmark acquisition. This technical guide aims to provide practical guidance for intraoperative recognition of landmarking and gap balance assessment errors during rTKA using the image-free VELYSTM system. Based on the authors' clinical experience with this system, the most common pitfalls as well as their intraoperative recognition are highlighted. Special focus is set on pin placement, bone reference checkpoints and landmark acquisition, with practical intraoperative cues that allow surgeons to detect these errors intraoperatively before bone resections are performed. The present article should support early adopters of the VELYSTM system, with the aim of preventing precision inaccuracies. Level of Evidence:Level V.
Purpose:To evaluate whether concomitant arthroscopic treatment of intra-articular chondral or meniscal pathology during valgus-producing high tibial osteotomy (HTO) improves clinical outcomes compared with HTO alone. Methods:MEDLINE, Embase and CENTRAL were searched from inception to 17 May 2026. Comparative studies reporting outcomes after HTO plus arthroscopic cartilage (microfracture, microdrilling, abrasion arthroplasty) and/or meniscal (meniscal centralization, meniscectomy, meniscal repair) procedures versus HTO alone were included. Data extraction and quality assessment were performed by two reviewers. Due to heterogeneity, meta-analysis was not performed, and outcomes were synthesized descriptively, stratified by specific arthroscopic adjunct. Results:Seventeen studies comprising 1271 knees were included, with 663 treated with HTO plus arthroscopy and 608 treated with HTO alone. The mean age was 57.0 years with HTO plus arthroscopy and 55.1 years with HTO. Mean follow-up was 32.9 months and 31.0 months, respectively. Concomitant procedures were microfracture in six studies, microdrilling in three, abrasion arthroplasty in two, meniscectomy in two, meniscal centralization in two and mixed arthroscopy in four. Both groups generally improved across patient-reported outcome measures (PROMs), functional outcomes and radiographic alignment. However, no arthroscopic adjunct demonstrated consistent additive clinical benefit. Microfracture showed inconsistent effects on Lysholm and Western Ontario and McMaster Universities Osteoarthritis Index scores; meniscectomy did not improve Knee Society Score; and meniscal centralization showed inconsistent Knee injury and Osteoarthritis Outcome Score and alignment findings. Mixed arthroscopy showed some favourable PROMs and radiographic outcomes, but did not isolate procedure-specific effects. Microfracture, microdrilling, abrasion arthroplasty and meniscal centralization improved cartilage findings on second-look arthroscopy, but these improvements did not consistently correspond to superior PROMs. Complication reporting was limited and heterogeneous. Conclusions:Current evidence does not demonstrate a consistent clinical benefit of adding arthroscopic chondral or meniscal treatment to HTO, despite some evidence of improved cartilage findings. Future procedure-specific comparative studies are needed to determine which, if any, arthroscopic adjuncts provide clinically meaningful additive benefit when performed with HTO. Level of Evidence:Level III.
Purpose:The ideal intraoperative correction target for medial opening wedge high tibial osteotomy (MOWHTO) remains debated. This study compared 10-year outcomes between two correction targets, 70% and 62% weight-bearing line (WBL). Methods:A total of 103 knees that underwent MOWHTO with a locking plate, performed by one surgeon and randomized to a 70% (n = 50) or 62% (n = 53) WBL target, were retrospectively reviewed. Hip-knee-ankle angle and WBL were measured at fixed time points; clinical scores were recorded at 10 years. Conversion to total knee arthroplasty (TKA) was the primary endpoint. Because Kaplan-Meier curves crossed, a landmark, time-varying analysis was used alongside standard tests. Results:Six-month WBL averaged 71.4% (70% group) and 62.2% (62% group). Both groups lost similar correction by 10 years (-5.5 vs. -4.8 percentage points, p = 0.429), leaving 45% of the 62% group undercorrected versus 13% of the 70% group (p < 0.001). Undercorrected knees were converted to TKA more often than normally aligned knees (36.7% vs. 9.6%, p = 0.012). The proportional hazards assumption was violated for the group effect (p = 0.0025); after 10 years, conditional on event-free survival, the hazard ratio for 70% versus 62% was 0.54 (95% confidence interval 0.245-1.182, p = 0.123). Overall survivorship was similar (22.0% vs. 24.5% converted, p = 0.954), but this comparison was underpowered (4.8%) and should not be read as equivalence. Clinical scores did not differ significantly. Conclusions:Both targets lost similar correction over 10 years, but the 62% target was closer to the undercorrection range, linked to more TKA conversion. Hazards were not proportional over time: The 70% target carried an early, overcorrection-related risk, while the 62% target carried a later, undercorrection-related risk undetectable by an overall Cox comparison alone. A target close to, but not exceeding, 70% may lower the risk of both patterns, pending confirmation with an intermediate target and a larger, adequately powered sample. Level of Evidence:Level II, retrospective long-term follow-up analysis of a prospectively randomized cohort.
Purpose:The prevalence and clinical consequences of falls in the early post-operative period after hip arthroscopy for femoroacetabular impingement syndrome (FAIS) remain unknown. The purpose of this study was to determine the prevalence of and risk factors for postoperative falls within 90 days of surgery in patients who undergo hip arthroscopy for FAIS and determine whether falls within 90 days are associated with increased risk of early revision surgery. Methods:Consecutive patients who underwent primary hip arthroscopy for FAIS were included. Falls were defined by ground impact by body parts other than the feet, and near-falls were defined as sudden, forceful and unanticipated loading of the operative extremity without impact. Bivariate and multivariate analyses were conducted to identify associations between demographic or clinical factors and fall occurrence as well as revision surgery within 1 year. Results:A total of 192 patients met inclusion criteria (median age 36.7 years, interquartile range [IQR] 23.4, 46.5; 72% female). Of these, 33 patients (17%) experienced a postoperative fall or near-fall (21 falls, 12 near-falls). Median time to fall was 16.5 days (IQR 8.3-44.5). Fall/near-fall patients had significantly higher rates of revision surgery within 1 year compared to controls (27% vs. 4%, p < 0.001; odds ratio [OR] = 9.4, 95% confidence interval [CI] 3.1-30.5). Fall/near-fall events were associated with worse baseline physical function (Physical Function Short Form of the Hip Disability and Osteoarthritis Outcome Score [HOOS-PS], p = 0.047), lower mental health scores (Mental Health Inventory-5 [MHI-5], p = 0.04) and lower activity levels (University of California, Los Angeles [UCLA] score, p = 0.03). Hearing or visual impairment (OR = 6.6, 95% CI 1.9-23.3, p = 0.004) and higher HOOS-PS score (OR = 1.1, 95% CI 1.1-1.3, p = 0.02) were significant predictors of postoperative falls/near-falls. Conclusion:Falls and near-falls within 90 days after hip arthroscopy were associated with higher rates of revision hip arthroscopy. Surgeons should counsel patients, particularly those with sensory impairments, regarding postoperative fall prevention and emphasize prompt reporting of any fall/near-fall events. Future studies are needed to determine whether reducing postoperative falls can decrease revision rates. Level of Evidence:Level III.
Purpose:The management of anterior cruciate ligament (ACL) tears in older adults remains controversial, although recent evidence suggests an increasing trend toward surgical treatment. To date, no studies have specifically investigated the outcomes of combined ACL reconstruction (ACLR) with over-the-top (OTT) technique and lateral extra-articular tenodesis (LET) in this population. The aim of this study was to evaluate clinical outcomes and failure rates of ACLR using OTT plus LET in patients aged 55 years or older. Methods:Patients aged ≥55 years who underwent primary ACLR with OTT and LET techniques and had a minimum follow-up of 2 years were included. Clinical outcomes were assessed using clinical scores, such as VAS, Lysholm, KOOS, comparing preoperative and post-operative values. Patient Acceptable Symptom State (PASS) thresholds were applied to KOOS subscales. Reoperations and graft failures were also recorded. Results:Twenty-eight patients met the inclusion criteria, with a mean age of 60.1 ± 3.2 years and a mean follow-up of 6.5 ± 3.8 years. One graft failure (3.6%) and one reoperation (3.6%) were observed. Significant improvements were noted in all clinical scores. The mean Lysholm score increased from 55.4 ± 15.9 preoperatively to 96.6 ± 6.6 postoperatively. KOOS subscales showed marked improvement, particularly in Quality of Life (41.6 ± 20.2 to 90.3 ± 12.9) and Pain (68.7 ± 12.1 to 94.2 ± 5.7). Conclusion:ACLR with OTT and LET techniques in older patients demonstrated low failure rates and favourable clinical outcomes. Larger studies are needed to confirm these findings and to establish the role of this combined technique in this population. Level of Evidence:Level IV.
Purpose:The objective of this pilot study was to determine clinically relevant phenogroups of professional football players with hamstring injuries using unsupervised cluster analysis based on demographic and injury-related characteristics, and to assess return to play (RTP) duration with respect to the characteristics of these phenogroups. Methods:This retrospective cohort study analysed 57 professional football players from Ferencvárosi Torna Club with magnetic resonance imaging (MRI)-confirmed acute hamstring injuries reported between 2018 and 2024. Three clustering approaches were implemented and compared: k-means clustering, hierarchical clustering using Ward's linkage method, and mixed-type clustering using Gower distance with partitioning around medoids (PAMs). The optimal number of clusters was determined using silhouette analysis. Between-cluster differences in RTP duration and injury characteristics were assessed using Kruskal-Wallis tests for continuous variables and chi-square tests for categorical variables, with post-hoc Bonferroni correction. Results:Mixed-type clustering identified seven phenogroups based on British Athletics Muscle Injury Classification (BAMIC) grade, lesion length, anatomical tear site, affected muscle and injury extensiveness. The average silhouette width was 0.290, indicating weak to moderate cluster separation. Clusters 1, 3, 4, 5 and 6 were characterised by low- to moderate-grade injury parameters and median RTP durations ranging from 9 to 27 days. Clusters 2 and 7 displayed high-grade injury characteristics with considerably prolonged RTP (medians of 46.5 and 94.5 days, respectively). Significant between-cluster differences were observed for days to RTP, lesion length, BAMIC grade, injury severity and anatomical tear site (p < 0.05). Conclusions:Unsupervised machine learning may help identify clinically relevant hamstring injury phenogroups based on MRI-derived tear characteristics, which may facilitate prognosis and inform decision-making regarding expected RTP duration in professional football players. Level of Evidence:Level IV, retrospective cohort study.
Purpose:To analyse return-to-play (RTP) rates, timing and performance outcomes following anterior cruciate ligament (ACL) reconstruction (ACLR) in elite European women's soccer players across the top five leagues. Methods:We reviewed ACL injuries sustained by female professional soccer players across the Bundesliga, Women's Super League, Primera División Femenina, Serie A Women and Première Ligue between 2007 and 2025. Players were included if they had a confirmed ACL injury requiring ACLR and one season of performance data pre- and post-injury. Players were excluded if the injury occurred during their rookie season or after the 2023 season. Data were collected from Soccerdonna.de and Transfermarkt. Results:A total of 242 ACL injuries in 206 unique players were included, with a median follow-up of 2.0 seasons (interquartile range [IQR]: 1.0-4.0). The cohort had a median age at injury of 22.7 years (IQR: 20.4-26.0; mean 23.4 ± 3.8 years). Of 242 injuries, 161 (66.8%) resulted in RTP. For those who returned, the median RTP time was 9.8 months (IQR: 7.9-11.4). Only 7 (5.1%) players achieved RTP before 6 months. In the first year following RTP, significant performance decreases were observed: games played (-47.4%, p < 0.001), total minutes (-57.8%, p < 0.001) and minutes per game (-24.4%, p < 0.001). Midfielders experienced the greatest decline in playing time (-41.2%, p < 0.001), while goalkeepers showed minimal change (-8.0%, p = 0.625). No significant age-related differences were observed. Median post-injury career length was 2.0 seasons (IQR: 2.0-4.0). Conclusions:A RTP rate of 66.8% was observed following ACLR in elite European women's soccer; however, returning players faced significant performance decreases in the first year post-return, with notable position-specific variations. These reductions likely reflect a combination of injury-related recovery factors and team selection dynamics. Rehabilitation and RTP strategies should therefore integrate position-specific demands, realistic performance expectations and gradual reintegration plans, particularly for midfielders who demonstrated the greatest performance decline. Level of Evidence:Level III.
Purpose:Patellar tilt is considered a key factor in patellofemoral instability, with a commonly accepted pathological threshold of 20° on computed tomography (CT) scan assessment. However, the clinical relevance of correcting tilt below this threshold remains unclear. This study aimed to determine whether functional improvement after isolated medial patellofemoral ligament (MPFL) reconstruction is better associated with achieving a postoperative tilt <20° or with the magnitude of tilt correction. Methods:A retrospective study was conducted on 182 patients who underwent isolated MPFL reconstruction. Functional outcomes, including International Knee Documentation Committee (IKDC) and Kujala scores, were collected preoperatively and at final follow-up. Patellar tilt was measured on CT scan preoperatively and at 6 months postoperatively, with both contracted and relaxed quadriceps. Patients were analysed according to postoperative tilt thresholds and correction differentials (diffQC and diffQR). Statistical analysis included group comparisons, correlation analyses, analysis of variance across correction categories and generalized linear models. Results:Patellar tilt on CT scan was significantly reduced postoperatively in both contracted and relaxed quadriceps across all groups (p < 0.001), with significant improvements in IKDC and Kujala scores at last follow-up (p < 0.001). No significant differences in IKDC or Kujala scores were observed between patients with postoperative tilt <20° and >20° (all p > 0.05). No correlation was found between functional outcomes and isolated preoperative or postoperative tilt values. In contrast, greater correction magnitude was significantly associated with improved functional outcomes. A progressive increase in IKDC and Kujala scores was observed with increasing correction, with maximal gains for corrections ≥20°. This relationship was consistent for both contracted and relaxed quadriceps (all p < 0.001). Conclusion:Functional improvement after isolated MPFL reconstruction was more strongly associated with the magnitude of patellar tilt correction than with achieving a specific postoperative tilt threshold. Corrections exceeding 15° in patellar tilt yielded the greatest clinical benefit. These results support an individualized correction-based strategy based on preoperative patellar tilt. Level of Evidence:Level III, retrospective comparative study.
Purpose:Synthetic grafts for anterior cruciate ligament (ACL) reconstruction aim to address limitations of biological grafts, such as donor-site morbidity and delayed recovery. JewelACL is a synthetic scaffold developed to enhance biological integration and mechanical durability. This multicenter study evaluated long-term patient-reported outcomes, adverse events, re-rupture rates and return-to-sport outcomes following ACL reconstruction using JewelACL, with a minimum follow-up of 9 years. Methods:A retrospective cohort of 58 patients who underwent ACL reconstruction between 2010 and 2014, using either JewelACL alone (n = 44) or JewelACL combined with hamstring autograft (hybrid technique; n = 14), was assessed. Patient-reported outcome measures (PROMs), including the International Knee Documentation Committee (IKDC), Lysholm and Tegner scores, as well as complication and re-rupture rates, were analysed. Long-term follow-up was based on telephone-administered PROMs; no standardised clinical laxity testing or imaging (magnetic resonance imaging or x-ray) was performed. Results:At a mean follow-up of 10.8 ± 0.9 years, the re-rupture rate was (5.2%) 3 cases out of 58. Median Lysholm and IKDC scores were 100 (interquartile range [IQR] 91-100) and 95 (IQR 89-99), respectively, indicating excellent long-term knee function. The mean Tegner score at follow-up was 5.2 ± 1.7, representing a modest decline from the pre-injury level of 6.5, consistent with age-related reductions in activity. No patient-reported infections or hospital admissions related to the operated knee were reported. IKDC scores were significantly higher in the JewelACL-only group than in the hybrid group (p = 0.02), while Lysholm and Tegner scores did not differ significantly. Conclusions:ACL reconstruction using JewelACL was associated with excellent long-term PROMs, low re-rupture rates and high return-to-sport rates. Although these findings are encouraging, interpretation is limited by the retrospective design, substantial loss to follow-up and the absence of imaging or objective clinical assessments. There was no statistically significant difference in return-to-sport rates between the JewelACL group (85%) and the hybrid group (86%) (p = 1.00). Level of Evidence:Level IV.
Purpose:To systematically evaluate postoperative internal rotation (IR) and external rotation (ER) strength recovery following the open Latarjet (OL) procedure performed through a subscapularis-split approach using isokinetic dynamometry. Methods:A systematic search of PubMed, Embase, and the Cochrane Library following PRISMA guidelines was performed to identify clinical studies reporting postoperative shoulder rotational strength after OL. Extracted outcomes included IR and ER peak torque and ER/IR ratios. A random-effects meta-analysis was conducted for studies reporting peak torque at 60°/s. Results:Eleven studies encompassing 274 patients met inclusion criteria. Across studies, rotational strength recovery followed a consistent temporal pattern. Early (<6 months) deficits were substantial for IR (18%-42%) and ER (8%-30%). Between 6 and 12 months, strength improved but did not fully normalise. At ≥18 months, IR strength typically recovered, whereas small but statistically significant ER deficits persisted (4%-15%). Meta-analysis demonstrated pooled deficits of 17.0% for ER (95% confidence interval [CI], 12.1-21.9) and 15.1% for IR (95% CI, 9.0-21.2), with significantly smaller deficits at late compared with early follow-up for both IR and ER strength. ER/IR ratios showed no overall asymmetry; however, subgroup analysis revealed a shift from early IR-dominant weakness to late ER-dominant weakness. Conclusions:Shoulder rotational strength recovery after the OL procedure through a subscapularis-split approach follows a predictable temporal pattern, with early internal rotation deficits resolving by 6-12 months and small but persistent external rotation deficits at long-term follow-up. These findings indicate that the split of the subscapularis muscle does not compromise IR strength at long-term follow-up, supporting its safety for young and active patients. Level of Evidence:Level III.
Purpose:To investigate the association between external GPS workload metrics and soleus muscle injuries (SMI) in elite professional football. Methods:A retrospective cohort study was conducted across seven consecutive seasons (2017/2018-2023/2024) in a single Italian Serie A first-team squad. One hundred and sixty player-season observations were included (25.4 ± 3.2 years; goalkeepers excluded), with 4704 match-hours and 31,686 training-hours recorded. SMIs were defined as time-loss soleus muscle complaints (excluding contact injuries) diagnosed by the club medical staff in accordance with FIFA consensus definitions and classified as structural or non-structural. External loads were quantified using 50 Hz GPS (Stats Perform) and included total distance, high-intensity distance (≥16 km·h-1), sprint distance (≥25 km·h-1), and acceleration/deceleration distances (≥±2.0 m·s-2). For injured players, workloads were averaged across the 7- and 28-day window preceding injury (excluding injury day) and compared to control periods of equal duration. Between-player comparisons contrasted injured players' injury periods with control periods in non-injured players. Results:Twenty-nine SMIs (52% were nonstructural) occurred in 17 players. Injured players were older than noninjured players (29.2 ± 3.9 vs. 25.0 ± 3.2 years; p = 0.041). Most injuries occurred in training (83%); incidence was 0.76/1000 training-hours and 1.06/1000 match-hours; injury burden was 10.86 days/1000 hours. No within-player differences were observed between injury and control weeks for any workload metric (p > 0.05). Over 28 days, injured players demonstrated lower sprint distance versus their control month (-37%; p = 0.014; d = -0.71). For between-player analyses, deceleration distance was higher in the 7-day injury period versus noninjured controls (+17%; p = 0.041; d = 0.44), with no 28-day differences. Conclusion:SMIs imposed a substantial burden in elite football and were not preceded by acute workload spikes relative to players' own control periods. Findings suggest SMIs may occur within a context of sustained high training volumes, with modest elevations in short-term deceleration exposure and reduced longer-term sprint distance observed prior to injury. Level of Evidence:Level III.
Purpose:Pain, joint laxity, deficits in functional performance and proprioception are common after anterior cruciate ligament reconstruction (ACLR). The role of accelerated rehabilitation (AR) in addressing these outcomes remains uncertain. This systematic review and meta-analysis aimed to evaluate the effects of AR on laxity, functional performance, proprioception and pain in individuals post-ACLR. Method:Four databases (PubMed, Web of Science, Scopus, Embase) were searched until March 2026. Eligible interventional studies comparing AR with standard exercise in individuals post-ACLR were included. Data extraction followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. Risk of bias was assessed using the PEDro and Newcastle-Ottawa scales. Knee pain and laxity were defined as the primary outcome, with functional performance and proprioception evaluated as secondary outcomes. Random-effects models calculated mean differences (MDs) or standardized mean differences (SMDs) with 95% confidence intervals (CIs). Results:Ten studies (n = 2180 participants) were included. AR resulted in statistically significant improvements in knee laxity (MD: -0.50; 95% CI: -0.65 to -0.36; p < 0.001), proprioception (SMD: 0.20; 95% CI: 0.10-0.30; p < 0.001) and performance outcomes, such as single-leg hop (SMD: 0.85; 95% CI: 0.43-1.27; p < 0.001), International Knee Documentation Committee (MD: 2.39; 95% CI: 0.74-4.03; p = 0.004) and Lysholm score (MD: 1.54; 95% CI: 0.01-3.07; p = 0.04). However, these changes did not reach established thresholds for clinical meaningfulness, and the knee pain outcome (SMD: -0.14, 95% CI: -0.54 to 0.24, p = 0.45) showed no significant changes. Conclusion:AR was associated with statistically detectable changes in knee laxity, functional outcomes and knee proprioception; however, these effects had limited clinical relevance and did not extend to pain reduction. Therefore, the clinical value of AR in optimizing post-ACLR recovery remains uncertain. Level of Evidence:Level I.
Purpose:To evaluate whether patients requiring surgical reintervention for postoperative stiffness following multiligament knee reconstruction achieve comparable functional outcomes to those who do not require additional surgery. Methods:A retrospective cohort study was conducted including patients who underwent surgical reconstruction for multiligament knee injuries between January 2015 and February 2023 at a single level-1 trauma centre, with a minimum follow-up of 24 months. Patients who developed postoperative flexion stiffness requiring arthroscopic fibroarthrolysis combined with manipulation under anaesthesia were identified and compared with those who did not require reintervention. The primary outcomes were the Lysholm score and Knee injury and Osteoarthritis Outcome Score (KOOS4) score at final follow-up. Results:A total of 95 patients were included in the final analysis, of whom 16 (16.8%) required surgical reintervention for postoperative stiffness. The mean age was 38.4 ± 13.5 years and the mean follow-up was 73.2 ± 25.1 months. The median time from index surgery to fibroarthrolysis was 5.0 months (interquartile range, 4.0-8.3). At final follow-up, no statistically significant differences were observed between groups in KOOS4 score (57.9 ± 2.8 vs. 62.9 ± 5.4; p = 0.640) or Lysholm score (64.1 ± 2.7 vs. 66.6 ± 6.0; p = 0.831), with minimal effect sizes (r = 0.05 and r = 0.02, respectively). Conclusion:Patients who required surgical reintervention for postoperative stiffness after multiligament knee reconstruction achieved functional outcomes comparable to those who did not require additional surgery. Arthroscopic fibroarthrolysis combined with manipulation under anaesthesia appears to be a safe and effective treatment option in this setting, supporting its consideration when conservative management has been exhausted. Level of Evidence:Level III, retrospective cohort study.
Purpose:This study aimed to compare three-dimensional patellar and tibial positional changes after medial open-wedge high tibial osteotomy (MOWHTO) and lateral closed-wedge high tibial osteotomy (LCWHTO) using computed tomography. Methods:This retrospective comparative cohort study included 18 patients who underwent high tibial osteotomy for medial knee osteoarthritis (9 MOWHTO, 9 LCWHTO). LCWHTO was selected for patients with patellofemoral joint degeneration, patellofemoral cartilage injury, anterior knee pain or correction angle ≥10°; MOWHTO was selected for the remaining patients. Full-length lower-limb computed tomography scans were obtained preoperatively and at 1 year postoperatively. Displacement and rotation of the patella and distal tibial fragment were quantified in the anterior-posterior, medial-lateral and proximal-distal directions and in the internal-external, varus-valgus and flexion-extension rotations and compared between groups. Results:In the MOWHTO group, the patella shifted distally (1.2 ± 1.9 mm) with internal (3.0° ± 1.9°) and valgus (1.9° ± 1.5°) rotation, whereas in the LCWHTO group it shifted proximally (1.6 ± 1.9 mm) with minimal rotation (proximal-distal displacement, p = 0.017; internal-external rotation, p < 0.001). The distal tibial fragment moved distally (3.5 ± 1.5 mm) with valgus rotation (8.1° ± 2.2°) in the MOWHTO group, but anteriorly (1.3 ± 0.7 mm), medially (6.7 ± 2.3 mm) and proximally (5.1 ± 2.2 mm) with internal rotation (4.5° ± 3.3°) in the LCWHTO group (all translations, p < 0.001; internal-external and varus-valgus rotation, p < 0.01). Patellar distalization and internal rotation correlated with tibial fragment distalization only in the MOWHTO group. Conclusion:MOWHTO and LCWHTO produced distinctly different three-dimensional positional changes of the patella and distal tibial fragment. These positional findings provide a mechanistic basis for individualised surgical decision-making, but their direct impact on PF cartilage status and long-term outcomes requires confirmation in future studies. Level of Evidence:Level III, retrospective comparative cohort study.
Purpose:To systematically review the available evidence on long-term outcomes following lateral unicompartmental knee arthroplasty in lateral knee osteoarthritis. Methods:An advanced search was done throughout three electronic databases (PubMed, Scopus and Embase) involving the words 'lateral unicompartmental knee arthroplasty' and 'lateral knee osteoarthritis'. Inclusion and exclusion criteria were set. The Newcastle-Ottawa scale was used in assessing the study quality. Extracted were study demographics, survival rate, follow-up period, indications and contraindications, implant type, revision rate and outcome tools. The data were systematically collected and meta-analysed. Results:After an initial screening of 1864 articles, 15 articles were selected for the review. The study quality was evaluated as 'high' in most of the selected articles. The pooled 10-year survival rate was 93.7% (95% CI: 92.5%-94.9%). The mean follow-up period ranged between 7 and 14 years (pooled mean follow-up 9.1 years). A significant negative correlation was found between patient BMI and survival rate (p = 0.03). Female participants were prevalent among the studies; however, no strong evidence linked the male proportion and survival rate (p > 0.05). The pooled revision rate was 4.6%. Conclusions:Lateral unicompartmental knee arthroplasty for isolated lateral knee osteoarthritis provided a high long-term survival rate with a low 10-year revision rate. This was provided in a non-ACL-deficient knee with a preoperative flexion of above 90 degrees and a correctable valgus by using a fixed-bearing implant. Females were more likely to undergo this procedure. A negative correlation was found between patient BMI and survival rate. There was a notable variability in the reported outcome measures among studies. Level of Evidence:Level IV, systematic review of therapeutic studies.
Purpose:The aim of this consensus was to provide evidence-based recommendations for individual rehabilitation interventions following anterior cruciate ligament reconstruction. These recommendations are intended to complement, rather than replace, comprehensive criterion-based rehabilitation protocols. Methods:A modified Delphi process conducted by the German Knee Society evaluated 29 rehabilitation topics. Evidence from systematic reviews, randomized controlled trials and prospective cohort studies (A1-C) was summarized and rated by an expert panel. Consensus was defined as ≥80% agreement between raters. Statements were graded using the Grading of Recommendations Assessment, Development and Evaluation framework, specifying the certainty of evidence. Results:Consensus was achieved for 25 topics (86%). Moderate-certainty evidence (B2) indicates that early weight bearing likely results in safe functional recovery. Supervised and unsupervised exercise (A2-B2) likely results in improved strength and function. Rehabilitation lasting ≥9 months (A1) likely results in optimal recovery guided by functional progress. Neuromuscular training (A1) and proprioceptive training (B2) likely improve sensorimotor control and functional outcomes. Plyometric (B2) and eccentric exercises (B2), as well as blood flow restriction (A1), likely result in enhanced quadriceps strength and muscle mass. Core stability exercises (C) and aquatic therapy (B1) likely improve knee function and facilitate early return to activity. Adjunctive modalities, such as cryotherapy (A2), likely reduce pain and swelling; KT (C) and digital applications (B1) may improve early-phase outcomes. Interventions such as whole-body vibration training (B2) and cross-education (C) showed inconsistent or insufficient benefits. Rehabilitation should be individualized according to patient-specific factors, concomitant injuries and functional progress. Conclusion:These consensus recommendations provide a multimodal, evidence-based framework for anterior cruciate ligament rehabilitation. Following these recommendations likely reduces variability in clinical practice, supports safe return to sport and might lower the risk of re-injury. Level of Evidence:Level V, expert consensus.
