Darren de Sa

Purpose: The medial collateral ligament (MCL) is the most commonly injured knee ligament, yet indications for reconstruction remain debated. Although consensus statements support allograft and hamstring autograft, comparative evidence regarding graft superiority is limited. This systematic review evaluated patient‐reported outcome measures (PROMs) and complication rates following MCL reconstruction using Achilles tendon (AT) allograft or hamstring autograft. Methods: A systematic review was undertaken according to the preferred reporting items for systematic reviews and meta‐analyses (PRISMA) guidelines. PubMed, Cochrane, Google Scholar and Scopus were searched on 11th February 2026. Studies published within the previous 20 years that included patients aged ≥16 years undergoing MCL reconstruction with hamstring autograft or AT allograft and reporting clinical, functional and patient‐reported outcomes were included. Data extraction and risk of bias assessment were performed. Due to heterogeneity, findings were narratively synthesised. Results: Sixteen studies were included: six AT allograft studies ( n = 107; four using a bone block) and ten hamstring autograft studies ( n = 275). Mean age was 33.9 and 31.3 years, with mean follow‐up of 37 and 29.1 months, respectively. Mean postoperative international knee documentation committee (IKDC) and Lysholm scores were 81.1 and 86.8 for allograft and 78.8 and 87.2, respectively, for autograft. Three allograft and six hamstring autograft studies reported preoperative and postoperative PROMs, all demonstrated significant improvement ( p < 0.05). Complication rates were 11.2% for AT allograft and 4.0% for hamstring autograft. AT allograft complications included two graft failures, four cases of residual asymptomatic valgus instability, three infections and three other complications. Hamstring autograft complications included one graft failure, four cases of asymptomatic valgus instability, three manipulations, one infection and two removals of hardware. Conclusion: Both AT allograft and hamstring tendon autograft significantly improve PROMs following MCL reconstruction. AT allografts demonstrated a numerically higher complication rate; however, the evidence is indirect and insufficient to determine the superiority of either graft type. Level of Evidence: Level III.

Purpose: To perform a systematic review evaluating the efficacy of orthobiologic injections as adjuncts to cartilage‐preserving surgery in improving clinical, radiographic, and histologic outcomes in adults with focal knee cartilage defects. Methods: Four databases (PubMed, MEDLINE, EMBASE, and Scopus) were searched through September 2025 for randomized controlled trials assessing adjunctive orthobiologic injections for knee focal chondral lesions. Inclusion criteria were randomized controlled trials reporting pain, function, or cartilage outcomes. Risk of bias was assessed using the Cochrane RoB 2 tool. Results: Five randomized controlled trials involving 217 patients were included. Interventions included platelet‐rich plasma (PRP), peripheral blood stem cells, adipose‐derived mesenchymal stem cells, and human adipose‐derived mesenchymal progenitor cells, administered intra‐ or postoperatively after cartilage‐preserving procedures including subchondral drilling and microfracture. Random‐effects subgroup meta‐analyses of 2 PRP studies showed a small reduction in pain (mean difference, −0.93; 95% confidence interval, −1.39, −0.47; I ² = 17%) and improvement in International Knee Documentation Committee scores in the injection group (mean difference, 13.4; 95% confidence interval, 10.1, 16.7; I ² = 0%). Peripheral blood stem cell + hyaluronic acid significantly improved magnetic resonance imaging and histological cartilage scores versus hyaluronic acid alone. Human adipose‐derived mesenchymal progenitor cell + hyaluronic acid improved Western Ontario and McMaster Universities Osteoarthritis Index and histological scores. Adipose‐derived mesenchymal stem cells + PRP showed promising arthroscopic and histological outcomes without patient improvement versus PRP alone. Per the RoB 2 tool, 3 studies had some concerns, 1 had low risk, and 1 had high risk of bias. Conclusions: Orthobiologic injections, including peripheral blood stem cells, adipose‐derived stem cells, and PRP, appear safe and may provide limited functional, radiographic, and histological benefits in select protocols and populations when used alongside cartilage‐preserving surgery for focal knee chondral lesions. Current evidence is insufficient to support such injections as stand‐alone procedures. Significant heterogeneity across included studies precludes specific clinical recommendations. Level of Evidence: Level II, systematic review of Level I and II studies.

Purpose: To systematically review and analyze the existing literature on the use of the Forgotten Joint Score‐12 (FJS‐12) in patients undergoing anterior cruciate ligament reconstruction (ACLR), with the aim of evaluating its effectiveness as a complementary tool to traditional patient‐reported outcome measures (PROMs) in assessing postoperative outcomes. Methods: PubMed, Embase, and MEDLINE were searched on February 7, 2026. Studies were included if they used the FJS‐12 to assess patients after ACLR. The quality of included studies was appraised, and data were extracted on demographics, surgical details, and outcome measures including FJS‐12 and its correlations with other PROMs. Descriptive statistics were used to summarize the findings. Results: Thirteen studies encompassing 1295 patients and 1316 knees were included. The mean age was 31.3 years, and the mean follow‐up time was 44.3 months (range of means, 12.0‐139.0 months). FJS‐12 scores ranged widely from 37.0 to 92.6. The score showed strong, significant positive correlations with International Knee Documentation Committee subjective knee form score, Lysholm, and Knee Osteoarthritis and Outcome Score ( r > 0.80 in 3 of 4 studies reporting correlations), particularly in isolated ACLR cases. FJS‐12 showed a significant low‐to‐moderate correlation with Tegner activity levels ( r = 0.318‐0.606, P  ≤  .003) in 2 of 3 studies. Subgroup analyses suggested higher FJS‐12 scores in patients with restoration of hyperextension >5° and symmetrical range of motion to the contralateral limb. Factors such as radiographic osteoarthritis and partial meniscectomy were associated with lower FJS‐12 scores. Across studies evaluating sex‐based differences, no consistent or clinically meaningful differences in FJS‐12 scores were observed between men and women. Conclusions: The FJS‐12 is a patient‐centered PROM that complements traditional metrics by capturing the subjective experience of joint awareness after ACLR. It shows moderate‐to‐strong correlations with established ACLR PROMs, supporting construct validity, and clinically meaningful thresholds have been reported, supporting clinical interpretability; however, the magnitude of responsiveness over time cannot be fully characterized because of limited reporting of longitudinal effect sizes. Level of Evidence: Level IV, systematic review of Level II to IV studies.

Purpose: The purpose of this scoping review was to map the existing literature describing revision anterior cruciate ligament reconstruction (ACLR) following failure of combined ACLR with lateral extra‐articular procedures (LEAPs), characterize reported surgical strategies, summarize available clinical outcomes and identify gaps in the current evidence base. Methods: A scoping review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta‐Analyses extension for Scoping Reviews guidelines. Ovid MEDLINE, Embase and PubMed were searched from inception to February 2026. Eligible studies included technical notes and clinical studies describing revision of failed combined ACLR with LEAPs, including lateral extra‐articular tenodesis (LET) or anterolateral ligament reconstruction (ALLR). Studies were included irrespective of outcome reporting, provided revision strategies were described. Single‐revision or re‐revision cases and adult and paediatric populations were included. Review articles, editorials and letters were excluded. Data were extracted and synthesized descriptively. Results: Nine studies were included. Three studies described detailed revision strategies, including single‐stage revision ACLR with ALLR, double‐bundle revision ACLR with LET preservation and all‐epiphyseal revision ACLR following failed LET. Six clinical studies included 594 patients within broader primary or revision ACLR cohorts, of whom 23 were explicitly identified as undergoing revision or re‐revision following failure of a combined ACLR with LEAP. Revision strategies were heterogeneous in graft selection and management of the LEAP, including LET preservation, LET revision or conversion to ALLR. Clinical outcomes were reported in two case reports, both demonstrating satisfactory short‐term stability and functional outcomes following revision ACLR with LET preservation. Conclusions: The current literature on the revision of failed combined ACLR with LEAPs is limited and heterogeneous. Revision strategies vary widely, and reporting of both technique and clinical outcomes is inconsistent. Based on the limited evidence and expert opinion, revision ACLR in this context should be individualized according to surgeon experience and patient‐specific factors, such as prior ACL graft harvest, tunnel interactions and the status of the prior LEAP. Level of Evidence: Level V.

Purpose: To evaluate the surgical methods, clinical outcomes, and complication profile of patients undergoing medial quadriceps tendon‐femoral ligament reconstruction (MQTFLR), either isolated or as medial patellofemoral complex reconstruction (MPFCR), for recurrent patellar instability. Methods: Three databases (PubMed, EMBASE, and MEDLINE) were searched on July 28, 2025, for clinical studies assessing patient outcomes following MQTFLR with or without concurrent medial patellofemoral ligament reconstruction (MPFLR). Data on functional outcomes including Kujala scores, International Knee Documentation Committee (IKDC) scores, Lysholm scores, Tegner score, and visual analog scale scores were collected, along with return to sport, redislocation rates, revisions, and other complications. The Methodological Index for Non‐Randomized Studies criteria were used to assess study quality. Results: Nine studies comprising 347 patients (68.3% female, mean age 18.6 years (range: 12.2‐29.0)) were included. Combined MQTFLR + MPFLR (MPFCR) showed favorable Kujala scores (range 85.9‐93.6), IKDC scores (range 81.5‐91.2), Lysholm scores (range 84.3‐93.3), and moderate Tegner scores (4.6‐6.0). Among MPFCR patients with available minimum clinically important difference data, the minimum clinically important difference was achieved in 61/61 knees (100%) for Kujala, 97/103 knees (94.1%) for IKDC, 60/61 knees (98.1%) for Lysholm, and 44/61 knees (72.1%) for Tegner. The IKDC patient acceptable symptom state score was surpassed by 28/42 knees (66.7%). Patients undergoing MPFCR were found to have a high return to sport rate (88.5%‐100%) and a low redislocation rate (1.6%). The single major complication was arthrofibrosis in 2 patients. Isolated MQTFLR and isolated MPFLR both showed comparable functional outcomes, but a higher rate of complications such as arthrofibrosis, flexion limitation, and patellar fracture compared with patients who underwent MPFCR. Conclusions: MQTFLR in combination with MPFLR (MPFCR) is a viable option for surgical management of patellofemoral instability, with favorable clinical outcomes supporting its use. Level of Evidence: Level IV, systematic review of Level III and IV studies.

Purpose: Obesity (body mass index [BMI] ≥ 30 kg/m ² ) is increasingly prevalent among total knee arthroplasty (TKA) patients and is associated with unique challenges. The role of various TKA alignment strategies in obese patients remains unclear. To evaluate the clinical, functional, radiographic, survivorship and complication outcomes of primary TKA in obese patients across alignment philosophies. Methods: Eligible studies (1) included patients who underwent primary TKA with defined alignment, (2) reported BMI ≥ 30 kg/m ² or provided stratified data for obese versus non‐obese groups, (3) reported at least one of: patient‐reported outcome measures (PROMs), range of motion (ROM), radiographic outcomes, or complications and (4) were randomized controlled trials (RCTs), cohort studies or case–control studies. Results: Thirty studies were included. 8468 obese patients (14,662 knees) underwent mechanically aligned TKA, with mean follow‐up of 91.1 ± 45.3 months (range, 0.5–110.5 months). Mechanically aligned TKA in obese patients was associated with post‐operative improvements in PROMs, including Knee Society Score, Western Ontario and McMaster Universities Osteoarthritis Index and Oxford Knee Score. Short‐term cumulative aseptic revision incidence was low, ranging from 0.5% to 1.3%, while revision‐free survivorship commonly exceeded 95% at short‐term and >90% at long‐term follow‐up. Radiographic outcomes demonstrated reliable restoration of near‐neutral limb alignment across BMI strata. One study evaluated a kinematically‐designed bicruciate‐stabilized implant with an unspecified alignment strategy in obese patients, and another study evaluated functional alignment in obese patients, limiting comparisons. Conclusion: Evidence evaluating the influence of alignment on outcomes in obese patients undergoing TKA remains insufficient to determine whether alignment philosophy meaningfully affects clinical or radiographic outcomes. Although mechanically aligned TKA demonstrated generally acceptable post‐operative outcomes in obese cohorts, the available literature was overwhelmingly dominated by mechanically aligned studies, with only limited evaluation of alternative approaches. Level of Evidence: Level IV.

This review specifically evaluates whether the presence of cartilage lesions, or their surgical treatment, modifies the clinical benefit of medial patellofemoral ligament (MPFL) reconstruction. A systematic review was conducted following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Embase, PubMed and Ovid MEDLINE were searched from inception to December 2025. Studies reporting MPFL reconstruction outcomes in adults with reported cartilage lesions and/or concomitant cartilage procedures were included. Comparative studies were analysed as MPFL reconstruction with cartilage restoration versus MPFL reconstruction without cartilage restoration. Cartilage restoration included microfracture, osteochondral grafting, chondrocyte implantation and fixation of osteochondral lesions. Chondroplasty, debridement and no cartilage treatment were classified as nonrestorative. Data were synthesised narratively and with weighted summary statistics. Eighteen studies comprising 1632 patients were included. The mean age was 22.2 years, 32.5% of patients were male, and the mean follow-up was 40.8 months. Cartilage lesions were graded using the International Cartilage Repair Society or Outerbridge classifications. Grade II-IV cartilage lesions were reported in 56.3% of patients, most commonly involving the patella. High-grade (III-IV) lesions were associated with worse baseline scores compared to lower-grade (0-II) lesions. MPFL reconstruction consistently led to significant improvements in pain and function, irrespective of lesion presence or treatment strategy. Weighted summary mean improvements were similar between patients undergoing MPFL reconstruction with cartilage restoration versus no restoration, based on Knee injury and Osteoarthritis Outcome Score (KOOS) Pain (+24.5 [standard deviation, SD = 2.9] vs. +26.2 [2.3]), Kujala (+32.0 [16.6] vs. +30.4 [4.3]) and International Knee Documentation Committee (IKDC) (+25.0 [5.7] vs. +32.7 [1.4]) scores. Chondroplasty and debridement were included in the no restoration category when reported. Reported complication rates were higher with cartilage restoration (5.7%) compared with no restoration (2.8%), although reporting was limited. Cartilage lesions are common during MPFL reconstruction and may be associated with worse baseline scores. MPFL reconstruction improves pain and function, but current evidence does not demonstrate a consistent additional clinical benefit of concomitant cartilage restoration. Higher-quality comparative studies with longer follow-up are needed. Level IV, systematic review.

Purpose: To compare tibial suspensory fixation (TSF) with tibial interference screw (TIS) in anterior cruciate ligament (ACL) reconstruction for clinical and radiological outcomes. Methods: A systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines using MEDLINE, PubMed, and Embase databases. The review was registered with the PROSPERO database. Clinical comparative studies of ACL reconstruction with hamstring autograft with TSF and TIS were included. Primary outcome measures include functional outcome in terms of International Knee Documentation Committee, Lysholm and Tegner scores, knee laxity, and radiologic outcomes in terms of tunnel widening. Secondary outcome measures include isokinetic muscle strength and complications like graft failure. Studies were appraised using Cochrane risk of bias tool for randomized controlled trials and Methodological Index for Non‐Randomized Studies score. Results: Seventeen clinical comparative studies (TSF, n = 4262; TIS, n = 3085) met eligibility criteria. Of these, 72.9% (TSF) and 75.7% (TIS) of patients were males. Follow‐up ranged from 24 to 40 months for clinical outcomes and 6 to 24 months for radiological outcomes. Included studies report no difference in knee functional scores (International Knee Documentation Committee [mean difference, range −3.40 to 5.10], Tegner [mean difference, range −1.20 to 0.60], and Lysholm score [mean difference, range −4.00 to 1.30]) between the TSF and TIS groups. The studies also report no difference in knee laxity (KT‐1000 [mean difference, range −0.40 to 1.50]). Two studies revealed superior knee flexor strength at 2 years with TSF compared with TIS (Goyal et al., 25.8 ± 4.2 vs 23.5 ± 2.5 lbs, P = .002). No major complications were reported in most of the studies except 1 which showed a higher revision rate with TIS (TSF 3.4% vs TIS 5.4%, P < .001). Radiologically, the studies show greater tibial tunnel widening with TIS compared with TSF (mean difference, range −2.40 to −1.61). Conclusions: TSF in hamstring autograft ACL reconstruction shows similar functional outcomes and knee stability when compared with interference screw at a minimum clinical follow‐up of 24 months. The present systematic review also highlights superior knee flexor strength with TSF with no major difference in the complications including graft failure rate. The use of TSF using hamstring autograft is a reliable option for ACL reconstruction. Level of Evidence: Level IV, systematic review of Level I to IV studies.

Purpose: Quadriceps tendon (QT) autograft is increasingly used for anterior cruciate ligament reconstruction (ACLR), yet rehabilitation guidelines remain extrapolated from patellar tendon (PT) or hamstring tendon (HT) protocols. This cross‑sectional study evaluated publicly available postoperative rehabilitation protocols from academic orthopaedic programmes to describe their content, assess variability and identify key trends. Methods: Accredited orthopaedic residency programmes were identified through the Electronic Residency Application Service (ERAS) and Canadian Resident Matching Service (CaRMS). A three‐step systematic web‐based search was conducted to identify publicly available QT‐ACLR rehabilitation protocols. Protocols were included if specific to QT autografts and excluded if addressing concomitant meniscal repairs. Two independent reviewers extracted data on rehabilitation components and timelines. The proportion of protocols including each component and the median initiation time were calculated. Results: Of 219 programmes screened, 16 eligible protocols were identified. Nine were QT‐specific and seven were general ACLR protocols. Key trends included: (1) use of a hinged brace locked in extension for 2–4 weeks (86.7%); (2) initiation of icing, cryotherapy and patellar mobilizations immediately postoperatively (68.8%); (3) neuromuscular electrical stimulation use within the first 4 weeks (56.2%); (4) target of full extension by 2–4 weeks and flexion by 3–4 months (100%); (5) strengthening, balance and proprioceptive training beginning between 1–3 months (93.8%–100%) and (6) return‑to‑sport (RTS) testing between 5 and 9 months, using time‐based and/or criterion‐based recommendations (100%). Substantial variability existed in exercise prescriptions, adjunctive therapy use and RTS criteria. Conclusions: Publicly available QT‐ACLR rehabilitation protocols from academic programmes emphasize early weight‐bearing, range of motion restoration and progressive strengthening but reveal considerable variability in timing, adjunctive therapies and RTS guidelines. Many protocols mirror those for PT and HT autografts rather than being tailored to QT‐specific considerations. Standardized, evidence‐based rehabilitation guidelines that address graft‐specific risks, psychological readiness and telehealth delivery are needed to optimize outcomes following QT‐ACLR. Level of Evidence: Level IV.