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.

Purpose: To evaluate test-retest reliability of physical fitness measures in hip osteoarthritis (OA) patients and assess longitudinal changes in these parameters following total hip arthroplasty (THA). This study incorporates previously unexamined parameters like V̇O2peak and trunk endurance, alongside physical activity monitoring through accelerometry and self-reported outcomes in 1-year follow-up. Methods: Seventy-eight patients (mean age 74 ± 4.5 years, 81% women) scheduled for THA performed physical fitness tests and accelerometry-measured physical activity. The test battery included muscle strength, motor fitness, and cardiorespiratory fitness. Assessments were conducted at two pre-operative timepoints and at 4-month and 1-year post-operative follow-up. Physical activity was objectively measured using hip-worn triaxial accelerometers. Results were compared with healthy older adults. Statistical analyses included test-retest reliability assessment, between-group comparisons, and longitudinal change analysis using repeated measures ANOVA. Results: Good to excellent test-retest reliability was demonstrated for most fitness parameters. Pre-operatively, hip OA patients showed significant deficits compared to healthy controls in moderate-to-vigorous physical activity (18.7 vs 44.7 min/day) and multiple physical fitness parameters. At 1-year post-op, significant improvements were observed in 23 of 45 measured parameters, including functional mobility (Timed Up and Go: –29%), walking distance (Six-Minute Walk Test: +16%), trunk endurance-strength (+71–82%), shoulder-press (+33%), various leg strength tests (+13–42%), and 4 m max walking-speed (+42%). Moderate-to-vigorous physical activity increased by 63% and daily step count improved from 6,004 to 7,558 steps/day (+26%). Notably, ipsilateral-to-contralateral step height asymmetry decreased from 27% pre-operatively to 8% at 1-year. V̇O2peak demonstrated modest but significant improvement from 22.7 to 23.6 mL/kg/min 1-year postoperatively (+4%). Conclusion: This study highlights significant pre-operative functional deficits in patients with hip osteoarthritis, with substantial improvements observed across multiple performance domains 1-year post-surgery. Notably, patients failed to meet the recommended physical activity guidelines prior to surgery but achieved them post-operatively. The demonstrated reliability of the test battery reinforces its value for both research and clinical applications.

PURPOSE:To compare 2-year anterior cruciate ligament reconstruction (ACLR) reoperation rates, subsequent meniscal procedures, patient-reported outcome measures (PROMs) between isolated ACLR and ACLR with concomitant meniscal repair or resection, including subgroup analyses of successful and failed repair, respectively, repair laterality. Higher subsequent meniscal procedure rates and inferior PROMs driven by failed repairs were hypothesised for concomitant repair, and inferior PROMs for combined versus medial or lateral repairs. METHODS:Patients undergoing primary ACLR with or without concomitant meniscal procedure at Capio Artro Clinic, Stockholm, Sweden, (2015-2022) were included. ACL reoperations, subsequent meniscal procedures within 2 years were identified through medical records. The knee injury and osteoarthritis score (KOOS) was collected preoperatively and at 2 years. The PROMs minimal important change (MIC), patient-acceptable symptom state (PASS) and treatment failure (TF) were evaluated using KOOS4. Multivariable logistic regression was performed for subsequent meniscal procedure, ACL reoperation and PROMs. Subgroup analysis compared PROMs by repair success and repair laterality. RESULTS:Among 5387 primary ACLRs, 1305 and 1097 underwent concomitant meniscal repair respectively resection. The mean age was 29.7 ± 12.1 years, 51.0% were male. Meniscal repair had more subsequent procedures (11.3%) than resection (4.8%) or isolated ACLR (5.4%, p = 0.02), and was associated with subsequent meniscal procedure (odds ratio [OR] = 1.58, 95% confidence interval [CI]: 1.16-2.16; p = 0.004). ACL reoperation rates were comparable across groups. Successful repair demonstrated MIC (40.0%), TF (8.9%), similar to isolated ACLR (31.4%, 5.4%). Failed repair was associated with TF (OR = 2.04, CI 1.06-4.31; p = 0.03). Lateral repair yielded superior MIC (45.2%, p = 0.04), PASS (58.2%, p < 0.001) than medial (37.1%, 45.2%), combined (32.4%, 36.6%) repair. CONCLUSION:ACLR with concomitant meniscal repair showed higher rates of subsequent meniscal procedures and worse PROMs than isolated ACLR or concomitant meniscal resection, predominantly driven by failed repairs. Successful repairs achieved PROMs comparable to isolated ACLR. These findings support meniscal preservation, while emphasising the need to improve repair success. LEVEL OF EVIDENCE:Level III.

PURPOSE:To evaluate failure rates across specific meniscal tear morphologies in patients undergoing all-inside meniscal repair with anterior cruciate ligament reconstruction (ACLR), and to identify factors associated with failure. METHODS:This retrospective cohort included 1355 patients who underwent all-inside meniscal repair during ACLR between 2015 and 2022 at Capio Artro Clinic, Stockholm, Sweden. Failure was defined as reoperation within 3 years. Tear morphology, meniscal laterality, age and sex were recorded. Kaplan-Meier (KM) analysis assessed survival, and Cox regression identified factors associated with failure. RESULTS:The 3-year failure rate was 12.3%. Medial repairs failed significantly more than lateral repairs (17.7% vs. 5.3%; p < 0.001) with lower medial survival on KM analysis (log rank p < 0.001). Bucket handle tears had the highest failure rate (18.6%), followed by undersurface (15.6%) and longitudinal tears (11.2%). Root (6.1%) and radial tears (RTs) (5.6%) had the lowest. In multivariable analysis, medial repair was the strongest predictor of failure (hazard ratio [HR] 3.08, 95% confidence interval [CI] 2.03-4.67, p < 0.001). Longitudinal tears had lower failure risk than bucket handle tears (HR 0.67, 95% CI 0.57-0.95, p = 0.03). Female sex increased failure risk (HR 1.38, 95% CI 1.02-1.88, p = 0.03), while age >30 years was not associated with failure. CONCLUSION:Meniscal repair performed during ACL reconstruction demonstrated a 12.3% failure rate at 3 years. Failure risk differed by tear morphology and meniscal side, with medial repairs and bucket‑handle tears showing the highest risk, while root and RTs showed the lowest. Female sex was independently associated with increased failure, whereas age was not. LEVEL OF EVIDENCE:Level III, retrospective cohort study.

Introduction: Total hip arthroplasty (THA) effectively alleviates pain and improves quality of life in patients with severe hip osteoarthritis (OA). However, there are limited comprehensive longitudinal data on physical function and objectively measured physical activity (PA) patterns after THA. The purpose of this study was to establish the test-retest reliability of physical fitness measures in patients with hip OA and to evaluate changes in physical fitness and activity over time following THA. METHODS:Seventy-eight OA patients (mean age 73.7 ± 4.2 years, 81% women) scheduled for THA underwent comprehensive physical fitness testing and accelerometry-based PA monitoring. Assessments were conducted at two preoperative time points and at 4-month (n = 57) and 1-year postoperative follow-up (n = 48). The test battery included measures of muscle strength, motor fitness, and cardiorespiratory fitness. PA was objectively measured using hip-worn triaxial accelerometers. Self-reported Hip Disability and Osteoarthritis Outcome Score (HOOS) were collected pre- and postoperatively. RESULTS:Good to excellent test-retest reliability was demonstrated across 23 of 24 fitness parameters. At 1-year post-op, significant improvements were observed in 23 of 45 measured parameters, including functional mobility (timed up-and-go: -29%), walking distance (Six-Minute Walk Test: +16%), trunk endurance-strength (+71 to 82%), shoulder press (+32%), various leg strength tests (+13 to 42%), 4-m max walking speed (+42%), moderate-to-vigorous physical activity (+63%) and daily step count from 6,004 to 7,558 steps/day (+26%). Ipsilateral-to-contralateral step height asymmetry decreased from 27% preoperatively to 8% at 1-year follow-up. VO2peak demonstrated a modest but significant improvement from 22.7 to 23.6 mL/kg/min (+4%) 1 year postoperatively. CONCLUSION:This study revealed low fitness and activity levels in patients with severe hip OA before surgery, with marked improvements in physical fitness and activity measurements 1 year after surgery. The high reliability of the comprehensive assessment battery supports its usefulness for both research and clinical practice. These findings contribute to the existing evidence on simple, field-based fitness tests for patients with hip OA, while also offering methodological insights and recovery trajectories. .

OBJECTIVES:The aim of this study was to evaluate patient-reported outcomes, knee stability, and reoperation rates after repair of posterior medial meniscus root tears (PMMRTs) performed concomitantly with anterior cruciate ligament reconstruction (ACLR) in a nondegenerative patient population. METHODS:This retrospective cohort study included patients who underwent arthroscopic PMMRT repair in conjunction with ACLR between 2015 and 2022, at a high-volume tertiary referral center for orthopedic sports medicine. Patients with prior meniscal surgery or radiographic or arthroscopic signs of degenerative joint disease were excluded. Patient-reported outcomes were assessed using the Knee injury and Osteoarthritis Outcome Score (KOOS) at 2-year follow-up. Patient acceptable symptom state (PASS) and treatment failure (TF) thresholds were applied. Objective outcomes included range of motion, anterior knee laxity, and isokinetic strength at 6 months. Reoperations during follow-up were recorded. RESULTS:Twenty-three patients were included, of whom 17 (73.9%) had available KOOS data at 2 years. Six-month clinical assessment data were available for 20 of 23 patients (87.0%). Mean KOOS values were 84.1 for Pain, 76.1 for Symptoms, 90.4 for Activities of Daily Living, 60.4 for Sport and Recreation, and 68.9 for Quality of Life. Overall, 70.6% of patients achieved PASS, while 11.7% met criteria for TF. Anterior knee laxity improved postoperatively, with no patients demonstrating a side-to-side difference greater than 5 mm at 6 months. Extension deficits greater than 5° were observed in 20% of patients. During follow-up, 43.5% of patients underwent additional surgical procedures, most commonly for arthrofibrosis-related conditions. No anterior cruciate ligament revisions or clinically detected re-ruptures of the repaired meniscal root were identified. CONCLUSION:In this cohort of patients with nondegenerative knees undergoing concomitant PMMRT repair and ACLR, acceptable patient-reported outcomes, satisfactory knee stability, and no clinically detected root failures were observed. Reoperations were common and primarily related to ACLR rather than meniscal failure. Due to the absence of a control group, the specific contribution of PMMRT repair to these outcomes cannot be determined. LEVEL OF EVIDENCE:IV.

PURPOSE:To compare subjective knee function and revision rates at the 5-year follow-up in young females (14-25 years) undergoing primary anterior cruciate ligament reconstruction (ACLR) with either hamstring tendon (HT) or bone-patellar tendon-bone (BPTB) autografts in a nationwide registry-based cohort. METHODS:Data were extracted from the Swedish knee ligament registry (SKLR). Female patients aged 14-25 years who underwent primary ACLR using either HT or BPTB autografts between 2005 and 2018 were identified. Patient-reported knee function was assessed using the Knee injury and Osteoarthritis Outcome Score (KOOS) and the average score for four of the five KOOS subscales (KOOS4), including Pain, Symptoms, Sport & Recreation, and Quality of Life (QoL). Patient acceptable symptom state (PASS) and treatment failure (TF) were calculated for the KOOS4. Patients who underwent revision ACLR within 5 years of primary surgery were identified through the SKLR. An analysis of covariance (ANCOVA) was used to compare preoperative and post-operative KOOS subscale scores between the graft groups, whereas a Cox regression analysis was performed to compare the 5-year hazard of revision ACLR. RESULTS:A total of 9923 patients were included, of whom 9472 (95.5%) received an HT graft and 451 (4.5%) a BPTB graft. The HT group scored significantly higher than the BPTB group in the Sport & Recreation subscale at the 1-year (65.7 ± 25.8 vs. 57.6 ± 24.6; p < 0.001), 2-year (63.9 ± 26.8 vs. 59.1 ± 25.5; p = 0.004) and 5-year follow-up (65.3 ± 27.5 vs. 60.6 ± 25.7; p = 0.015), with no significant differences in the other KOOS subscales. KOOS4 scores were higher in the HT group at 1-year (71.0 ± 18.2 vs. 68.3 ± 17.4; p = 0.015), but no between-group differences were observed at 2- or 5-year follow-up. The proportion of patients achieving a PASS on KOOS4 at 1-year was significantly higher in the HT group compared with the BPTB group (39.5% vs. 33.0%; p = 0.028); however, no differences were observed at the 2- or 5-year follow-up. No differences were observed between the groups in TF outcomes at 1-, 2- or 5-year follow-up. The 5-year revision rates were 7.0% for HT and 7.5% for BPTB groups, with no significant difference in the hazard of revision ACLR between the groups (hazard ratio = 1.05, 95% confidence interval = 0.75-1.49; p = n.s.). CONCLUSION:Similar 5-year revision rates were observed between HT and BPTB autografts in young females. HT autografts were associated with higher subjective knee function scores than BPTB autografts, although the clinical relevance of this difference is uncertain. LEVEL OF EVIDENCE:Level III.

PURPOSE:To determine the incidence of second anterior cruciate ligament (ACL) injuries in football players after index ACL reconstruction (ACLR). Secondary objectives were to assess second ACL injury rates across subgroups (laterality, sex, age, playing level, graft type, return to play [RTP] and follow-up duration) and to review factors associated with reinjury. METHODS:A systematic review and meta-analysis were conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, EMBASE and the Cochrane Library were searched from inception to 10 December 2025. Studies reporting second ACL injuries or subsequent ACLRs in football players were included. Incidence was defined as the proportion of players sustaining a subsequent ACL injury or ACLR relative to those undergoing index ACLR. RTP was defined as participation in at least one official match. Key limitations include substantial heterogeneity across studies, the inclusion of mixed data sources and the operational definition of second ACL injury, combining ACL injuries (graft rupture or contralateral tear) or, when not reported, subsequent ACLRs. RESULTS:Thirty-four studies (16,905 players; 50.5% male) were included. The pooled incidence of second ACL injury was 21.6% (95% confidence interval [CI] 17.9%-25.9%). Contralateral (10.6%, 95% CI 8.0%-13.9%) and ipsilateral injuries (10.4%, 95% CI 8.4%-12.9%) were of similar magnitude. Higher pooled incidence was observed in female (23.5%, 95% CI 18.0%-30.1%) compared with male players (14.5%, 95% CI 14.5%-23.4%), with 30% increased odds (odds ratio [OR] 1.3, 95% CI 1.1%-1.7%, p < 0.01). Among professionals, incidence was 19.2% (95% CI 15.1%-24.2%). No significant differences were found between hamstring tendon and bone-patellar tendon-bone (BPTB) autografts. The highest rates were observed in players <21 years (31.9%, 95% CI 23.6%-41.6%) and in cohorts with high RTP rates (29.2%, 95% CI 24.7%-34.1%). CONCLUSION:Second ACL injuries are common in football, affecting roughly between one in three to one in five players after ACLR. Higher rates of second ACL injury were observed in female players, younger individuals, those who returned to play, and in studies with longer follow-up duration. Contralateral ACL injuries had a similar magnitude to ipsilateral injuries. No significant differences in ipsilateral ACL reinjury rates were found between hamstrings tendon and BPTB autografts. LEVEL OF EVIDENCE:Level IV, systematic review and meta-analysis.

OBJECTIVE: The aim was to (1) describe structural changes of the anterior cruciate ligament (ACL), evaluated by magnetic resonance imaging (MRI), within 6 weeks until 24 months after ACL injury, and (2) investigate the relationship between ACL structural continuity and patient-reported and clinically assessed outcomes. DESIGN: Longitudinal pragmatic cohort study. METHODS: We included 129 patients, aged 15 to 40 years, with acute ACL injury from the NACOX (natural corollaries and recovery after an acute ACL injury) cohort. Patients were treated according to usual clinical practice, which comprised supervised rehabilitation before considering ACL reconstruction. At baseline and at 3, 6, 12, and 24 months follow-up, 3-Tesla 3-dimensional proton-density fat-saturated MRI scans, and patient-reported and objectively measured outcomes were assessed. The ACL Continuity, Thickness, and Shape (ACTS) scoring system was used for MRI assessment. RESULTS: At 24 months, 60 (47%) participants had received ACL reconstruction. At the last available MRI, 55 (48%) patients had overall ACL structure in continuity and 49 (43%) had ACL fibers in continuity. The overall ACL structure and fiber continuity on ACTS improved by at least 1 step in 31% to 81% of the patients at the different follow-ups. Ligament structure in continuity was associated with fewer giving-way episodes (11% versus 50%, P = .033) and reduced knee laxity at 12 months (side-to-side difference ≥ 3 mm: 53% versus 88%, P = .026) and 24 months (52% versus 100%, P = .013). Results for patient-reported outcomes were inconclusive due to wide confidence intervals. CONCLUSION: The ACL structure improved during the first 24 months after ACL injury when managed without ACL reconstruction. Continuity of ligament structure was associated with fewer giving-way episodes and lower knee laxity. J Orthop Sports Phys Ther 2026;56(3):209-219. Epub 4 February 2026. doi:10.2519/jospt.2026.13397

PURPOSE:To assess the prevalence of, and factors associated with, meniscal ramp lesions in patients with anterior cruciate ligament (ACL) tears. METHODS:All patients who underwent primary ACL reconstruction (ACLR) during 2018 were evaluated. Preoperative magnetic resonance imaging (MRI) scans and surgical reports were reviewed searching for the presence of meniscal ramp lesions. The Greif classification was applied to MRI-detected lesions. Univariable and multivariable logistic regression analyses, and a backward logistic regression analysis, were used to evaluate the associations between patient characteristics and concomitant knee injuries and the presence of meniscal ramp lesions on MRI and at ACLR, respectively. RESULTS:Of the 579 patients included in this study (51.0% men; mean age 28.4 ± 11.4), 250 (43.2%) meniscal ramp lesions were diagnosed on MRI, and 57 (9.8%) were diagnosed at ACLR. None of the 25 MRI-detected Greif´s type 1 and 2 meniscal ramp lesions were confirmed intraoperatively. Posteromedial tibial bone bruising increased likelihood of having meniscal ramp lesions on MRI (odds radio 4.04, 95% confidence intervals 2.85-5.76; P < .001) and at ACLR (odds radio 2.29, 95% confidence intervals 1.29-4.19; P < .01). CONCLUSIONS:Meniscal ramp lesions were frequently detected on MRI in patients undergoing ACL reconstruction, although less commonly observed at the time of surgery. MRI-detected stable meniscal ramp lesions according to the Greif classification (type 1 and 2) showed poor surgical correlation, with no lesions identified at subsequent arthroscopy. Posteromedial tibial bone bruising on MRI was associated with the presence of meniscal ramp lesions both on MRI and at surgery. LEVEL OF EVIDENCE:Level III, retrospective cohort study.

IMPORTANCE:The second anterior cruciate ligament (ACL) injury after ACL reconstruction is a well-known complication. Several studies have suggested that the risk of contralateral ACL injury is comparable to that of graft re-rupture. However, this comparison is not well established in previous reviews for studies with minimum five-year follow-up and mean ten-year outcomes. OBJECTIVE:This systematic review and meta-analysis aimed to evaluate the ten-year risk of graft re-rupture and contralateral ACL injury after primary ACL reconstruction and to assess the influence of graft type, return-to-sport, and other factors on second ACL injuries. EVIDENCE REVIEW:A systematic search was conducted across the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed, EMBASE, and Cochrane from 2000 to 2025. The literature search strategy included the following keywords: "anterior cruciate ligament reconstruction," "ACL reconstruction," "graft rupture," "graft failure," "contralateral anterior cruciate ligament injury," and "contralateral ACL injury." All studies that compare the risk of re-rupture and contralateral ACL injuries after ACL reconstruction and with a follow-up of at least five years after ACL reconstruction were included. Exclusion criteria included case reports, reviews, studies using allografts or artificial ligaments, and multi-ligament injuries. FINDINGS:A total of 18 studies were included in this meta-analysis with 5,735 participants. The pooled rates of graft rupture and contralateral injuries were 11 % and 12 %, respectively, with no statistically significant difference (p = 0.421). The ipsilateral graft-rupture rate was higher in patients with hamstring tendon (HT) autografts compared with bone-patellar tendon-bone (BPTB) autografts, at 13.0 % and 7.74 %, respectively (odds ratio [OR] = 1.75, 95 % confidence interval [CI]: 1.33-2.31; p = 0.004). Younger age (<18 years) was identified as the most substantial risk factor, with patients under 18 years showing nearly a threefold increased risk of graft rupture (OR 2.22, 95 % CI: 1.16-4.23, p = 0.016). Age <18 years also conferred increased risk for contralateral injury (OR 1.87, 95 % CI: 1.32-2.65, p = 0.001). Return to sport (RTS) was achieved by 51 %-73 % of patients in the included studies. However, delaying RTSs did not result in a statistically significant reduction in the risk of reinjury. CONCLUSION AND RELEVANCE:Contralateral anterior cruciate ligament injuries and graft re-ruptures occurred at similar rates (12 % and 11 %, respectively, p = 0.421), which suggests that risk of second injury is similar between ipsilateral graft failure and contralateral anterior cruciate ligament injury. Therefore, second ACL injuries remain a crucial concern over extended follow-up periods (mean: 10.3 years), driven primarily by younger age, hamstring graft use, and participation in high-demand sports. LEVEL OF EVIDENCE:Level III.

PURPOSE:To determine the failure rate and identify factors associated with failure following all-inside revision meniscal repair in patients with persistent or recurrent symptoms after primary meniscal repair. METHODS:This was a retrospective cohort study including 108 consecutive patients who underwent arthroscopic all‑inside revision meniscal repair between 2015 and 2022 at Capio Artro Clinic, Stockholm, Sweden. Evaluated factors included demographic variables (age, sex), surgical variables (concomitant anterior cruciate ligament reconstruction [ACLR]) and tear-specific characteristics (tear morphology and meniscal laterality). Failure was defined as repeat surgery for the index tear. Patients were followed for up to 3 years. Survivorship was assessed using Kaplan-Meier analysis, and factors associated with failure were evaluated using multivariable Cox regression. RESULTS:Failure occurred in 54 of 108 repairs (50.0%) at a mean of 18.3 ± 16.0 months. In unadjusted analyses, tear morphology was associated with failure (p = 0.026), with radial and horizontal tears showing the highest failure proportions and longitudinal tears the lowest. In the adjusted Cox model, female sex (hazard ratio [HR] 2.60, 95% confidence interval [CI] 1.36-4.95; p = 0.004) and absence of concomitant ACLR (HR 3.63, 95% CI 1.67-7.90; p = 0.001) were independently associated with failure. Age, meniscal laterality and tear morphology were not associated with adjusted survivorship. CONCLUSION:All-inside revision meniscal repair demonstrated a high failure rate of 50% at mid-term follow-up. Female sex and absence of concomitant ACLR were independently associated with an increased risk of failure. These findings highlight the importance of patient- and procedure-specific factors when considering revision meniscal repair as a tissue-preserving option. LEVEL OF EVIDENCE:Level III.

BACKGROUND:Quadriceps tendon (QT) autografts are increasingly used worldwide in anterior cruciate ligament (ACL) reconstruction (ACLR). However, comparative outcome studies across graft types, particularly by sex, remain limited. PURPOSE:To compare patient-reported outcomes (PROs) and revision rates after primary ACLR with QT autografts in relation to patellar tendon (PT) and hamstring tendon (HT) autografts, stratified by sex. STUDY DESIGN:Cohort study; Level of evidence, 3. METHODS:Patients who underwent primary ACLR (2008-2022) were identified in the Swedish Knee Ligament Registry. The primary outcome was 2-year patient-reported knee function, assessed using the Knee injury and Osteoarthritis Outcome Score (KOOS). Clinical relevance was evaluated using the KOOS4 (mean of KOOS Pain, Symptoms, Sports/Recreation, and Quality of Life subscales), with thresholds for minimal important change (MIC, ≥9), patient acceptable symptom state (PASS, ≥79), and treatment failure (TF, ≤42). Adjusted logistic regression analyses assessed factors associated with MIC, PASS, and TF. The secondary outcome was 2-year revision ACLR, reported as rates and analyzed using Cox regression to estimate hazard ratios. RESULTS:A total of 18,920 patients (44%) had 2-year KOOS data available. Women receiving QT grafts had a lower proportion of MICs achieved than those with HT grafts (61% vs 71%; P = .027). Among men, PASS was more frequently achieved with QT (51%) and HT grafts (48%) than with PT grafts (40%) (both P≤ .030). In the regression analyses, women with HT grafts had higher odds of achieving MIC (odds ratio [OR], 1.69 [95% CI, 1.19-2.42]; P = .004) and PASS (OR, 1.81 [95% CI, 1.28-2.58]; P < .001), and lower odds of TF (OR, 0.53 [95% CI, 0.31-0.88]; P = .015) compared with QT grafts. Additionally, no significant differences were observed between QT and PT grafts in women or among graft types in men.Of 44,513 patients, 1019 (2.3%) underwent revision ACLR within 2 years: QT graft, 2.2% (28/1274); PT graft, 2.5% (50/2019); and HT graft, 2.3% (941/41,220) (P = .830). QT revision rates were 2.7% in women and 1.8% in men (P = .288). Graft type was not associated with revision hazard in adjusted Cox regression. CONCLUSION:QT autografts were associated with lower PROs compared with HT autografts in women, whereas no such differences were observed when compared with PT autografts or among men. Revision rates were similar across graft types, both overall and by sex.

BACKGROUND:Anterior cruciate ligament reconstruction (ACLR) rates are rising, and quadriceps tendon (QT) autografts have gained popularity in recent years. Although QT autografts show objective and subjective outcomes comparable to hamstring tendon (HT) and bone-patellar tendon-bone (BPTB) autografts, nonrevision reoperations across graft types and their impact on patient-reported outcome measure (PROM) scores remain poorly studied. PURPOSE:To compare nonrevision reoperation rates and PROM scores between primary ACLR using HT, BPTB, and QT autografts at 2 years' follow-up. STUDY DESIGN:Cohort study; Level of evidence, 3. METHODS:In this retrospective cohort study, 5653 primary ACLR procedures (2015-2022) were categorized by autograft type. Reoperations for extension deficit or pain, meniscal injuries, or cartilage injuries within 2 years were identified through medical records. Revision ACLR and graft failure were not included. Patient-reported outcomes were assessed preoperatively and at 2 years postoperatively using the Knee Injury and Osteoarthritis Outcome Score (KOOS). The minimal important change, patient acceptable symptom state, and treatment failure were evaluated using the KOOS4. Subgroup analysis examined associations between graft diameter, sex, and reoperations for extension deficit or pain. RESULTS:The QT group had a higher overall reoperation rate (19.2%) than the HT (8.9%) and BPTB (6.9%) groups (P < .001), driven by extension deficit or pain (11.9% vs 5.5% and 4.7%, respectively; P < .001). QT grafts remained independently associated with reoperations for extension deficit or pain after adjusting for confounders (odds ratio [OR], 1.96 [95% confidence interval (CI), 1.44-2.67]; P < .001). The QT group demonstrated lower odds of achieving the minimal important change than the HT (OR, 0.56 [95% CI, 0.41-0.77]; P < .001) and BPTB (OR, 0.48 [95% CI, 0.32-0.72]; P < .001) groups. The QT and BPTB groups showed higher odds of experiencing treatment failure (OR, 1.98 [95% CI, 1.21-3.23]; P = .01 and OR, 2.00 [95% CI, 1.10-3.63]; P = .02) and lower odds of achieving the patient acceptable symptom state (OR, 0.65 [95% CI, 0.49-0.85]; P = .002 and OR, 0.57 [95% CI, 0.41-0.79]; P < .001) than the HT group. On sex-stratified analysis, female patients demonstrated higher reoperation rates for extension deficit or pain than male patients (7.3% vs 5.5%, respectively; P = .01), and female patients receiving larger grafts (9.5-12.0 mm) demonstrated 72% higher odds of having this outcome (OR, 1.72 [95% CI, 1.14-2.56]; P = .01). CONCLUSION:QT autografts were associated with significantly higher reoperation rates for extension deficit or pain and inferior PROM scores compared with HT autografts at 2 years after primary ACLR.

PURPOSE:To evaluate surgical trends over time in meniscal procedures during anterior cruciate ligament reconstruction (ACLR) and compare meniscal reoperation rates and subjective outcomes between 2015-2019 and 2020-2023. METHODS:This study included 2748 knees undergoing primary ACLR with concomitant meniscal procedures at Capio Artro Clinic, Stockholm, Sweden, stratified by time period (2015-2019 vs. 2020-2023). Meniscal reoperations within two years were identified through medical records, Knee injury and Osteoarthritis Outcome Score (KOOS) was collected preoperatively and at two years for patients undergoing meniscal repair. Minimal important change (MIC), patient-acceptable symptom state (PASS) and treatment failure (TF) were assessed through KOOS4. Subgroup analysis compared reoperation rates following medial, lateral and combined medial and lateral meniscal procedures. RESULTS:The proportion of meniscal repairs increased (18.0%-30.2%, p < 0.001), whereas meniscal resections decreased (21.1%-15.1%, both p < 0.001) from 2015-2019 to 2020-2023. Meniscal reoperation rates did not differ significantly between cohorts for repairs (9.0% vs. 11.4%, p = not significant (n.s.)) or resections (5.0% vs. 3.9%, p = n.s.). Combined medial and lateral meniscal procedures had significantly higher meniscal reoperation rates overall (11.7%) compared to medial (6.5%) and lateral (7.8%) meniscal procedures (p < 0.001). Lateral meniscal resections resulted in significantly more reoperations (2.8%) compared to medial (1.4%) and combined (1.5%) meniscal resections (p = 0.04) within the full cohort. There were no significant differences between cohorts in MIC, PASS, or TF. Multivariable analysis showed lower odds of reoperation in 2020-2023 compared to 2015-2019 (odds ratio [OR] = 0.39; 95% confidence interval [CI] 0.26-0.60; p < 0.001). CONCLUSION:Meniscal repair rates during ACLR increased significantly over time, while short-term reoperation rates and patient-reported outcomes remained unchanged. These findings align with the increasing emphasis on meniscal preservation in clinical practice. LEVEL OF EVIDENCE:Level III.

PurposeTo investigate whether changing medical equipment suppliers in anterior cruciate ligament reconstruction (ACLR) influences surgical time, revision rates and subjective outcomes.MethodsA retrospective cohort study was conducted using data from the Swedish Knee Ligament Registry (SKLR). On 1 September 2016, Capio Artro Clinic, Stockholm, Sweden, changed its supplier for all medical equipment, from Smith & Nephew (SN) to Arthrex (AR). Patients who underwent primary ACLR during the preceding year (from 1 September 2015) formed group SN and were compared with patients operated between 1 September 2016 and 1 September 2017, divided into three consecutive 4-month cohorts (AR1-3) for temporal comparison. Primary outcome was surgical time. Secondary outcomes were revision rates at 2 and 5 years, and the aggregate Knee injury and Osteoarthritis Outcome Score (KOOS4) at 2 years using thresholds for minimal important change (MIC), Patient Acceptable Symptom State (PASS), treatment failure (TF) and perioperative complications.ResultsA total of 1175 patients underwent a primary ACLR during the study period. Group SN included 521 patients, and Groups AR1-3, 654. Of the 521 patients in Group SN, 488 (93.7%) had surgical time recorded, with a median of 61 (interquartile range [IQR]: 50-73) min. In Groups AR1-3, 560 patients (85.6%) had surgical time recorded, with median times of 63 (IQR: 52-78), 60 (IQR: 50-70) and 60 (IQR: 50-70) min, respectively, showing no significant differences. Of the included patients, 573 (48.8%) completed KOOS at the 2-year follow-up, with no significant differences between groups regarding MIC, PASS or TF. Within 2 years, 31 patients (2.6%) underwent revision ACLR, and after 5 years, an additional 21 patients, totalling 52 (4.4%), with no significant group differences.ConclusionExperienced ACL surgeons can transition between suppliers with acceptable outcomes, comparable surgical times and low complication rates.Level of EvidenceLevel III.

PURPOSE:To investigate the failure rate, predictive factors associated with failure and clinical outcomes after a two-stage surgery; meniscus repair followed by subsequent anterior cruciate ligament (ACL) reconstruction (ACLR). METHODS:Patients with a concomitant traumatic meniscus tear and ACL injury who underwent a two-stage surgery between January 2015 and January 2021 were identified. The primary outcome was meniscal repair failure, defined as a reoperation (re-repair or resection). A Cox-regression analysis was used in order to analyse factors associated with meniscal repair failure within 3 years after the primary surgery for a meniscal repair. Secondary outcomes were range of motion (ROM), anterior knee laxity and the Knee Injury and Osteoarthritis Outcome Score (KOOS) at 1- and 2-year follow-up. The thresholds of patient acceptable symptom state (PASS), treatment failure (TF) and minimum important change (MIC) were applied to KOOS4 (mean score of the KOOS Pain, Symptoms, Sports/Rec and QoL subscales). RESULTS:A total of 150 patients were included. The meniscal repair failure rate after 3 years was 36.7%. Failure of meniscal repair was significantly associated with a time interval >1 year between the meniscal repair to the ACLR (hazard ratio [HR] = 2.5; 95% confidence interval [CI] = 1.2-5.5; p < 0.01), medial meniscus repair (HR = 2.3; 95% CI = 1.6-3.4; P < 0.01), and female sex (HR = 1.42; 95% CI = 1.0-1.9; p = 0.01). The age of the patient was not associated with meniscal repair failure. At the 6-month follow-up, most patients (72.5%) showed less than 2 mm of knee laxity; four patients (6.7%) experienced loss of extension and four patients (1.7%) experienced loss of flexion. On the KOOS4, at the 2-year follow-up, PASS was achieved in 53.4%, TF occurred in 1.7%, and MIC was reached in 36.4% of patients. CONCLUSION:The meniscus repair failure rate after the staged procedure was 36.7% at 3 years. A longer time interval from meniscal repair to ACLR, medial meniscus repair, and female sex were associated with an increased risk of meniscal repair failure. Age was not associated with meniscal repair failure. LEVEL OF EVIDENCE:Level IV, case series retrospective study.

PURPOSE:To determine the proportion of patients and the factors associated with the achievement of a patient-acceptable symptom state (PASS) 5 years after primary anterior cruciate ligament reconstruction (ACLR). METHODS:Patients who underwent primary ACLR between 2005 and 2018 at Capio Artro Clinic, Stockholm, Sweden, were eligible for inclusion. The primary outcome was the achievement of a PASS on each Knee injury and Osteoarthritis Outcome Score (KOOS) subscale at the 5-year follow-up. Multivariable logistic regression analyses were used to assess associations with age, sex, time from injury to surgery, pre-injury Tegner activity level, graft type, cartilage injury, meniscal resection or repair, and symmetrical 6-month limb symmetry index (LSI ≥ 90%) in isokinetic extension and flexion strength and single-leg-hop performance. RESULTS:A total of 2663 patients were analysed. The proportion of patients achieving a PASS varied between the KOOS subscales as follows: Pain 64.8%; Symptoms 93.8%; Activities of Daily Living (ADL) 49.1%; Sport and Recreation (Sport&Rec) 65.4% and Quality of Life (QoL) 73.5%. Age ≥30 years was positively associated with PASS across all subscales. Female sex reduced the odds of achieving a PASS on the Pain (OR 0.80; 95% confidence interval [CI] 0.65-0.99; p = 0.04), Symptoms (OR 0.57; 95% CI 0.36-0.90; p = 0.02) and Sport&Rec (OR 0.73; CI 95% 0.59-0.90; p = 0.004) subscales. A surgical delay of ≥3 months was negatively associated with the achievement of a PASS on the QoL (OR 0.71; 95% CI 0.51-0.99; p = 0.04) subscale. Medial meniscus (MM) repair reduced the odds of achieving a PASS on the Sport&Rec (OR 0.61; 95% CI 0.41-0.92; p = 0.02) and QoL (OR 0.56; 95% CI 0.37-0.86; p = 0.01) subscales. Hamstring tendon (HT) autograft rather than bone-patellar-tendon-bone autograft had increased odds of achieving a PASS on the Sport&Rec (OR 2.13; 95% CI 1.31-3.47; p = 0.002) subscale. Achieving a LSI ≥ 90% in isokinetic extension strength was associated with a PASS on ADL (OR 1.01; 95% CI 1.00-1.02; p = 0.02) and QoL (OR 1.01; 95% CI 1.00-1.02; p = 0.02) subscales, whereas an LSI ≥ 90% in single-leg-hop test was associated with a PASS on the Symptoms (OR 1.03; 95% CI 1.01-1.05; p < 0.001), ADL (OR 1.01; 95% CI 1.00-1.02; p = 0.02), Sport&Rec (OR 1.01; 95% CI 1.01-1.02; p = .003), and QoL (OR 1.01; 95% CI 1.00-1.02; p = 0.01) subscales. CONCLUSION:The achievement of a PASS was over 64% on at least four out of five KOOS subscales 5 years after ACLR. Older age (≥ 30 years) was consistently associated with higher odds of achieving a PASS, while female sex was associated with lower odds. MM repair was associated with reduced odds of achieving a PASS on the Sport&Rec subscale, whereas the use of HT grafts was associated with higher odds on the same subscale. Symmetrical isokinetic extension strength and single-leg-hop test performance at 6 months were associated with higher odds of achieving a PASS; however, the effect sizes were small, suggesting limited clinical relevance. LEVEL OF EVIDENCE:Level III.

The role the posterolateral corner (PLC) plays in controlling varus and posterolateral rotatory laxity is crucial, especially in the setting of combined cruciate ligament injuries. PLC reconstruction is essential to restore knee laxity, helping to reduce the risk of cruciate ligament graft failure. The LaPrade technique is the most used anatomic PLC reconstruction technique; however, it requires 2 tendon grafts. Advancements in techniques, including the use of adjustable-loop suspensory fixation devices and internal brace, have been introduced in recent years. The purpose of this Technical Note is to describe a single-tendon anatomic PLC reconstruction technique with adjustable-loop femoral fixation and internal brace. The advantages of this technique are the need for only 1 tendon for anatomic PLC reconstruction, the possibility of graft retensioning through the adjustable-loop femoral fixation until satisfactory stability is achieved, and graft protection offered by the internal brace during the healing period.