Jay Moran

Tunnel malposition is among the most common technical causes of failure after anterior cruciate ligament reconstruction, and tunnel osteolysis can further complicate revision by limiting anatomic tunnel placement and secure graft fixation. When existing tunnels cannot be safely incorporated into a single‐stage revision, first‐stage tunnel bone grafting remains an important consideration. Multiple graft sources are available, including iliac crest autograft, reamer‐irrigator‐aspirator‐harvested autograft, allograft bone dowels and chips, and synthetic substitutes; however, comparative evidence remains heterogeneous, and no option has shown clear superiority. Manually contoured femoral head and neck allograft is an appealing option because multiple structural dowels can be fashioned from a single graft and tailored to irregular or combined femoral and tibial tunnel defects. Recent computed tomography‐based evidence has shown high mean filling of reamed tibial tunnels, lower filling of femoral tunnels, significantly greater tibial than femoral filling across all measurements, no perioperative or postoperative complications, and lower modeled graft‐material costs than prefabricated allograft dowels. Although radiographic percent filling is a promising metric, future investigation will need to further define which tunnel defects truly require staging and correlate quantitative computed tomography findings with fixation quality, patient‐reported outcomes, and subsequent graft survival.

Background: Heterotopic ossification (HO) is a common complication following knee dislocation (KD) and multi-ligament knee injury (MLKI). The patterns of HO in the knee following KD or MLKI are not well understood.Purpose: The purpose of this exploratory study was to describe the spatial distribution of HO following KD and MLKI using a radiographic grid-based mapping system.Methods: Patients who had sustained a KD or MLKI from January 2001 to May 2023 at a level I trauma center were identified using a MLKI database. Patients who developed HO following complete injury of ≥2 of the four primary knee ligaments, with initial and ≥6-month follow-up x-rays available, were included. Two senior musculoskeletal radiologists independently assessed HO presence and location. Primary outcome measures included location and timing of HO and grid inter-rater reliability. Univariable Cox proportional hazards models were used to describe spatiotemporal HO patterns using exploratory, unadjusted analyses.Results. Thirty-five patients were ultimately included. Inter-rater reliability for HO localization was good (intraclass correlation coefficient (ICC) = 0.83, 95%CI:0.82-0.84). HO most frequently occurred in the medial, posterior, and proximal knee. Proximal patellar tendon avulsions were associated with medial HO (HR=5.93; 95%CI:2.02-17.4; p=0.001) whereas distal avulsions were associated with central HO (HR=15.81; 95%CI:2.58-96.73; p=0.003). Femoral-sided lateral collateral ligament (LCL) avulsions were associated with lateral-proximal (HR 2.27, 95% CI 1.18-4.35; p=0.014) and lateral-mid HO (HR=2.09, 95%CI:1.12-3.91; p=0.02). Surgery involving the proximal central regions, including patellar fixation, multi-ligament reconstruction, medial soft-tissue repair, and knee-spanning external fixation, was associated with lateral (HR=3.02; 95%CI:1.18-7.73; p=0.021), medial (HR=2.82; 95%CI:1.15-6.93; p=0.024), posterior (HR=3.31; 95%CI:1.18-9.27; p=0.023), and central HO (HR=4.91; 95%CI:1.63-14.74; p=0.005). Surgery involving the anterior regions, typically extensor mechanism repair performed alongside multi-ligament reconstruction, was associated with medial (HR=2.79; 95%CI:1.04-7.50; p=0.042) and central HO (HR=6.31; 95%CI:2.08-19.11; p=0.001).Conclusion. The radiographic grid-based mapping system demonstrated good inter-rater reliability and enabled consistent spatial localization of HO following KD/MLKI. HO occurred most frequently in the medial, posterior, and proximal peri-articular regions and was spatially associated with several injury and surgical patterns. This work provides a framework for localizing HO after KD/MLKI and identifies regions and injury patterns that warrant further investigation.

Purpose: To compare radiographic parameters obtained from supine versus standing pelvic radiographs in patients with femoroacetabular impingement (FAI) and acetabular dysplasia (AD). Methods: This study was registered on the International Prospective Register of Systematic Reviews and performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines. PubMed, Cochrane Central Register of Controlled Trials, and Scopus were queried in June 2025. Included studies compared supine versus standing radiographic parameters in patients with FAI or AD. Articles were excluded if they failed to provide extractable radiographic data for both positions. Demographics, study design, and radiographic parameters, including lateral center‐edge angle (LCEA), pelvic tilt, Tönnis angle, femoral head translation, Sharp angle, joint space width, and femoroepiphyseal acetabular roof index, were analyzed. Meta‐analyses with a random‐effects model were performed to evaluate mean differences in supine versus standing measurements for LCEA, Tönnis angle, and pelvic tilt, stratified by FAI and AD cohorts. Results: Twelve studies were analyzed, comprising 824 hips in 675 patients. Statistically significant differences in individual‐study supine versus standing comparisons were identified for pelvic tilt (10/10 studies), Tönnis angle (7/8), and LCEA (6/10). Four studies reported sex‐disaggregated data. Meta‐analyses showed greater pelvic tilt in supine in FAI (+1.38 cm, 95% confidence interval [CI]: 0.92, 1.84; P < .001) and AD (+1.98 cm, 95% CI: 0.37, 3.59; P = .020) populations. Tönnis angle was smaller in supine in FAI (−1.14°, 95% CI: −2.19, −0.09; P = .030) and AD (−1.93°, 95% CI: −3.20, −0.65; P = .003). LCEA measurements were not significantly different in FAI (+0.97°, 95% CI: −0.80, 2.74; P = .28) and AD (+1.03°, 95% CI: −0.70, 2.76; P = .24). Conclusions: Supine pelvic radiographs resulted in greater pelvic tilt measurements, decreased Tönnis angles, and similar LCEA compared with standing radiographs. Supine and standing radiographic parameters should not be considered interchangeable. Level of Evidence: Level IV, systematic review of Level II to IV studies.

Purpose: Knee dislocations (KDs) can be limb‐threatening injuries that may require a temporising knee‐spanning external fixator (KSEF) for stabilisation. Precise indications for this commonly utilised invasive immobilisation technique remain controversial and poorly defined. The purpose of this study was to establish consensus‐driven indications for temporising KSEF use in the initial management of KDs. Methods: A working group of fellowship‐trained orthopaedic surgeons generated clinical scenarios reflecting commonly debated indications for temporising KSEF application. Utilising a modified Delphi technique, 23 surgeons from the International Knee Dislocation Study Group completed two anonymous online survey rounds. Consensus was defined a priori as ≥70% agreement or disagreement. Results: Response rates were 100% for Round 1 and 96% for Round 2. Four scenarios achieved unanimous consensus: (1) KD without post‐reduction instability (100% disagreement), (2) inability to maintain tibiofemoral reduction in the sagittal/coronal plane with non‐invasive knee immobilisation (NIKI) after initial reduction (i.e., redislocation/subluxation) (100% agreement), (3) tibial plateau fracture‐dislocation with post‐reduction subluxation (100% agreement), and (4) in bilateral closed KDs where one limb is indicated and the other is NOT, span ONLY the indicated limb (100% agreement). Two scenarios achieved strong positive consensus (90%–99.9% agreement): (1) morbid obesity (BMI ≥ 40) without NIKI of sufficient size (91.3% agreement), and (2) extensor mechanism injury with post‐reduction subluxation (91.3% agreement). Four and one additional scenarios achieved positive and negative consensus, respectively. Conclusions: This modified Delphi study established consensus‐driven indications for temporising KSEF application in the initial management of KDs, which advocate for more selective use than what is demonstrated in the literature. Level of Evidence: Level V.

Orthopaedic surgeons are routinely exposed to a variety of occupational hazards in the operating room; however, intraoperative noise exposure remains an underrecognized risk that may contribute to the development of occupational noise‐induced hearing loss. Although traditional metrics such as time‐weighted average noise levels (average decibels [dBA] over an 8‐hour period) below 85 dBA may be considered low risk, repeated intraoperative exposure to maximum decibel levels ≥85 dBA may represent a clinically relevant cumulative hazard. These concerns are further supported by recent high‐level evidence, suggesting that orthopaedic spine and arthroplasty surgeons are frequently exposed to hazardous intraoperative noise levels and that a substantial proportion may exhibit evidence of noise‐induced hearing loss; however, few studies have specifically evaluated the intraoperative noise patterns during arthroscopic surgeries. Recent evidence suggests that maximum decibel levels consistently exceed recommended safety thresholds (≥85 dBA) across shoulder, hip, and knee arthroscopic procedures. Although shoulder arthroscopy may be associated with the highest intraoperative maximum decibel levels, potentially due to the closer proximity of noise‐generating instruments to the surgeon when procedures are performed with the patient in the beach‐chair position, elevated noise exposure is observed across all arthroscopic procedures. As such, the selective use of hearing protection or consideration of modifiable procedural factors, such as patient positioning, may be appropriate during the higher risk, noise‐generating arthroscopic procedures. Ultimately, continued efforts to better understand cumulative intraoperative noise exposure, procedure‐specific variability, and mitigation strategies are needed to optimize the long‐term occupational health of sports medicine surgeons.

Background: Medial meniscus posterior root tears (MMPRTs) have been associated with rapidly progressive cartilage degeneration when left untreated in adults. However, their clinical presentation, tear morphology, and associated cartilage pathology remain poorly characterized in pediatric and adolescent patients. Purpose: To identify risk factors for medial tibiofemoral compartment cartilage injury in pediatric and adolescent patients undergoing MMPRT repair, and secondarily to characterize MMPRT morphologies and skeletal maturity–associated injury patterns. Study Design: Case series; Level of evidence, 4. Methods: Patients P < .001), whereas skeletally mature adolescents more commonly had ligament-associated MMPRTs (89% vs 40%; P < .001). Overall, medial compartment cartilage injury was arthroscopically identified in 34 patients (45%) at the time of surgery. Most cartilage injuries involved the MFC (82%) and were classified as ICRS grade 1 (15%) or grade 2 (62%), while 24% were high-grade (ICRS grade 3 or 4). Multivariable logistic regression demonstrated that age (OR per year, 1.33; 95% CI, 1.02-1.73; P = .03) and delayed surgery (≥90 days after injury) (OR, 4.96; 95% CI, 1.6-15; P = .005) were significantly associated with medial compartment cartilage injury. The association between delayed surgery and medial compartment cartilage injury remained consistent in a sensitivity analysis incorporating concomitant ligament injury. Conclusion: Concomitant medial compartment cartilage injury was arthroscopically identified in 45% of pediatric and adolescent patients undergoing MMPRT repair. While most of these cartilage injuries involved the MFC and were classified as ICRS grade 2, nearly one-quarter were high-grade lesions (ICRS grade 3 or 4). Increasing age and delayed surgery (≥90 days after injury) were significantly associated with medial compartment cartilage injury. Overall, these findings underscore the potential importance of timely recognition and surgical treatment of MMPRTs in young patients.

Background: In pediatric and adolescent patients with medial meniscal ramp lesions (MMRLs) undergoing anterior cruciate ligament reconstruction (ACLR), the presence of concomitant lateral meniscal tears (LMTs) are not well-characterized. Purpose: To describe the characteristics and surgical management of concomitant LMTs in pediatric and adolescent patients undergoing MMRL repair during primary ACLR. Study Design: Case series; Level of evidence, 4. Methods: Patients P = .044) and obesity (OR, 2.5; 95% CI, 1.0-6.1; P = .046). Conclusion: In this multicenter study, 65% of pediatric and adolescent patients undergoing MMRL repair during primary ACLR had a concomitant LMT and the majority were localized to the posterior horn and posterior root. As 31% of concomitant LMTs were missed on preoperative MRI, the posterior aspect of the lateral meniscus should be carefully evaluated at the time of surgery in pediatric patients with MMRLs. Nearly half of the concomitant LMTs identified in this cohort were LMRTs, complex tears, complete radial tears, or bucket-handle tears. Overall, surgeons should anticipate performing an additional lateral meniscal repair in nearly half of pediatric patients undergoing an MMRL repair during primary ACLR.

Background: Heterotopic ossification (HO) may occur after multiligament knee injuries (MLKIs), with the potential to cause significant functional deficits. However, risk factors for HO after MLKI are not well understood. Purpose: To identify the incidence and risk factors for HO after MLKI. Study Design: Case-control study; Level of evidence, 3. Methods: Patients were included if they had undergone treatment for an MLKI by a single surgeon at a level 1 trauma center between 2001 and 2023, with radiographs at the time of injury and at a minimum 6-month follow-up. All data were obtained from electronic medical records. Two senior musculoskeletal radiologists reviewed all cases for the presence of HO in the most recent radiographs, using the initial radiographs obtained at the time of injury for comparison. Patients were grouped by whether they had developed HO after MLKI. Univariable analyses were performed to compare patient, injury, and treatment characteristics between groups. Odds ratios (ORs) for HO were assessed by multivariable logistic regression, adjusted for ligament injury classification, mechanism of injury, documented dislocation, central nervous system (CNS) trauma, and knee-spanning external fixation (KSEF). Results: The studied cohort included 128 patients, of whom 28 were excluded due to insufficient follow-up. Of the remainder, 35 (35%) developed HO, with a mean follow-up of 35.17 months. In the univariable analysis, the HO group had significantly higher rates of documented dislocation, CNS trauma, and KSEF. In the multivariable analysis, KSEF (OR, 8.51; 95% CI, 21.81-31.717; P = .001) and CNS trauma (OR, 6.63; 95% CI, 1.507-29.209; P = .012) remained independent predictors of HO after MLKI. Conclusion: The incidence of HO after MLKI was 35%. KSEF and CNS trauma were independently associated with HO. Recognition of these risk factors may help identify at-risk patients for closer monitoring and consideration of HO prophylaxis and should therefore be included in the decision-making strategy for KSEF versus early surgical treatment after MLKI.

Background: Meniscal allograft transplantation (MAT) is an emerging treatment for patients with symptomatic meniscal deficiency. Purpose: To systematically evaluate the long-term clinical outcomes and graft survivorship of MAT with a minimum follow-up of 10 years. Study Design: Systematic review and meta-analysis; Level of evidence, 4. Methods: A review was conducted following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and registered on Prospero. The PubMed, Cochrane Central Register of Controlled Trials, and Scopus databases were queried in January 2025. Studies assessing MAT patient-reported or objective outcomes with ≥10 years of follow-up were included. Non–English-language studies, case reports, non–peer-reviewed articles, editorials, commentaries, and reviews were excluded. The Lysholm score, Tegner Activity Scale score, visual analog scale (VAS) for pain score, Knee injury and Osteoarthritis Outcome Score (KOOS), and graft survivorship were extracted for analysis. MAT failure was defined by individual studies based on clinical, surgical, and/or radiographic criteria. Results: Thirteen studies, consisting of 619 patients and 632 MATs and performed from 1984 to 2012, met inclusion criteria. The mean patient age ranged from 24.5 to 43.5 years, with 47% to 87% males and a mean follow-up duration of 11.1 to 20.0 years. Fixation techniques included soft tissue (5 studies), bone plug (6 studies), and bone trough (4 studies). Statistically significant improvements were observed in the Lysholm score (7/9 studies), Tegner score (3/4 studies), VAS score (3/5 studies), and KOOS (1/1 studies). Two studies reported Patient Acceptable Symptom State rates ranging from 70.2% to 71% for Lysholm score and 58.5% to 82% for KOOS. Two studies also reported minimal clinically important difference rates, which ranged from 70.4% to 89.9% for the Lysholm score and 61% to 78.2% for the KOOS subscales. Ten-year MAT survival ranged from 45% to 100%. Most studies (5/9) demonstrated survivorship ≥73% at a minimum 10-year follow-up. MAT survival after ≥15 years ranged from 19% to 87%. Conclusion: MAT demonstrated favorable long-term clinical outcomes and variable graft survivorship beyond 10 years. Included studies varied based on graft type, fixation technique, and patient selection. Continued prospective, high-level studies are warranted to standardize surgical approaches, improve the durability of this joint-preserving intervention, and identify modifiable risk factors for inferior long-term outcomes.

Background: Medial meniscal ramp lesions (MMRLs) can occur in up to 28% of pediatric patients at the time of anterior cruciate ligament (ACL) reconstruction (ACLR). However, limited studies have examined the outcomes after combined MMRL repair and ACLR in this at-risk patient population. Purpose: To evaluate the mid-term clinical outcomes after MMRL repair and ACLR in pediatric and adolescent patients and investigate possible risk factors for a secondary medial meniscal surgery. Study Design: Case series, Level of evidence, 4. Methods: Patients <18 years old who underwent MMRL repair during primary ACLR between 2015 and 2022 at 5 institutions with a minimum of 2-year follow-up were included. MMRLs were defined as an arthroscopically diagnosed partial or complete peripheral vertical/longitudinal tear of the posterior horn of the medial meniscus at/or within 3 mm of the meniscocapsular junction that underwent repair at the time of ACLR. Postoperative outcome measures included subjective International Knee Documentation Committee (IKDC) scores, return to sport (RTS), patient satisfaction, complications, rate of secondary medial meniscal surgery, and other reoperations. Descriptive statistics were used to report the demographic characteristics, operative findings, and postoperative outcomes for the cohort. Risk factors were assessed for a secondary medial meniscal surgery. Results: A total of 54 patients who underwent MMRL repair during primary ACLR at a mean age of 16.1 years (range, 12.4-17.9 years) were included in this study. Most patients reported a sports-related injury (82%), with 52% occuring during American football or basketball participation. At the time of surgery, 50% of patients demonstrated a high-grade pivot-shift (grade 2 or 3) examination under anesthesia, and 59% were arthroscopically diagnosed with a concomitant lateral meniscal tear. A total of 48 MMRL repairs (89%) were performed using all-inside techniques, while 5 (11%) were performed using inside-out techniques, and only 3 (6%) patients underwent a concomitant lateral extra-articular procedure. The mean follow-up was 60 months (range, 24-118 months). Postoperatively, 11 (20%) patients underwent a secondary medial meniscal surgery at a mean of 14 months (range, 6-28 months) after the index procedure. All 11 patients were initially treated with all-inside MMRL repairs, and were arthroscopically diagnosed with a tear involving or extending into the initial repair site at the time of revision surgery. The majority of retears were complex morphologies that occurred in the setting of an intact ACL graft and were the result of acute trauma within the first 2 postoperative years. Six (55%) were treated with a medial partial meniscectomy, while 5 (45%) underwent revision repair. No significant risk factors were associated with the presence of a secondary medial meniscal surgery. Overall, the cohort demonstrated a mean IKDC score of 88 ± 12 (range, 41-100), and for those who wished to RTS, an RTS rate of 76%. Conclusion: In this multicenter cohort of pediatric and adolescent patients who underwent MMRL repair during primary ACLR, with a mean follow-up of 5 years, the rate of secondary medial meniscal surgery was 20%. Overall, while the subjective patient-reported outcome measures were cautiously reassuring, larger studies are needed to better understand the modifiable risk factors for MMRL repair failure after ACLR in pediatric patients.