IMPORTANCE:Anterior cruciate ligament (ACL) injuries in paediatric and adolescent athletes are increasingly common, and ACL reconstruction (ACLR) carries a high risk of reinjury in this population. Graft selection and return to sport (RTS) timing are potentially modifiable determinants of reinjury risk and the rapid accumulation of new evidence continues to challenge established dogma, warranting an updated synthesis of their combined influence in skeletally immature patients. OBJECTIVES:This systematic review will establish the impact of autograft type and RTS timing on reinjury rates including ipsilateral graft rupture and contralateral ACL injury, following primary paediatric ACLR. A secondary objective is to examine the role of lateral extra-articular tenodesis (LET) augmentation as a modifier of these outcomes. EVIDENCE REVIEW:This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines and registered with PROSPERO ID (CRD420251167612). PubMed, Embase, Web of Science and the Cochrane Library were searched from inception to August 2025. Eligible studies included paediatric patients (≤19 years) undergoing primary ACLR with reported outcomes on graft failure, contralateral injury or RTS. Prospective and retrospective cohort studies, case-control studies, case series (n > 10), and randomised controlled trials (RCT's) were included. Two independent reviewers assessed methodological quality using the Modified Coleman Methodology Score (MCMS), and certainty of evidence for principal outcomes using the Grading of Recommendations Assessment, Development and Evaluation (GRADE). FINDINGS:In total, 51 studies encompassing 4,153 patients were included. Study quality was predominantly fair (mean MCMS 58.5; 13.7% graded Poor). Hamstring tendon (HT) autograft was the most frequently studied graft, with re-rupture rates of 0-34.6% across studies. In all comparative studies, HT was associated with higher re-rupture rates than bone-patellar tendon-bone (BTB; range 0-10%) or quadriceps tendon (QT; range 0-10%) autograft. LET augmentation consistently reduced re-rupture risk across all graft types, with HT+LET demonstrating 0-5.3% re-rupture versus 11.9-15% for HT and QT+ LET reporting 0% versus 7.7% for QT alone in comparative studies. Reported RTS rates ranged from 42.2% to 100%, although definitions varied between return at any level and return to the preinjury level of sport, limiting direct comparison between studies. Mean RTS timing ranged from 6.4 to 11.6 months; a restrictive protocol delaying RTS beyond 9 months was associated with lower revision rates in one comparative study. Functional outcomes were broadly favourable, but reporting was heterogeneous. CONCLUSION AND RELEVANCE:In paediatric ACLR, HT autograft is associated with higher reported re-rupture rates than BTB (in skeletally mature patients) or QT in comparative studies. LET augmentation was associated with lower re-rupture rates without compromising RTS or functional outcomes. Current paediatric evidence does not justify routine RTS before 9 months without objective functional clearance. The evidence base is dominated by retrospective case series of moderate quality, and no randomised controlled trial has directly compared graft selection or return to sport timing in skeletally immature patients, highlighting an urgent need for prospective, adequately powered studies in this population. LEVEL OF EVIDENCE:Level III.
Introduction Cam morphology is prevalent in physically active adolescent males and is associated with the development of femoroacetabular impingement, yet the biomechanical factors associated with its development remain unclear. Objectives: (1) To investigate longitudinal changes in squat kinematics and their association with Cam morphology development; and (2) to compare kinematics between asymptomatic athletes with and without Cam morphology. Methods This prospective two-year study evaluated spinopelvic and hip kinematics in elite adolescent soccer players aged 12 to 16 years (baseline n=29; follow-up n=20), classified as having or not having Cam morphology based on skeletal maturity and an alpha angle >60° on hip radiographs. Three-dimensional motion capture was performed at both timepoints during standardized and unstandardized deep squats. Inverse kinematics of the trunk, lumbopelvic region, pelvis, and hip were analyzed. Results At baseline and follow-up, 58.5% of participants were classified as having Cam morphology (right hips=16; left hips=15). Statistical parametric mapping paired t-tests showed no statistically significant longitudinal changes in kinematic waveforms within either group. In the skeletally age-matched cross-sectional comparison, the Cam group demonstrated greater trunk flexion (17%-34%, p=0.032), lumbopelvic flexion (11%-30%, p=0.027), anterior pelvic tilt (35%-55%, p=0.012), and hip internal rotation (45%-55%, p=0.024) during the unstandardized squat compared with the No Cam group. Pelvic range of motion was also greater in the Cam group (28.0 ± 5.3° vs 20.5 ± 4.6°). No between-group differences were observed during the standardized squat. Conclusion Asymptomatic adolescents with Cam morphology demonstrate distinct, task-dependent spinopelvic and hip kinematics during deep squatting, including greater pelvic motion. These patterns remain stable over time and are evident only under self-selected conditions, suggesting preferred movement strategies rather than fixed limitations in movement capacity. Level of Evidence III
Introduction/objectives: Patient-reported outcome measures (PROMs) are essential tools in sports medicine for assessing subjective treatment outcomes in athletic populations who have higher functional demands. The 4-Domain Sports patient-reported outcome measure (4-DSP) is a recently developed questionnaire evaluating injury perception, treatment expectations, and outcomes. However, no validated Persian version currently exists. The aim of this study was to perform adaptation and psychometric validation of the Persian 4-DSP questionnaire in patients undergoing anterior cruciate ligament reconstruction (ACLR). Methods: The 4-DSP questionnaire was translated and culturally adapted into Persian following Beaton guidelines and COnsensus-based Standards for the selection of health Measurement INstruments recommendations. Ninety-seven ACLR patients (mean age: 34.9 ± 12.1 years) completed the Persian 4-DSP questionnaire twice at a 1-week interval. Internal consistency was assessed using Cronbach’s alpha, and test-retest reliability using intraclass correlation coefficients (ICCs). Construct validity was examined through correlations with the Persian versions of the International Knee Documentation Committee Subjective Form (IKDC-SF) and Lysholm knee score (LKS). Floor and ceiling effects were also evaluated. Results: The Persian 4-DSP questionnaire demonstrated acceptable internal consistency (Cronbach’s α = 0.67). Test-retest reliability was good overall (ICC = 0.693), with excellent item-level stability (ICC range: 0.96–1.00). Construct validity showed low to moderate correlations with Persian version of IKDC-SF and LKS, consistent with the instrument’s multidimensional and sports-specific construct. Floor effects were minimal (0–2%), while ceiling effects ranged from 14% to 48% across domains. No meaningful improvement in internal consistency was observed after item deletion, supporting structural stability of the instrument. Conclusion: The Persian version of the 4-DSP questionnaire is a valid, reliable, and culturally adapted PROM for ACLR patients. It provides complementary information to conventional knee-specific instruments and is suitable for use in Persian-speaking athletic populations. Level of Evidence: III.
Meniscal root tears-defined as complete radial tears within 1 cm of the bony insertion or direct avulsion of the root attachment-represent a biomechanically distinct injury pattern with a high and likely underestimated prevalence. By abolishing hoop stress transmission, root tears produce tibiofemoral contact mechanics equivalent to total meniscectomy, with attendant risks of meniscal extrusion, cartilage degeneration, and early osteoarthritis. Despite their mechanically important consequences, root tears are frequently underdiagnosed due to atypical clinical presentation and limited physician awareness, earning the designation of a "silent epidemic." Two epidemiologically distinct populations exist. Posterior medial root tears predominantly affect older (mean age 57 years), obese patients with varus alignment through a degenerative mechanism, while lateral posterior root tears disproportionately affect younger, active patients and are closely associated with an anterior cruciate ligament injury. Physical examination findings are nonspecific in many patients, and diagnosis depends on a high index of suspicion combined with magnetic resonance imaging evaluation. Treatment decision-making is guided by articular cartilage status, limb alignment, time elapsed from injury, and tear characteristics. Surgical repair-predominantly via transtibial pullout fixation-is most commonly considered the treatment of choice in symptomatic patients with preserved joint space, demonstrating superior functional outcomes and significantly lower rates of osteoarthritis progression and arthroplasty conversion compared with partial meniscectomy and nonoperative management. Emerging suture anchor techniques have been introduced, but clinical evidence supporting their routine adoption still remains limited. Meniscal centralization addresses persistent postoperative extrusion; however, a Level II randomized controlled trial demonstrated that meniscal extrusion increased in 96.2% of knees at 6 months regardless of centralization, underscoring the limitations of current techniques in achieving durable extrusion correction. Optimal management of concomitant deformities-including varus malalignment and high posterior tibial slope-remains an area of active investigation. Geographic variation in root tear epidemiology, particularly the higher degenerative medial root tear burden in East Asian populations attributable to floor-based activity patterns, underscores the global relevance of this injury. Future directions include standardization of patient selection criteria, development of biologics to enhance repair healing, further investigation of tibial slope correction, and establishment of consensus rehabilitation protocols. This state-of-the-art review provides a comprehensive synthesis of root anatomy, biomechanics, epidemiology, classification, clinical evaluation, surgical technique, and outcomes to guide evidence-based management and future directions.
Importance: Arthroscopic shoulder stabilization is widely used for treating anterior shoulder instability, yet the optimal patient positioning (beach chair [BC] vs. lateral decubitus [LD]) remains controversial, with unclear implications for operative efficiency and clinical outcomes. Aim or objective: To systematically compare BC and LD positioning in patients undergoing arthroscopic anterior stabilization for shoulder instability, focusing on operative parameters, surgical technique variables, and clinical outcomes. Evidence review: A systematic review was conducted following Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. PubMed, MEDLINE, Scopus, and the Cochrane Central Register of Controlled Trials were searched from inception to June 2026 for studies comparing BC and LD positioning in arthroscopic anterior shoulder stabilization. Studies involving rotator cuff tears or other shoulder pathologies were excluded. Study quality was assessed using the modified Newcastle–Ottawa Scale (mNOS). Data extracted included demographics, operative time, number of anchors, revision surgery, and recurrent instability. Both qualitative synthesis and comparative quantitative analysis were performed. Findings: Three studies met the inclusion criteria, comprising 1649 patients (BC: 1025; LD: 624). Two were cohort studies and one was a cross-sectional study, all conducted in the United States (US) between 2021 and 2023. Baseline characteristics were comparable between groups. No statistically significant differences were observed in operative time or the number of anchors used. Revision surgery and recurrent instability were numerically higher in the BC group, but the differences were not statistically significant. Exploratory effect size estimates numerically favored the LD position; however, these differences were not statistically significant and were associated with wide confidence intervals. Conclusion and Relevance: Current evidence does not demonstrate statistically significant differences between BC and LD positioning regarding operative parameters or early clinical outcomes following arthroscopic anterior shoulder stabilization. Given the limited number and methodological heterogeneity of available comparative studies, no conclusion regarding the superiority of either position can be drawn. Patient positioning should therefore be individualized according to surgeon experience, technical considerations, and patient-specific factors. Level of evidence (LoE): III.
INTRODUCTION/OBJECTIVES:To compare 5-year revision rates and patient-reported knee function after primary anterior cruciate ligament reconstruction (ACLR) using hamstring tendon (HT) versus bone-patellar tendon-bone (BPTB) autografts in a national registry-based cohort of young male patients aged 16-25 years. METHODS:Data were retrieved from the Swedish Knee Ligament Registry. Male patients aged 16-25 years undergoing primary ACLR with either HT or BPTB autografts between 2005 and 2018 were included. Patient-reported knee function was evaluated using the Knee injury and Osteoarthritis Outcome Score (KOOS), and the composite KOOS4 (pain, symptoms, sport and recreation, and quality of life [QoL]). Patient acceptable symptom state (PASS) and treatment failure (TF) thresholds were defined based on previously published thresholds for the KOOS4. Patients who underwent revision ACLR within 5 years of primary ACLR were identified. Between-group differences in KOOS outcomes were analyzed using analysis of covariance, while Cox proportional hazards regression analysis was applied to assess the 5-year risk of revision. RESULTS:Overall, 10,038 patients were included (HT: n = 9440 [94.0%]; BPTB: n = 598 [6.0%]). The sport and recreation subscale was higher in the HT group at both 1-year (68.5 ± 25.6 vs. 64.1 ± 26.5; p = 0.009) and 2-years (67.1 ± 26.9 vs. 59.9 ± 29.7; p < 0.001) follow-up. At the 2-year follow-up, patients in the HT group reported higher QoL scores (58.9 ± 25.1 vs. 55.2 ± 25.9; p = 0.038) and KOOS4 scores (71.7 ± 19.5 vs. 68.2 ± 20.7; p = 0.007). No significant differences were observed between the graft groups in the proportion of patients achieving a PASS based on the KOOS4 at the 1-, 2-, or 5-year follow-up. However, the proportion of patients classified as TF was lower in the HT group at the 2-year follow-up (9.8% vs. 14.0%; p = 0.039). The 5-year revision rate following ACLR was 7.3% in the HT group and 5.4% in the BPTB group. The hazard of revision ACLR was not significantly different between the graft groups (hazard ratio [HR]: 1.39, 95% confidence interval [CI]: 0.98-1.99; p = 0.064.). CONCLUSION:No statistically significant differences in revision rates following primary ACLR were observed between HT and BPTB autografts in young males, although a trend toward a higher revision risk was observed in the HT group. HT autografts were associated with improved patient-reported knee function in the early follow-up; however, these differences were not sustained at 5 years, suggesting similar long-term patient-reported knee function between graft types. LEVEL OF EVIDENCE:III.
INTRODUCTION:Trochlear dysplasia is one of the most relevant anatomic factors predisposing patients to patellofemoral instability and its recurrence. This study introduces two novel radiographic measurements: the crossing-sign angle and the trochlear dysplasia length. METHODS:A concordance study was conducted in patients aged 10-40 years with at least one episode of patellofemoral dislocation and radiographic evidence of trochlear dysplasia on a true lateral knee radiograph. Three observers independently measured the crossing-sign angle, the trochlear dysplasia length, and bump height, as well as classified the degree of trochlear dysplasia according to a modified Dejour classification. Inter- and intra-observer reliability for continuous variables were assessed using the intra-class correlation coefficient (ICC), while agreement for the modified Dejour classification was evaluated using Krippendorff's alpha (α) and weighted kappa (κ). Pearson correlation analysis was performed between the radiographic measurements, and an analysis of variance (ANOVA) test was performed between these and Dejour grades. RESULTS:The crossing sign angle demonstrated moderate inter-observer reliability (ICC = 0.71) and excellent intra-observer reliability (ICC = 0.96). Trochlear dysplasia length showed moderate inter-observer reliability (ICC = 0.73) and excellent intraobserver reliability (ICC = 0.95). Bump height exhibited good inter-observer reliability (ICC = 0.87) and excellent intra-observer reliability (ICC = 0.97). The modified Dejour classification demonstrated substantial inter-observer agreement (α = 0.62) and perfect intraobserver agreement (κ = 1.00). A strong positive correlation was found between trochlear dysplasia length and bump height (r = 0.73; 95% confidence interval [CI]: 0.52 to 0.85; p < 0.001). Bump height and trochlear dysplasia length increased progressively from Dejour type A to higher grades (B and D, ANOVA p < 0.001). CONCLUSIONS:The crossing sign angle and trochlear dysplasia length provide a novel quantification of trochlear dysplasia and demonstrate moderate inter- and excellent intra-observer reliability. Bump height and the modified Dejour classification, when using a standardized protocol, also showed high inter- and intra-observer reliability. Bump height and trochlear dysplasia length have a strong positive correlation. The clinical and surgical implications of these new parameters need further investigation in future studies. LEVEL OF EVIDENCE:II.
IMPORTANCE:Arthroscopic rotator cuff repair (ARR) and mini-open rotator cuff repair (MRR) are both widely used, but whether ARR offers clinical advantages over MRR remains uncertain. OBJECTIVE:The aim of this study was to compare the clinical and structural outcomes of ARR and MRR in adult patients with rotator cuff tears. EVIDENCE REVIEW:A systematic search of PubMed, Scopus, and the Cochrane Library was performed from inception to November 2025 for randomized controlled trials (RCTs) directly reporting functional score, shoulder range of motion (ROM), re-tear rate, pain, or complications with a minimum follow-up of 6 months. Random-effect models pooled standardized mean differences (SMDs) for functional scores; mean differences (MDs) for ROM and pain; and risk ratios (RRs) for dichotomous outcomes, each with 95% confidence intervals (CIs). FINDINGS:Seven studies (725 shoulders) were included, predominantly involving small- to medium-sized full-thickness tears. Functional outcomes did not differ between ARR and MRR at 3, 6, or 12 months (SMD range: -0.26 to 0.33; p ≥ 0.53). Pain measured using the visual analog scale was comparable at 3 and 6 months, with minimal between-group differences (MD < 0.1 points; p ≥ 0.82). ROM was also comparable at 6 and 12 months for both forward flexion and external rotation, with small pooled differences (MD < 2°; p ≥ 0.18). There were no statistically significant differences in re-tear rates (RR: 1.28, 95% CI: 0.87 to 1.86, p = 0.21), postoperative stiffness (RR: 0.86, 95% CI: 0.47 to 1.60, p = 0.64), or infection (RR: 0.19, 95% CI: 0.02 to 1.59, p = 0.12). CONCLUSION AND RELEVANCE:ARR and MRR yielded comparable functional recovery, pain relief, structural integrity, and complication rates. Current evidence does not support the superiority of either technique. Technique selection should be individualized to tear characteristics, surgeon expertise, and resource availability. LEVEL OF EVIDENCE:I-II, systematic review and meta-analysis of RCTs).
Importance: Soccer is associated with a substantial global injury burden, particularly involving lower-extremity and head injuries. Despite extensive research growth, a comprehensive long-term evaluation of trends, impact, and thematic evolution in soccer injury literature has been lacking. Objective: To systematically map the global landscape of soccer injury research from 1904 to 2025, focusing on publication trends, scientific impact, collaboration networks, and emerging research hotspots. This review emphasizes epidemiology, prevention, and risk factors influencing injury patterns across soccer populations. Evidence review: A bibliometric analysis was conducted using the Scopus database, including 2864 English-language journal articles and reviews published between 1904 and 2025. A structured search strategy using “soccer/football” and “injury” in titles was applied with predefined filters (articles/reviews, final publication stage, journals, English language). No manual screening was required. Bibliographic data including authors, institutions, countries, citations, and keywords were extracted and analyzed. Descriptive statistics (counts, percentages, citations per paper, and H-index) were used. Network and co-occurrence analyses were performed using VOSviewer to identify collaboration patterns and thematic clusters. No formal risk-of-bias or inferential statistical analyses were performed due to the bibliometric nature of the study. Findings: Soccer injury research increased markedly from 1 publication in 1904 to 239 in 2025, with accelerated growth after 2006. The United States led in publication volume (28.9%), while Sweden, Norway, and Switzerland demonstrated the highest citation impact. A small group of institutions and authors contributed disproportionately to total output and citations. Leading journals included the American Journal of Sports Medicine and the British Journal of Sports Medicine. Key research hotspots included injury epidemiology and prevention, workload-related injury risk, and rehabilitation strategies. Knee injuries—particularly anterior cruciate ligament (ACL) tears—along with hamstring, ankle, and concussion-related injuries dominated the literature. Temporal evolution showed a shift from descriptive epidemiology to integrated models incorporating biomechanics, workload monitoring, and technology-assisted injury prevention. Conclusion: and Relevance: Soccer injury research has evolved into a mature, high-impact, and collaborative field with clear thematic priorities centered on prevention, performance, and rehabilitation. Current evidence highlights the need for improved global collaboration, greater inclusion of underrepresented regions, and integration of advanced technologies such as wearable monitoring and artificial intelligence. Clinicians should prioritize evidence-based prevention strategies, particularly for high-risk injuries such as ACL tears and hamstring strains, while tailoring interventions for specific populations including youth and female athletes. This study provides a strategic framework to guide future research and support clinical decision-making aimed at reducing injury burden and improving athlete outcomes. Level of Evidence: IV.
Introduction: Unstable knee dislocations (KDs) may be assessed with magnetic resonance imaging (MRI) and treated with knee spanning external fixation (ex-fix) prior to definitive multiligament reconstruction. The order in which ex-fix and MRI are performed is debated due to the risk of complications. The following study evaluates the risks associated with MRI completion before versus after ex-fix placement, including the risk of redislocation compared to the risk of MRI related injury. Methods: KDs treated with knee spanning ex-fix were retrospectively reviewed at a level-I academic center over a 10-year period. Exclusion criteria included the absence of MRI completion or ex-fix removal prior to MRI. Study groups were defined as KDs that received MRI prior to ex-fix (MRI-first) and ex-fix prior to MRI (ex-fix-first). Demographic data were collected, including age, sex, and body mass index (BMI). Primary outcomes were adverse events during MRI, including redislocation/subluxation events, pin pullout, or thermal injury. Secondary outcomes included radiographic malreduction, early MRI termination, and repeat MRI within 3 months. Data analysis was conducted with the Mann–Whitney U, Chi-squared, and Fisher's exact tests, with a p-value <0.05 indicating significance. Results: Twenty-four knees met the inclusion criteria: 8 were MRI-first versus 16 that were ex-fix-first. No statistically significant differences in demographic variables were found between the study groups. In the MRI-first group, 4/8 (50%) had a redislocation or severe subluxation event in the scanner versus 0/16 (0%) in the ex-fix-first group (p = 0.007). In the ex-fix first group, 0/16 (0%) suffered thermal injuries or pin pullout. MRI-first knees were significantly more radiographically malreduced in the sagittal and coronal plane (p = 0.017 and 0.047, respectively, after excluding MRIs completed with redislocation and KD Vs with marked tibial plateau displacement). Repeat MRI occurred in 3/8 (37.5%) of MRI-first knees and 1/16 (6.3%) of ex-fix-first knees (p = 0.091). Conclusions: In the setting of grossly unstable KDs, MRI prior to ex-fix placement put the patient at a high risk of redislocation and more often required repeat MRI. There were no cases of thermal injury or pin pullout with ex-fix placement before MRI. We advocate for a multidisciplinary protocol to assure prompt and appropriate treatment. Level of evidence: Level III: Retrospective comparative study.
Purpose: Posterolateral corner (PLC) injuries of the knee remain a complex and heterogeneous clinical entity, with substantial variability in surgical management and no widely accepted criteria to guide treatment selection. The purpose of this study was to develop and internally validate a clinically applicable decision-making algorithm for PLC injuries and to evaluate the outcomes of a minimally invasive reconstruction strategy in a consecutive cohort of patients. Methods: A retrospective cohort of 120 patients undergoing surgical treatment for PLC injuries, including both isolated PLC reconstructions and combined ligament procedures (ACL and/or PCL), was analyzed. Baseline demographic, clinical, radiographic, and intraoperative variables were collected. The primary outcome was defined as a successful clinical outcome at final follow-up, including absence of revision surgery, restoration of clinical stability, and functional improvement. Predictors of outcome were identified using multivariable logistic regression. Internal validation was performed using bootstrap resampling (1000 iterations). Model performance was assessed using discrimination (area under the curve [AUC]) and calibration analysis. A simplified clinical score and decision-making algorithm were derived from the final model. Results: At a mean follow-up of 24.8 ± 6.3 months, 92 patients (76.7%) achieved a successful clinical outcome. Independent preoperative predictors of unsuccessful outcome included varus laxity >4 mm on stress radiographs (odds ratio [OR]: 3.12; p = 0.005), a positive dial test at 90° of knee flexion (OR: 2.67; p = 0.018), and combined ligamentous injury involving the posterior cruciate ligament (OR: 2.94; p = 0.010). The final model demonstrated good discrimination (area under the curve [AUC]: 0.81; 95% confidence interval [CI]: 0.73–0.89), with a bootstrap-corrected AUC of 0.78 and good calibration (slope 0.94). The derived clinical algorithm, based on a weighted score including varus laxity >4 mm, dial test positivity at 90°, and PCL-associated injury, stratified patients into low-, intermediate-, and high-risk categories, supporting tailored selection of minimally invasive versus anatomic reconstruction strategies. Each variable was assigned points according to its regression coefficient, allowing classification into three groups based on cumulative score: low risk (0–1 points), intermediate risk (2–3 points), and high risk (≥4 points). Conclusion: A clinically applicable and internally validated algorithm can effectively guide surgical decision-making in PLC injuries of the knee. By integrating key clinical and radiographic variables, this model enables safe selection of minimally invasive reconstruction in appropriately selected patients while preserving the indication for anatomic techniques in complex instability patterns. Level of evidence: Level III, retrospective cohort study.
Introduction/objectives: The aim of this study is to determine the differences between static and dynamic patella alta measurements for assessing patellar height. Patella alta is an abnormally high patella in relation to the femoral trochlea. Previously, magnetic resonance imaging (MRI) has been used for a more precise patella alta analysis of the overlap between the patellar and trochlear cartilage (patellotrochlear index [PTI]). Methods: We included consecutive patients with anterior knee pain who had both MRI and dynamic weight-bearing conical beam computerized tomography (CBCT) available. Patients with previous knee surgery, inadequate imaging quality, or incomplete datasets were excluded. Twenty-nine patients underwent standard static (supine, 3.0T MRI standard knee coil) and dynamic PTI assessment (single-leg, weight-bearing high-resolution cone-beam CT with quadriceps contraction). CBCT allows the analysis of patellar and trochlear cartilage overlap similar to MRI. Patellar height relative to the trochlea was quantified by PTI (<15% overlap defines patella alta). The Caton–Deschamps (C-D) and Insall–Salvati (I-S) indices were measured as originally described. The presence and effect of trochlea dysplasia on patella alta was assessed by measuring the lateral trochlear inclination (LTI) angle. A crude comparison between static and dynamic assessments were performed with a paired sample t-test and adjusted comparison in relation to the lateral trochlear inclination (LTI) angle with linear mixed model analysis. Results: In standard static MRI, patellar height measurements had lower values than in dynamic assessment with PTI or C–D. More importantly, PTI was 28% lower (95% confidence interval [CI], 21%–35%, p < 0.01) in dynamic assessment than in static assessment, indicating significantly more frequent patella alta diagnosis in dynamic assessment than in static MRI. The mean C–D was 10% less (95% CI, 7%–14%, p < 0.01) in static than in dynamic assessment. However, I-S was similar in both imaging modalities, indicating an invaluable method of patellar alta assessment concerning patellar engagement to the trochlea. The mean distal cartilage margin of the patella in sagittal view was 3.3 mm (range, 0 mm–6.7 mm) more proximal in dynamic than in static imaging when quadriceps is contracted. Conclusion: Diagnosis of patella alta is challenging because dynamic and static imaging modalities result in significant differences when measuring patella-trochlea overlap. A dynamic imaging modality may be considered a more precise method of assessing patellar engagement within the trochlea. The results of this study suggest the diagnostic value of standard static MRI is limited. Level of Evidence: III
Introduction/objectives: General-purpose large language models (LLMs) have substantial limitations, including fabricated references and inconsistent concordance with evidence-based clinical practice guidelines (CPGs). OpenEvidence (OE) (Cambridge, MA) is a retrieval-augmented generation (RAG) platform designed to provide accurate, evidence-based, citation-supported answers. This study assessed the concordance, quality, and citation characteristics of OE responses to the 2022 American Academy of Orthopaedic Surgeons (AAOS) CPG for anterior cruciate ligament reconstruction (ACLR). It was hypothesized that OE would deliver relevant, accurate, clear, complete, and evidence-based responses, with low rates of hallucination and irrelevant citations. Methods: Fifteen prompts reflecting the 2022 AAOS ACLR CPG were curated and categorized into three domains: (1) preoperative evaluation and diagnosis, (2) surgical timing and technique, and (3) rehabilitation and prevention. Each prompt was entered into OE in a new session to minimize context bias. Two orthopedic surgeons rated response quality on a 5-point Likert scale for relevance, accuracy, clarity, completeness, and evidence-based content. Inter-rater reliability was assessed using intra-class correlation coefficients (ICCs). All citations were extracted and classified as relevant, irrelevant, or hallucinated, and journal sources and publication years were recorded. Results: Inter-rater reliability was high across all domains (overall ICC, 0.90; 95% confidence interval, 0.82–0.96). Median scores exceeded 4.0 for all domains, with perfect scores for evidence-based (5.0 [5.0–5.0]) and the lowest scores for clarity (5.0 [4.0–5.0]). Across 15 prompts, OE generated 127 PubMed-indexed citations (mean, 8.5 per response; range 6–11) with zero hallucinated and only 2.4% irrelevant citations. Citations spanned 29 journals from 1997 to 2025. Conclusion: OE produced highly relevant, accurate, clear, complete, and evidence-based responses to AAOS ACLR CPG prompts, with trustworthy PubMed-indexed citations and no hallucinations. Its RAG architecture may offer a credible, citation-oriented adjunct to evidence-based decision support in orthopedic surgery. Level of Evidence: Level V, descriptive study.
Introduction/Objectives: Arthroscopic management of post-traumatic anterior glenohumeral micro-instability, in the non-athletes, has not yet been thoroughly investigated. The current study compared the outcomes of antero-inferior capsulo-labral repair for the management of anterior glenohumeral microinstability (following a single-event trauma in the nonathletes) versus those of Bankart repair for the management of recurrent anterior gleno-humeral dislocation/macro-instability. Methods: Conducted between March 2018 and February 2024, this case–control study included 62 patients allocated according to the managed pathology into 2 groups. Group A included 21 nonathletes with anterior glenohumeral microinstability (following single-event trauma) managed with suture-anchor antero-inferior capsulo-labral repair coupled with the intra-articular soft arthroscopic Latarjet technique (in-SALT), including soft-tissue biceps tenodesis to the upper subscapularis. Whereas group B, on the other hand, included 41 nonathletes with recurrent anterior glenohumeral dislocation/macroinstability (i.e. type-V superior labrum anterior to posterior [SLAP] lesion) managed with suture-anchor Bankart repair coupled with in-SALT. Outcome measurements included the 2-year postoperative visual analog scale (VAS) score; range of forward flexion (FF) and external rotation (ER) at 90°-abduction; and the American Shoulder and Elbow Surgeons (ASES) and Rowe scores. Results: There were no intergroup statistically significant differences in baseline patient characteristics. The mean age of the patients was 26.8 ± 7.0 in group A and 26.6 ± 6.8 in group B. Other than 1 female patient in each group, all included patients were male. Except for range of motion in group A, patients in both groups had significant postoperative improvement in all outcome measurements (P < 0.05 for all). Both groups showed comparable postoperative outcomes in terms of the VAS score (1.0 ± 0.8 vs 1.1 ± 0.9; P = 0.607), FF (173.8° ± 7.4° vs 172.2° ± 5.2°; P = 0.324), ER at 90°-abduction (83.3° ± 7.3° vs 80.7° ± 6.1°; P = 0.142), ASES score (91.5 ± 4.4 vs 92.1 ± 3.0; P = 0.582); Rowe score (89.8 ± 4.0 vs 88.2 ± 5.8; P = 0.264), and instability persistence/recurrence (4.8% vs 2.4%; P = 0.624), respectively. Conclusion: Anterior glenohumeral micro-instability following a single-event trauma in nonathletes could be successfully managed (in a way similar to that of type-V SLAP lesion of the recurrent anterior glenohumeral dislocation/macroinstability) via in-SALT-augmented suture-anchor antero-inferior capsulo-labral repair with comparable outcomes. Trial Registration: The study was approved by the Institutional Committee of Scientific Research and Ethics (IRB: 2/2023 ORTH 30-3). Level of evidence: III.
Introduction/Objectives: Pediatric anterior cruciate ligament reconstruction (ACLR) outcomes, particularly long-term functional recovery and return-to-sport (RTS), remain debated and have not been well characterized in skeletally immature patients. This study evaluated functional movement competency, balance, and subjective knee function over a two-year follow-up in skeletally immature patients undergoing ACLR. Methods: Forty-four skeletally immature patients (15 girls, 29 boys, median age 14, range 9–16) undergoing transphyseal ACLR using semitendinosus tendon autograft in a single center were prospectively assessed. Functional Movement Screen (FMS), Simple Knee Value (SKV), Single Leg Squat (SLS), and Y-Balance Test-Lower Quarter (YBT-LQ) were administered preoperatively and at 6, 12, and 24 months postoperatively. Linear mixed models (ANOVA or non-parametric tests) and post-hoc comparisons were used for statistical analysis. Results: FMS scores improved throughout the two-year follow-up (p = 0.024), with increases observed from 6 months postoperatively. SKV also demonstrated continuous improvement at all time points (p < 0.001). However, no clinically meaningful correlation was found between SKV and FMS scores over time. SLS showed differences at 24 months for both the operated (0.6; p = 0.004) and contralateral leg (0.6; p = 0.03), though with minimal clinical relevance. YBT-LQ composite scores statistically improved bilaterally at 24 months, with minimal clinical relevance in the contralateral leg (−3.7; p = 0.011). The inter-limb difference in composite scores remained stable over time. YBT-LQ anterior reach distance progressively improved in the operated leg from 6 to 24 months. The inter-limb difference in anterior reach distance did not change over time. Conclusion: Pediatric ACLR patients demonstrated progressive functional improvement over two years, with additional improvements occurring beyond 12 months, supporting the potential value of extended rehabilitation and reassessment. The lack of correlation between subjective and objective measures underscores the need for comprehensive assessments, including functional tests, for safe RTS decisions, as subjective knee perception poorly reflects actual movement capacity. Level of evidence: II.
Introduction: The Knee Injury and Osteoarthritis Outcome Score (KOOS) is widely used in anterior cruciate ligament (ACL) research. Although a Thai KOOS exists, its validation was limited to patients with osteoarthritis. Furthermore, Thai KOOS short forms remain unvalidated. Therefore, this study evaluated the validity, reliability, and responsiveness of the Thai KOOS and 3 short forms (KOOS-12, KOOSglobal, and KOOS-ACL) in patients with ACL injury. Methods: This prospective cohort study involved 95 patients (age range, 18–50 years) scheduled for primary ACL reconstruction. Participants completed the Thai KOOS and International Knee Documentation Committee Subjective Knee Form (IKDC-SKF) at baseline, 2 weeks after baseline, and 3 months postoperatively. Construct validity was assessed via Spearman correlation with the IKDC-SKF. Internal consistency and test-retest reliability were evaluated using Cronbach α and intraclass correlation coefficients, respectively. Responsiveness was quantified via effect size, standardized response mean, and receiver operating characteristic analysis. Results: All KOOS subscales and short forms demonstrated moderate to high correlations with the IKDC-SKF (Spearman correlation coefficients, 0.51–0.87). Internal consistency was excellent (Cronbach α, 0.88–0.93), and test-retest reliability was good (intraclass correlation coefficients, 0.78–0.87). All measures improved significantly at 3 months postoperatively (P < 0.001). Effect sizes (0.63–1.34) and standardized response means (0.66–1.25) were moderate to large. The KOOSglobal and KOOS-12 demonstrated excellent discriminative ability (area under the curve, 0.96 and 0.92, respectively). However, ceiling effects occurred in the Activities of Daily Living (21.1%) and KOOS-ACL Function (20.0%) subscales at 3 months. Conclusion: The Thai KOOS and its 3 short forms (KOOS-12, KOOSglobal, and KOOS-ACL) demonstrated good validity, reliability, and responsiveness in patients with ACL injury. Level of Evidence: II.
Purpose: Cyclops syndrome remains a clinically relevant cause of extension deficit after anterior cruciate ligament reconstruction (ACLR), yet its prevention, diagnosis, and management are not standardized. The purpose of this study was to characterize practice patterns, identify areas of consensus and controversy, and derive a clinically applicable management framework based on an international survey of knee surgeons. Methods: A 69-item online survey was distributed to orthopedic surgeons specialized in knee surgery through multiple international societies. The questionnaire explored five domains: surgeon characteristics, surgical techniques, preventive strategies, diagnostic approaches, and management of cyclops syndrome. Descriptive statistics were used to summarize responses. Results: A total of 250 surgeons from 25 countries completed the survey. Most respondents estimated the incidence of cyclops syndrome between 1% and 5%, with symptomatic presentation typically occurring within 3–6 months after ACLR. Loss of extension greater than 5° was consistently identified as the key clinical finding. Magnetic resonance imaging was the preferred first-line diagnostic modality.Despite heterogeneity in several aspects of care, consistent patterns emerged. Accurate tibial tunnel positioning and restoration of full preoperative knee extension were considered the most critical preventive factors. Initial management was predominantly conservative, with most surgeons advocating an extension-focused rehabilitation trial before surgical intervention. Arthroscopic excision was generally reserved for persistent extension deficits and was associated with favorable outcomes and low recurrence rates.However, substantial variability persisted regarding the role of remnant preservation, timing of surgery, and indications for imaging, highlighting unresolved clinical controversies. Conclusions: While substantial variability exists in the management of cyclops syndrome after ACLR, consistent clinical patterns can be identified. Based on these findings, a stepwise management approach can be proposed, emphasizing early recognition of extension deficit, selective use of imaging, and a staged treatment strategy. These results provide a foundation for future efforts toward consensus guidelines and standardized care pathways. Level of Evidence: Level V, cross-sectional survey study.
Proximal tibiofibular joint (PTFJ) dislocation is a rare and frequently underdiagnosed injury that may occur following both sports-related trauma and high-energy mechanisms. Irreducible dislocations represent a particular challenge because they often reflect complex injury patterns requiring surgical management. We report two cases of irreducible PTFJ dislocation with distinct displacement patterns: an anterolateral dislocation following a sports injury and a posteromedial dislocation associated with high-energy trauma and common fibular nerve palsy. In both cases, closed reduction was unsuccessful, necessitating open reduction. Surgical stabilization was tailored to the specific injury characteristics and intraoperative findings, using suture anchor-based ligament repair in the anterolateral dislocation and adjustable cortical button fixation in the posteromedial dislocation. The latter case additionally required repair of associated posterolateral soft-tissue injuries. At 12-month follow-up, both patients demonstrated maintenance of reduction, restoration of joint stability, substantial functional improvement, and no persistent neurological deficits or recurrent instability. These cases highlight the importance of recognizing irreducible PTFJ dislocations and addressing associated lesions when closed reduction fails. Rather than supporting a single fixation method, they illustrate a pattern-based surgical approach in which satisfactory short-term outcomes were achieved through anatomic reduction, restoration of soft-tissue stability, and protection of the common fibular nerve. Level of evidence: Level V.
Introduction/objectives: Developmental dysplasia of the hip is associated with inferior clinical outcomes when treating concomitant intra-articular pathologies. Shelf acetabuloplasty has been proposed as a less invasive alternative to periacetabular osteotomy for developmental dysplasia of the hip; however, there is a lack of biomechanical studies regarding its efficacy. We hypothesized that a cadaveric dysplasia model would cause increased range of motion and lateral femoral head translation compared to native, and that shelf acetabuloplasty would restore native biomechanics. Methods: Ten cadaveric hips were dissected down to the capsule and mounted to a six-degree-of-freedom robotic arm. Each specimen was tested sequentially in 4 states: 1) Native, 2) Capsular repair, 3) Acetabular dysplasia model created by acetabular rim resection to achieve a lateral center-edge angle (LCEA) of 15–20° under fluoroscopic guidance, and 4) Shelf acetabuloplasty restoring LCEA of 35–40° utilizing a bone graft harvested from the iliac crest. Robotic testing included: 1) 5- Newton Meter (Nm) abduction, 2) 5-Nm internal rotation (IR) at 75° flexion, 3) 5-Nm flexion, and 4) 88-N lateral drawer. Range of motion under standardized torque was used as a surrogate measure of rotational stability. The effect of specimen state was determined using analysis of variance, and post hoc pairwise comparisons were made using Tukey's method. Results: Capsular repair did not statistically significantly differ from the native state. Compared to native, the acetabular dysplasia model showed increased abduction (+2.3°, p = 0.004) and IR at 75° flexion (+0.9°, p = 0.017) without statistically significant changes in flexion or lateral translation. Shelf acetabuloplasty restored native abduction and IR at 75° flexion but reduced hip flexion (−1.7°, p = 0.003). Conclusion: This study demonstrated that acetabular rim resection increased rotational motion under applied torque, while shelf acetabuloplasty restored rotational motion to native levels. However, shelf acetabuloplasty resulted in a statistically significant reduction in hip flexion (−1.7°, p = 0.003), suggesting potential over-constraint depending on graft positioning. Level of evidence: Not Applicable, Controlled Laboratory Study.
ABSTRACT: Lateral meniscus posterior horn tears are frequently associated with pivoting trauma and anterior cruciate ligament injuries, but they encompass heterogeneous and incompletely characterized patterns. We present four cases of tears at the junction of the anterior meniscofemoral ligament (MFL) and the posterior horn of the lateral meniscus. Two patterns were identified: an isolated tear and a combined tear associated with an oblique radial tear of the lateral meniscus. These lesions mimic root tears and are often not detected by magnetic resonance imaging and may compromise anterolateral rotational stability if unrecognized or neglected. Intraoperative diagnosis is established by probing-induced hypermobility of the posterior horn despite an intact-appearing root. Repairs are conducted using different types of all-inside approaches, restoring continuity at the MFL-root junction. Postoperative rehabilitation follows standard meniscal root repair protocols. In a consecutive series of four young, active patients with minimum 12-month follow-up, this technique yielded stable menisci, resolution of pain, and no reoperations or recurrent effusions. Level of evidence: V.
