Background: The optimal graft choice for anterior cruciate ligament reconstruction (ACLR) remains a subject of ongoing debate. In practice, graft selection in ACLR is multifactorial, with patient characteristics, activity level, and surgeon preference/training background all playing a crucial role in the clinical decision-making process. While graft trends have been reported across select professional sports leagues, none have focused specifically on professional soccer. Purpose: To report current trends in graft preference for ACLR among Major League Soccer (MLS) surgeons. Study Design: Cross-sectional study. Methods: A 39-question survey was distributed to 27 orthopaedic surgeons affiliated with MLS teams in January 2025. The questionnaire captured each respondent's preferences regarding ACLR management in both the general population and high-level/professional soccer athletes. Descriptive statistics were used to summarize responses. Results: Surgeons averaged 7.7 years caring for MLS teams and performed a mean of 80 ± 27 ACLRs annually. In primary ACLR for professional soccer athletes, the bone-patellar tendon-bone (BPTB) autograft was preferred (74%), followed by the quadriceps tendon (QT) autograft (22.2%). The hamstring tendon (HT) autograft was uncommon (3.7%). Similar trends were reported for the general population: BPTB autograft (70%), QT autograft (22.2%), and HT autograft (3.7%). For revision procedures, QT autograft was favored (48.2%), followed by BPTB autograft (25.9%) and BPTB allograft (11.1%). Contralateral autografts were more common in revisions (44.4%) than in primary cases (7.4%). Lateral extra-articular augmentation (LEA) was performed in 31.5% of primary cases and 76% of revision cases; iliotibial band tenodesis was favored over anterolateral ligament reconstruction (74.1% vs 25.9%). LEA utilization increased compared with 5 years prior (6.4% vs 29.4%). Conclusion: Among orthopaedic surgeons caring for MLS athletes, BPTB autografts were the preferred graft for primary ACLR. QT autografts were preferred over HT autografts in primary ACLR, and QT autografts were most commonly used in revision surgery. HT autografts were rarely used in primary ACLR and were not preferred in revision scenarios. LEA procedures were widely used among professional soccer athletes.

Background:A critical component of conducting systematic reviews or meta-analyses is assessing the methodological quality and bias of included studies. Several methodological quality assessment tools have been developed; however, these tools may not be relevant to observational sports medicine research, which carries numerous unique nuances and biases. Purpose:To develop the Sport Publication Observational Research Tool (SPORT), which evaluates and scores the methodological quality of observational sports medicine research. Study Design:Consensus statement. Methods:SPORT was developed through a modified Delphi approach involving members from the Herodicus Society and The FORUM. All active members were invited to participate in the process aimed at building consensus on SPORT content and scoring. After finalizing SPORT, a power analysis led to the independent selection of 55 observational clinical sports medicine studies, which were scored twice by 4 reviewers of varying training levels. Interrater and intrarater reliability for SPORT was assessed using intraclass correlation coefficients (ICCs). The distribution and percentiles for total SPORT score across the 55 studies were calculated. SPORT was also compared with the methodological index for non-randomized studies (MINORS), a commonly utilized quality assessment tool. Results:A total of 51 members participated and achieved 100%, 100%, 98.0%, and 98.0% completion rates for rounds 1 through 4, respectively. The final SPORT included 19 subscores related to methodological quality and bias and achieved 94% consensus approval. Mean SPORT completion time was 6 minutes and 19 seconds per study, which varied significantly by reviewer training level. The subscore "peer review" demonstrated unacceptable reliability and was removed. The remaining 18 subscores exhibited ICC ranges of 0.599 to 0.955 for interrater reliability and 0.530 to 0.936 for intrarater reliability. Total SPORT score demonstrated excellent agreement, for interrater (ICC, 0.967) and intrarater reliability (ICC, 0.966). Median SPORT score across the 55 studies was 20.0 and skewed toward lower scores. There was a moderate significant correlation between SPORT and MINORS (r[53] = 0.575; P < .001). Conclusion:An objective tool to assess the methodologic quality of observational sports medicine research (SPORT) was successfully developed through a modified Delphi approach with numerous content experts in the field. This tool may be useful in assessing the methodological quality of primary observational sports medicine studies included in systematic reviews and meta-analyses.

Quadriceps tendon ruptures (QTR) lead to significant lower extremity weakness, gait abnormalities, and disability. Outcomes following surgical management of chronic QTR remain largely unknown. This study aimed to systematically review the management of chronic QTR to better understand the incidence, indications for repair versus reconstruction, complications, and outcomes. Studies published in PubMed, EMBASE, and the Cochrane Library reporting on patients with chronic QTR were identified. Inclusion criteria consisted of patients with chronic QTR (injuries ≥6 weeks) undergoing operative management, with reported injury mechanism, tear characteristics, surgical repair versus reconstruction, graft type (if used), postoperative complications, and outcomes. A total of 26 studies, consisting of 44 patients undergoing repair or reconstruction for chronic QTR, were identified. The mean patient age was 48.5 (range, 15-80) years, with 83% (n = 33/40) of patients being male. The mean interval between injury and surgery was 17.2 months (range, 6 weeks-303 months). Falls were the most frequently reported injury mechanism (59%, n = 16/27). Patient-related factors-primarily patient delay in seeking treatment-accounted for delayed management in 55% (n = 11/20) of patients. Tendon reconstruction using graft augmentation was performed in 46% (n = 20/44), most frequently with hamstring autograft (40%; n = 8/20). Quadriceps atrophy (n = 3) and superficial wound infection (n = 3) were the most commonly reported adverse outcomes, while no subsequent re-ruptures, revisions, or additional surgeries were reported. Postoperative active range of motion (ROM) was comparable in patients undergoing repair versus reconstruction (mean ROM = 0.0-124.4 degrees vs. 4.3-120.5 degrees, respectively). Chronic QTR was identified in 44 patients undergoing operative management, an average of 17.2 months following injury. The majority of patients were males, with a mean age of 48.5 years. Falls comprised the majority of injuries, while patient deferral in seeking treatment represented the most common reason for delay. Reconstruction was performed in 46% of cases, most commonly utilizing hamstring autograft. ROM was comparable irrespective of surgical management. Quadriceps atrophy and wound infection were the most commonly reported adverse outcomes, with no reported re-ruptures or revision procedures.

First responders, including firefighters, law enforcement, and emergency medical services, represent a unique patient population at high risk of knee injury. High rates of on-scene and training injuries are driven by dynamic and repetitive maneuvers often done under load. Excellent care of first responders starts with an understanding of the patient's occupational demands to provide the treatment and rehabilitation that optimizes their ability to return to high-level activity. By aligning treatment algorithms with real-world job demands and realistic return-to-duty timelines, orthopaedic surgeons can optimize functional outcomes and maintain the operational readiness of these essential public safety professionals. This review discusses the current literature pertaining to knee injuries in first responders.

Introduction: Femoroacetabular impingement (FAI) is the leading cause hip osteoarthritis (OA). PPARγ has been reported to have a protective effect on articular cartilage. Autophagy is important for maintaining cellular homeostasis. We have previously observed suppression of PPARγ expression and dysregulation of autophagy markers with progression of human hip OA. This study aims to investigate the effect of PPARγ on autophagy in articular cartilage in human tissue. Methods: Full-thickness articular cartilage explants were harvested from the femoral neck impingement zone in patients with hip FAI who underwent hip arthroscopy (n=7) for the treatment of hip cam-FAI (early-FAI) and patients with end stage of FAI disease (late-FAI-OA) who underwent total hip replacement (n=7). As a non-disease (ND) group, seven healthy samples were procured from fresh allografts. The cartilage explants were cultured in unstimulated condition or catabolic stimulus (IL1β) with or without PPARγ agonist (Rosiglitazone) or PPARγ inhibitor (T0070907). After 48 hours of culture, RNA was extracted and gene expression was analysed via qPCR for the following markers: GAPDH, LC3B, Beclin, and MMP-13. Safranin-O/ fast green staining was used for histological assessment (Mankin score). Comparisons among groups were performed using one-way analysis of variance followed by the post hoc Bonferroni correction test. Results: Cartilage tissue showed severe cartilage degeneration with an increased Mankin score significantly increased following catabolic stimulus with IL1β and treatment with PPARγ inhibitor Contrary, there was reduced catabolism when cartilage was treated with PPARγ agonist. Similarly, MMP13 significantly decreased after treatment with PPARγ agonist and increased after inflammatory stimulus with IL1β and treatment with PPARγ inhibitor in all three groups (ND, early-FAI and late-FAI-OA groups). Concomitant treatment with PPARγ agonist rescued the catabolic state (MMP13 expression) by IL1β stimulus, whereas concomitant treatment with PPARγ inhibitor promoted catabolism. The expression of autophagy-related markers (LC3B and Beclin) significacntly increased after treatment with PPARγ agonist and decreased after inflammatory stimulus with IL1β and treatment with PPARγ inhibitor in all three groups. The decreased expression of autophagy-related markers by IL1β stimulus increased after concomitant treatment with PPARγ agonist, suggesting a rescue of the cartilage from abnormal cartilage autophagy seen in cartilage disease. Conclusion: Cartilage catabolism is observed in hip OA progression. PPARγ agonist can rescue catabolic cells via promotion of autophagy. Further investigation will be needed to assess if regulation of this pathway could potentially slow down progression of hip OA in hip FAI disease.

Background:Anterior cruciate ligament (ACL) injuries are among the most debilitating injuries in professional soccer, often leading to extended recovery times and performance impacts. While much is known about ACL injury outcomes in European leagues, data specific to the Major League Soccer (MLS) remains limited. Purpose/Hypothesis:This study aimed to assess the return to play (RTP) times, RTP rates, and performance outcomes after ACL reconstruction in MLS athletes. It was hypothesized that RTP times would improve over the study period and that player performance would stabilize by the third post-injury season, consistent with findings from other professional soccer leagues. Study Design:Cohort study; Level of evidence, 3. Methods:The MLS Injury Surveillance database was queried for ACL injuries from 2010 to 2021. Player characteristics, injury characteristics, and performance metrics were collected for 132 players with ACL injuries and compared with 396 uninjured controls matched by age, position, and seasons played. The injured cohort was divided into 2 groups: 2010-2015 and 2016-2021 to compare changes in RTP times, performance outcomes, and trends over time. RTP was defined as participation in at least 1 MLS match after injury. Statistical analyses, including the chi-square and t tests, were performed to evaluate differences between the 2 time periods and matched controls, with significance set at P < .05. Results:RTP time decreased significantly from 269.6 days (2009-2015) to 219 days (2016-2021) (P = .044). Forwards experienced significant performance declines starting in the third post-injury year, with reductions in goals scored, minutes played, and offsides (P < .05). Midfielders showed improved performance in goals scored by the third post-injury year, while defenders exhibited recovery by the second year, with no significant long-term performance deficits. Conclusion:Our study demonstrated that while overall RTP times have improved, position-specific performance outcomes vary significantly, with forwards exhibiting long-term deficits compared with midfielders and defenders. These findings suggest that position-specific rehabilitation protocols may be beneficial for athlete education in RTP and for potential prevention strategies.

Background Femoroacetabular impingement is the leading cause of hip osteoarthritis (OA) and has been linked to 50% of total hip arthroplasty (THA) cases. Still, the mechanism by which the joint progresses to OA remains unknown. Previous studies indicate that peroxisome proliferator-activated receptor gamma (PPARγ) suppression occurred during hip OA progression. We have observed the hypermethylation of the CpG PPARγ promoter area through DNA methyltransferase 3A (DNMT3A), resulting in cartilage catabolism and hip OA. However, its precise mechanism remains unclear. We hypothesized that DNMT3A gain-of-function (GOF) leads to chondrocyte catabolism through PPARγ suppression, and DNMT3A loss-of-function (LOF) rescues the catabolism in OA chondrocytes. Methods Healthy chondrocytes were isolated from osteochondral allografts, and OA chondrocytes from patients undergoing THA secondary to femoroacetabular impingement disease. Chondrocytes were treated to evaluate the GOF and LOF effects of DNMT3A using lentiviral particles. Interleukin 1 beta (IL1β) was used to mimic the OA phenotype in healthy chondrocytes. Groups included a scramble control, DNMT3A GOF, IL1β+scramble control, IL1β+DNMT3A GOF, and IL1β+DNMT3A LOF for healthy chondrocytes, and scramble control, DNMT3A GOF, and DNMT3A LOF for OA chondrocytes. The DNMT3A, PPARγ, Col2, and MMP13 expression levels were analyzed, with significance set at P < 0.05. Results The IL1β treatment and DNMT3A GOF in healthy chondrocytes significantly increased DNMT3A and MMP13 while decreasing PPARγ and Col2 expression. The DNMT3A LOF in IL1β-treated chondrocytes increased PPARγ and Col2 and decreased MMP13 expression. In OA chondrocytes, DNMT3A GOF increased MMP13 expression while suppressing PPARγ and Col2, whereas DNMT3A LOF resulted in opposite effects, suggesting DNMT3A LOF treatment can alleviate catabolic changes. Conclusions The DNMT3A LOF treatment partly reversed chondrocyte degeneration and catabolism, positioning the modulation of DNMT3A as a potential therapeutic intervention in hip OA progression.

Acute Isolated Meniscal Pathology Evidence-Based Clinical Practice Guideline is based on a systematic review of published studies for the treatment of acute isolated meniscal pathology. This guideline contains three recommendations and six options to assist orthopaedic surgeons and all qualified physicians managing patients with acute meniscal pathology based on the best current available evidence. It is also intended to serve as an information resource for professional healthcare practitioners and developers of practice guidelines and recommendations. In addition to providing pragmatic practice recommendations, this guideline also highlights gaps in the literature and informs areas for future research and quality measure development.

Background: Medial meniscal repair performed at the time of primary anterior cruciate ligament reconstruction (ACLR) has been shown to be significantly associated with subsequent surgery, and subsequent surgery has been associated with increased Knee injury and Osteoarthritis Outcome Score (KOOS) pain score and decreased patient satisfaction. Hypothesis/Purpose: The purpose was to determine if medial meniscal repair decreases KOOS pain 10 years after ACLR and to assess the consequences of subsequent surgery on the development of KOOS pain. The authors hypothesized that medial meniscal repair performed at the time of primary ACLR decreases the likelihood of developing KOOS pain. It was further hypothesized that surgery performed subsequent to medial meniscal repair and primary ACLR increases KOOS pain 10 years after ACLR. Study Design: Cohort study; Level of evidence, 2. Methods: Our inclusion criteria were all patients undergoing unilateral primary ACLR from 2002 to 2008 who were enrolled in the Multicenter Orthopaedic Outcomes Network without a history of medial or lateral meniscal surgery and contralateral ACLR. Causal mediation analysis using R software (Version 4.2.3) was employed to compare 2 effects on the development of significant knee pain, as represented by a KOOS pain score <80, at 10-year follow-up: (1) medial meniscal repair for longitudinal tears >10 mm in medial-to-lateral length and (2) medial meniscal excision at baseline of ACLR. A directed acyclic graph was constructed to provide a qualitative representation of the influence of known confounders that have been shown to affect the outcome of interest. Missing data were multiply imputed using multivariate imputation by chained equations. All tests were 2-sided, assuming a type I error rate of .05. Results: In total, 2387 participants (1074 female [45%]; 1313 male [55%]) were included in the final analysis. In 1502 (62.9%) cases, there was no medial meniscal tear reported. Of the 885 cases with medial meniscal tears, no treatment was performed in 109 (12.4%), meniscal excision was performed in 396 (44.7%), and meniscal repair was performed in 380 (42.9%). An overall 1825 of 2387 (76.5%) patients reported KOOS pain at 10-year follow-up: 252 (13.8%) had KOOS pain <80 and 1573 had ≥80. In the KOOS pain <80 group, 75 (29.8%) had subsequent surgery. In the KOOS pain ≥80 group, 223 (14.2%) had subsequent surgery. The step-by-step approach to causal mediation analysis demonstrated that a medial meniscal procedure (ie, no treatment for the tear, repair, or excision) significantly affected the likelihood of subsequent surgery (χ 2 = 28.9; P < .001) and subsequent surgery significantly increased the likelihood of KOOS pain <80 (χ 2 = 17.3; P < .001). However, the direct effect of a successful medial meniscal repair without subsequent surgery decreased the likelihood of KOOS pain <80 by 7.1% when compared with medial meniscal excision (95% CI, –13.3% to −1%; P = .024). When subsequent surgery was performed after medial meniscal repair and ACLR, the likelihood of KOOS pain <80 increased by 2.9% (95% CI, 1.1%-5.3%; P < .001.) Conclusion: Successful medial meniscal repair performed at the time of primary ACLR decreased clinically significant knee pain 10 years postoperatively. However, the mediating effect of subsequent surgery was significant and diminished the overall contribution of medial meniscal repair in decreasing the likelihood of KOOS pain. Continued efforts should be made to decrease the likelihood of subsequent surgery after medial meniscal repair performed at the time of primary ACLR.

Background: Knee injuries resulting in purely cartilaginous defects are rare, and controversy remains regarding the reliability of chondral-only fixation. Purpose: To systematically review the literature for fixation methods and outcomes after primary fixation of chondral-only defects within the knee. Study Design: Systematic review; Level of evidence, 5. Methods: A literature search was conducted following the 2020 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using keywords and Boolean phrases in PubMed, Embase, Cochrane, and Scopus on October 10, 2023. Human studies reporting fixation methods and outcomes after primary fixation of chondral-only defects within the knee were included in this systematic review. Studies reporting subchondral bone involvement were excluded. Study quality was assessed using the Joanna Briggs Institute critical appraisal tool. Postoperative outcomes, reoperations, and return to sport/activity were evaluated. Failure was defined as chondral fragment dislodgement or failure of healing postoperatively. Results: A total of 18 studies (N = 93 patients) were identified. The mean patient age was 16 years (mean range, 11-32 years), with a mean final follow-up of 42.4 months (mean range, 5-61.2 months). Men comprised 81% (n = 59/73) of patients. Bioabsorbable implants (n = 13 studies) were the most commonly reported fixation method. Complications related to fixation of the chondral fragment occurred in 10.8% of patients (n = 10/93), with all other complications occurring in 9.8% (n = 9/93) of patients. Revision surgery directly associated with the chondral fragment was reported in 10.8% (n = 10/93) of patients. Successful return to sport/activity was observed in 90% (n = 60/67) of patients. Intact fixation was reported in 85% (n = 75/88) of patients undergoing postoperative magnetic resonance imaging, computed tomography, or second-look arthroscopy. Conclusion: Primary fixation of chondral-only defects can lead to low rates of failure and revision surgery with a high return to sport/activity in young patients, even with relatively large lesions. Bioabsorbable implants and absorbable sutures were the most common fixation methods, primarily performed via open arthrotomy after diagnostic arthroscopy. Failure of fixation and implant irritation were the most commonly reported complications related to fixation, with reoperations directly related to fragment fixation performed in 10.8% of patients. Healing of the chondral fragment as evaluated using postoperative magnetic resonance imaging, computed tomography, or second-look arthroscopy was reported in 85% of patients.

Background:Regional differences in primary anterior cruciate ligament (ACL) reconstruction (ACLR) remain largely unknown. Purpose:To systematically review the literature examining Level 1 and Level 2 studies to identify global differences in surgical techniques associated with primary ACLR. Study Design:Scoping review; Level of evidence, 1. Methods:A literature search was conducted following the 2020 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using keywords and Boolean phrases in Embase, Cochrane, and PubMed on October 25, 2024. A total of 741 articles were identified. The inclusion criteria were as follows: Level 1 and Level 2 human studies reporting on primary ACLR, with a minimum 2-year follow-up. Studies were categorized into 3 regions (Europe, Asia, and North America), and patient characteristics, surgical details, and graft failure/revision rates were compared between regions using parametric/nonparametric tests. Results:In the 141 studies (n = 11,048 patients) identified, the mean patient age of 28.9 years (range, 13-79 years) and the follow-up of 53.8 months (range, 24-252 months) did not differ by region. Hamstring tendon (HT) autograft use was associated with Asian studies, while bone-patellar tendon-bone (BPTB) and quadriceps tendon (QT) autograft use were associated with European and North American studies. Suspensory fixation was the most common femoral fixation method (n/N = 4605/10,403 patients; 44%), associated with use in Asian studies and with HT autografts, whereas bioabsorbable screws were the most common overall method of tibial fixation (n/N = 4470/10,235 patients; 44%). Graft failure (n/N = 399/8314; 4.8%) was reported less often in Asian than in North American studies. Revision surgery (n/N = 222/6065; 3.7%) was reported less often in Asian than European and North American studies. Conclusion:Our study demonstrated that European and North American studies were associated with BPTB and QT autografts, whereas studies from Asia were associated with HT autografts. Femoral suspensory fixation and tibial bioabsorbable screw were most commonly reported. Graft failure and revision rates were broadly similar between regions. These findings suggest potential cultural and training differences worldwide to improve patient treatment outcomes.

Purpose:To evaluate changes in limb symmetry index (LSI) in thigh circumference and single-leg hop for distance (SLHD) after anterior cruciate ligament reconstruction (ACLR) out to 18 months postoperatively and their association to changes in dynamic postural stability after ACLR out to 24 months. Methods:Patients were prospectively enroled after ACLR and followed up at 3-month intervals. Thigh circumference was measured preoperatively out to 18 months postoperatively, dynamic postural stability out to 24 months, and SLHD from 6 to 18 months following ACLR. LSI was calculated from the thigh circumference and SLHD measurements. Dynamic postural stability (DPS) was measured on a multidirectional platform that tracked the patient's centre of mass, creating a dynamic motion analysis (DMA) score that reflected ability to maintain their centre of mass. Results:A total of 47 patients with mean age of 19.1 ± 5.8 years completed the study. LSI in thigh circumference worsened initially and improved at longer follow-up. LSI in SLHD improved significantly at 9- and 12-months consecutively. Overall mean DMA scores improved significantly at 3- and 6-month postoperatively. No significant correlation between LSI and DMA scores was appreciated at any time point. Conclusions:LSI in thigh circumference decreases initially after ACLR and then improves, while LSI in SLHD and dynamic postural stability improved after ACLR. DPS improved primarily in translational planes of motion. No significant association between LSI in thigh circumference/SLHD and DPS was found at any follow-up point. Level of Evidence:Level IV, case series.

Background: Bone-patellar tendon-bone (BTB) and hamstring tendon (HT) autografts are the most commonly utilized grafts for primary anterior cruciate ligament reconstruction (ACLR). While previous studies have compared outcomes using BTB and HT grafts for ACLR at short- and mid-term follow-ups, outcomes at long-term follow-ups remain unclear. Purpose: To perform a systematic review and meta-analysis of randomized controlled trials (RCTs) evaluating BTB versus HT autografts for primary ACLR at a minimum 10-year follow-up. Study Design: Systematic review; Level of evidence, 2. Methods: A systematic review was performed in accordance with the 2020 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines by querying 5 databases from inception through May 2024 to identify level 1 and 2 RCTs evaluating outcomes of BTB versus HT autografts for primary ACLR at a minimum 10-year follow-up. A meta-analysis was performed using random-effects models with risk ratios (RRs) for discrete outcomes and mean differences (MDs) for continuous outcomes. Results: Six RCTs—consisting of 495 (BTB, n = 235; HT, n = 260) patients—were identified. The mean age at the follow-up was 41.3 ± 7.4 years, with men comprising 64% (n = 316/495) of patients. The mean final follow-up time was 14.6 ± 0.7 years (range, 10-17 years). No significant differences were observed in ACL graft rupture or revision rates (RR, 0.88; P = .70), contralateral ACL rupture rates (RR, 1.27; P = .46), Lysholm scores (MD, –1.27; P = .45), Tegner scores (MD, –0.01; P = .97), extension deficits (RR, 2.67; P = .23), or KT-1000 side-to-side differences (MD, –0.56; P = .10). There was a significantly greater risk of osteoarthritis (OA) progression in ACLR knees compared with the contralateral knee (RR, 3.64; P < .0001); however, there was no difference in OA progression between BTB and HT groups (RR, 1.01; P = .91). Conclusion: BTB and HT autografts for primary ACLR demonstrate similar outcomes and rates of OA progression at long-term follow-ups. Knees undergoing ACLR have a greater risk of OA progression compared with healthy contralateral knees.

Background:Concomitant anterior cruciate ligament (ACL) and medial collateral ligament (MCL) injuries are among the most commonly reported injury patterns in high-energy knee injuries. Concomitant ACL and MCL reconstruction (ACLR + MCLR) is indicated in patients with full-thickness tears and persistent valgus laxity. Purpose:To systematically review the literature to identify studies reporting on patients undergoing concurrent primary ACLR + MCLR to better understand current indications, surgical techniques, complications, and outcomes. Study Design:Systematic review; Level of evidence, 4. Methods:Under the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, 702 studies published in PubMed, EMBASE, and the Cochrane Library reporting on patients undergoing ACLR + MCLR from inception to April 2025 were initially identified. The inclusion criteria included studies reporting on human subjects undergoing ACLR + MCLR with injury mechanism, tear characteristics, surgical technique, graft types used for reconstruction, complications, and postoperative outcomes. Incidence rates for variables of interest were pooled as proportions with inverse variance weighting and displayed in forest plots, with heterogeneity of included studies assessed using the I 2 statistic. Results:Seventeen studies, including 902 patients undergoing concurrent ACLR + MCLR, with a mean follow-up of 30.6 months (range, 15-61 months), were identified. The weighted mean patient age was 32.9 years (range, 14-74 years), and 68.4% (n = 471/689) of patients were men. Sports-related traumatic knee injuries accounted for 51.3% (n = 309/602) of injuries, while motor vehicular accidents comprised 12.1% (n = 73/602). Reported indications for MCLR in the setting of ACL injury were chronic (≥6 weeks) valgus knee laxity despite nonoperative management (81.5%, n = 667/818) and grade 3 MCL injury (22.2%, n = 182/818). Autografts were utilized in 69.7% (n = 265/380) of ACLR and 61.1% (n = 140/262) of MCLR procedures, while anterior tibialis allografts (28.4%; n = 108/380) and hamstring tendon autografts (53.4%; n = 140/262) were the most frequently reported graft types in ACLR and MCLR, respectively. Complications were reported in 14 cases, including persistent medial knee pain (n = 7) and reconstruction failure (MCLR, n = 1; ACLR, n = 2). Mean Lysholm scores improved from 55.9 to 87.6, while mean Tegner and subjective International Knee Documentation Committee (IKDC) scores improved from 3.1 to 4.8 and 46.5 to 88.5, respectively. Conclusions:Our review revealed that concomitant ACLR + MCLR is most commonly performed for injuries sustained during pivoting sports, which result in persistent valgus laxity. Autografts were used in 70% of ACLR and 61% of MCLR procedures. Improvements in Lysholm, Tegner, and IKDC scores were noted in the majority of patients with a low incidence of complications (7.9%) and reconstruction failures (1.7%). These findings may enhance the understanding of proper surgical indications and methodology, thereby optimizing treatments and postoperative outcomes.

BACKGROUND:Management of symptomatic osteochondral defects of the knee remains challenging because of the limited inherent vascularity and healing potential of articular cartilage. Osteochondral allograft (OCA) transplantation has yielded satisfactory results in appropriate patients; however, the effect of OCA transplantation on athletes seeking to return to sport (RTS) remains largely unknown. PURPOSE:To systematically review the literature to better understand outcomes after OCA, focusing on RTS rate and timing, and the incidence of postoperative complications. STUDY DESIGN:Systematic review; Level of evidence, 4. METHODS:Studies included in the PubMed, EMBASE, and Cochrane Library databases from inception to August 2024 that reported on athletes participating at the recreational, high school, collegiate, and professional levels undergoing OCA transplantation for osteochondral defects in the knee were identified. Inclusion criteria included studies reporting on patients identified as athletes undergoing OCA transplantation with reported origin, lesion characteristics (size and location), RTS rate and timing, complications, reoperations, and patient-reported outcomes. RESULTS:A total of 14 studies, consisting of 471 athletes undergoing OCA transplantation with a weighted mean follow-up of 51.1 months, were identified. The weighted mean patient age was 31.4 years (range, 15-69 years), with 61% of patients being male. Lesion origin was reported in 49% (230/471) of patients, with osteochondritis dissecans (OCD) reported in 44% (100/230). The medial femoral condyle was the most common defect location (44%; 68/153). Lesion size ranged from 1 to 13.94 cm2. Sixteen percent (75/471) of patients were classified as competitive athletes, with basketball (n = 21) being the most common sport. RTS was reported in 72% (338/468) of patients, with 84% (231/275) returning at an equal or higher level of play at a weighted mean of 11.1 months (range, 6-26 months) after OCA. Complications were reported in 12% (41/351) of patients, with graft failure accounting for 54% (22/41) of complications in 6% (22/351) of patients. CONCLUSION:For athletes undergoing OCA transplantation to the knee, OCD was the most commonly reported cause, with the medial femoral condyle most frequently affected. Successful RTS was reported in 72% of patients at a mean of 11.1 months, with graft failure representing the most common complication in 6%.

INTRODUCTION:Aspiration of a posttraumatic hemarthrosis has been postulated to improve pain and reduce the burden of proinflammatory cytokines and chemokines that accumulate in the aftermath of an acute anterior cruciate ligament injury. However, the clinical implications of routine aspiration have not been fully investigated. The purpose of this study was to determine the effect of routine preoperative aspiration on (1) the development of arthrofibrosis and (2) overall revision surgery rate following ACL reconstruction (ACLr). METHODS:The population of interest for this study was individuals with an isolated (ie, without notable concurrent ligamentous or chondral injury) ACL rupture indicated for ACLr, with or without concurrent meniscal pathology. Patients were randomized to either routine preoperative care or in-office aspiration of their traumatic effusion upon initial presentation. Patients underwent routine diagnostic arthroscopy at the time of ACLr to evaluate for concurrent chondral or meniscal pathology. Patients underwent standard postoperative rehabilitation and follow-up care. RESULTS:Eighty-seven patients were enrolled in this study, with 46 patients (53%) undergoing preoperative aspiration. At a mean follow-up of 2.54 ± 1.34 years, 14 of 87 patients (16%) underwent revision surgery for any reason and 10 patients (11.5%) underwent débridement of arthrofibrosis. Preoperative aspiration was not markedly associated with a decreased rate of revision surgery or arthrofibrosis. However, aspiration was markedly associated with a longer time to débridement for arthrofibrosis (125 vs. 457 days; P = 0.0029). CONCLUSION:Preoperative aspiration does not modify rates of subsequent surgery following ACLr. Arthrofibrosis developed markedly later in patients who were aspirated preoperatively, possibly as a result of decreased intra-articular inflammation.

BACKGROUND:National Football League (NFL) athletes face a substantial risk for anterior cruciate ligament (ACL) injuries, particularly during special team plays. ACL injuries commonly occur during change-of-direction (CoD) scenarios. Player tracking is standardized for all NFL games and can be used to quantify player motion intensity during CoD injury scenarios. PURPOSE:The purpose was to identify ACL injuries during CoD scenarios in the NFL. We investigated whether player tracking metrics derived from on-field play can predict an increased ACL injury risk during CoD scenarios. STUDY DESIGN:Descriptive epidemiology study. METHODS:For all ACL injuries (n = 216) occurring in games during the 2018 to 2022 NFL seasons, the injury timing and injury scenario were identified through a video review. Motion characteristics of ACL injuries during CoD scenarios were identified from player tracking data, and a generalized linear mixed model (GLMM) was developed to quantify whether player tracking metrics were predictive of the ACL injury risk during CoD scenarios. RESULTS:Among the ACL injuries reviewed, 32% were noncontact, 42% were indirect contact, and 46% were classified as CoD scenarios. Of the athletes involved in a CoD scenario, 98% were decelerating at the time of their ACL injury. Maximum speed (odds ratio, 1.52 per 1-m/s increase in maximum speed) and normalized maximum deceleration power (odds ratio, 1.08 per 1-W/kg increase in maximum deceleration power) were both significant predictors of the CoD ACL injury risk. Punt and kickoff returns had a significantly increased CoD ACL injury risk only when maximum speed and normalized maximum deceleration power metrics were excluded from the GLMM. CONCLUSION:ACL injuries in NFL games primarily occurred during CoD scenarios. Player tracking data analyzed for CoD ACL injuries demonstrated a consistent movement pattern involving high speeds and deceleration at the time of the injury. Both a player's maximum speed and normalized maximum deceleration power were significant predictors of an increased CoD ACL injury risk. The inclusion of these metrics in a GLMM helped to explain the variation in CoD ACL injury rates observed across different play types.

Osteoarthritis (OA) is a progressive joint disorder that leads to pain and disability for millions of people worldwide. Post-traumatic OA (PTOA), a form of OA, arises secondary to joint injury and often impacts younger individuals. Among the most common joint injuries leading to disrupted joint homeostasis and PTOA is anterior cruciate ligament (ACL) rupture. Even with successful surgical stabilization, the risk of developing PTOA persists due to several factors, including altered biology that contributes to disease progression. Recent research into the biology of ACL injuries has advanced our understanding of the mechanisms by which PTOA develops, including the inflammatory pathways involved, the expression of biomarkers specific to ACL injuries, and their interaction with factors such as the chronicity of the injury. Evidence suggests that homeostatic balance of anabolic and catabolic processes in the knee is disturbed after ACL tears, triggering a catabolic and degenerative phenotype, ultimately leading to premature joint degeneration, pain, and disability. Several key knowledge gaps exist, such as the determinants of the transition from acute to chronic inflammation, inter-patient variability in inflammatory responses, and influence of systemic factors on disease development. PTOA research faces numerous challenges, including protracted nature of the disease, the complexity of joint biology, and difficulties in translating molecular discoveries into clinical practice. Future research should prioritize improving biomarker precision for early detection, developing targeted therapies, and leveraging emerging technologies like machine learning to personalize treatment. This approach will enhance our understanding of the biological basis of PTOA resulting from ACL injuries and identify opportunities to mitigate the long-term consequences of these injuries.

BACKGROUND:Osteochondral allograft transplantation (OCA) is well established as a viable chondral restoration procedure for the treatment of symptomatic, focal chondral defects of the knee. The efficacy of secondary OCA in the setting of failed index cartilage repair or restoration is poorly understood. PURPOSE:To evaluate radiographic and clinical outcomes, failures, and reoperations after OCA after failed index cartilage repair or restoration of the knee. STUDY DESIGN:Systematic review; Level of evidence, 4. METHODS:A systematic review was conducted in accordance with the 2020 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A literature search was conducted by querying PubMed, MEDLINE, Scopus, the Cochrane Database for Systematic Reviews, and the Cochrane Central Register for Controlled Trials databases from inception through September 2023 to identify studies reporting on outcomes of patients undergoing OCA after failed index chondral repair or restoration. RESULTS:A total of 6 studies, entailing 349 patients, met inclusion criteria. The mean patient age was 34.6 ± 10.2 years. The mean chondral defect size at the time of secondary OCA was 5.8 cm2 (range, 4.0-9.5 cm2), and the most common defect location was the medial femoral condyle (53.6%; n = 171/319). The most common index chondral procedures were marrow stimulation (73.8%; n = 256/347 patients), OCA (11.8%; n = 41/347), and autologous chondrocyte implantation (4.9%; n = 17/347). The overall failure rate after secondary OCA was 16.6% (95% CI, 8.8%-24.4%). The overall reoperation rate was 42.8% (95% CI, 31.7%-53.9%). Failure and reoperation rates were associated with increasing chondral defect size (P < .01). Defects 9-10 cm2 had a reoperation rate of 67% and a failure rate of 39%. The 5-year survival rate after secondary OCA was 79% to 87.8%, and the 10-year survival rate was 61% to 82%. A total of 42 clinical outcome scores were reported, and 71.0% (n = 22/31) of patient-reported outcome measures yielded significant improvement from preoperative to postoperative levels for patients undergoing secondary OCA. CONCLUSION:After index chondral surgery, the overall failure rate after secondary OCA was 16.6%, with an overall reoperation rate of 42.8%. The majority of clinical outcomes reported suggest improvement when compared with preoperative values. Larger chondral defects may be associated with higher rates of failure and reoperation.