The anterior cruciate ligament (ACL) is frequently injured in elite athletes, with females up to eight times more likely to suffer an ACL tear than males. Biomechanical and hormonal factors have been thoroughly investigated; however, there remain unknown factors that need investigation. The mechanism of injury differs between males and females, and anatomical differences contribute significantly to the increased risk in females. Hormonal factors, both endogenous and exogenous, play a role in ACL laxity and may modify the risk of injury. However, data are still limited, and research involving oral contraceptives is potentially associated with methodological and ethical problems. Such characteristics can also influence the outcome after ACL reconstruction, with higher failure rates in females linked to a smaller diameter of the graft, especially in athletes aged < 21 years. The addition of a lateral extra-articular tenodesis can improve the outcomes after ACL reconstruction and reduce the risk of failure, and it should be routinely considered in young elite athletes. Sex-specific environmental differences can also contribute to the increased risk of injury, with more limited access to and availablility of advanced training facilities for female athletes. In addition, football kits are designed for male players, and increased attention should be focused on improving the quality of pitches, as female leagues usually play the day after male leagues. The kit, including boots, the length of studs, and the footballs themselves, should be tailored to the needs and body shapes of female athletes. Specific physiotherapy programmes and training protocols have yielded remarkable results in reducing the risk of injury, and these should be extended to school-age athletes. Finally, psychological factors should not be overlooked, with females’ greater fear of re-injury and lack of confidence in their knee compromising their return to sport after ACL injury. Both intrinsic and extrinsic factors should be recognized and addressed to optimize the training programmes which are designed to prevent injury, and improve our understanding of these injuries.

Cite this article: Bone Joint J 2023;105-B(10):1033–1037.

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Despite the increase in the surgical repair of proximal hamstring tears, there exists a lack of consensus in the optimal timing for surgery. There is also disagreement on how partial tears managed surgically compare with complete tears repaired surgically. This study aims to compare the mid-term functional outcomes in, and operating time required for, complete and partial proximal hamstring avulsions, that are repaired both acutely and chronically.

Deep gluteal syndrome is an increasingly recognized disease entity, caused by compression of the sciatic or pudendal nerve due to non-discogenic pelvic lesions. It includes the piriformis syndrome, the gemelli-obturator internus syndrome, the ischiofemoral impingement syndrome, and the proximal hamstring syndrome. The concept of the deep gluteal syndrome extends our understanding of posterior hip pain due to nerve entrapment beyond the traditional model of the piriformis syndrome. Nevertheless, there has been terminological confusion and the deep gluteal syndrome has often been undiagnosed or mistaken for other conditions. Careful history-taking, a physical examination including provocation tests, an electrodiagnostic study, and imaging are necessary for an accurate diagnosis.

After excluding spinal lesions, MRI scans of the pelvis are helpful in diagnosing deep gluteal syndrome and identifying pathological conditions entrapping the nerves. It can be conservatively treated with multidisciplinary treatment including rest, the avoidance of provoking activities, medication, injections, and physiotherapy.

Endoscopic or open surgical decompression is recommended in patients with persistent or recurrent symptoms after conservative treatment or in those who may have masses compressing the sciatic nerve.

Many physicians remain unfamiliar with this syndrome and there is a lack of relevant literature. This comprehensive review aims to provide the latest information about the epidemiology, aetiology, pathology, clinical features, diagnosis, and treatment.

Cite this article: Bone Joint J 2020;102-B(5):556–567.

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To validate the Sydney Hamstring Origin Rupture Evaluation (SHORE), a hamstring-specific clinical assessment tool to evaluate patient outcomes following surgical treatment.

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To evaluate the donor site morbidity and tendon morphology after harvesting whole length, full-thickness peroneus longus tendon (PLT) proximal to the lateral malleolus for ligament reconstructions or tendon transfer.

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The aim of this study was to investigate the incidence, risk factors, and outcome of venous thromboembolism (VTE) following anterior cruciate ligament (ACL) reconstruction in a nationwide cohort.

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The success of anterior cruciate ligament reconstruction (ACLR) depends on osseointegration at the graft-tunnel interface and intra-articular ligamentization. Our aim was to conduct a systematic review of clinical and preclinical studies that evaluated biological augmentation of graft healing in ACLR.

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Our aim was to evaluate the radiographic characteristics of patients undergoing total hip arthroplasty (THA) for the potential of posterior bony impingement using CT simulations.

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Different methods of anterior cruciate ligament (ACL) reconstruction have been described for skeletally immature patients before closure of the growth plates. However, the outcome and complications following this treatment remain unclear. The aim of this systematic review was to analyse the outcome and complications of different techniques which may be used for reconstruction of the ACL in these patients.

Aims

The aim of this study was to investigate the long-term clinical and radiological outcome of patients who suffer recurrent injuries to the anterior cruciate ligament (ACL) after reconstruction and require revision surgery.

Instability in flexion after total knee replacement (TKR) typically occurs as a result of mismatched flexion and extension gaps. The goals of this study were to identify factors leading to instability in flexion, the degree of correction, determined radiologically, required at revision surgery, and the subsequent clinical outcomes. Between 2000 and 2010, 60 TKRs in 60 patients underwent revision for instability in flexion associated with well-fixed components. There were 33 women (55%) and 27 men (45%); their mean age was 65 years (43 to 82). Radiological measurements and the Knee Society score (KSS) were used to assess outcome after revision surgery. The mean follow-up was 3.6 years (2 to 9.8). Decreased condylar offset (p < 0.001), distalisation of the joint line (p < 0.001) and increased posterior tibial slope (p < 0.001) contributed to instability in flexion and required correction at revision to regain stability. The combined mean correction of posterior condylar offset and joint line resection was 9.5 mm, and a mean of 5° of posterior tibial slope was removed. At the most recent follow-up, there was a significant improvement in the mean KSS for the knee and function (both p < 0.001), no patient reported instability and no patient underwent further surgery for instability.

The following step-wise approach is recommended: reduction of tibial slope, correction of malalignment, and improvement of condylar offset. Additional joint line elevation is needed if the above steps do not equalise the flexion and extension gaps.

Cite this article: Bone Joint J 2014;96-B:1644–8.

We used immediate post-operative in vivo three-dimensional computed tomography to compare graft bending angles and femoral tunnel lengths in 155 patients who had undergone single-bundle reconstruction of the anterior cruciate ligament using the transtibial (n = 37), anteromedial portal (n = 72) and outside-in (n = 46) techniques.

The bending angles in the sagittal and axial planes were significantly greater but the coronal-bending angle was significantly less in the transtibial group than in the anteromedial portal and outside-in groups (p < 0.001 each). The mean length of the femoral tunnel in all three planes was significantly greater in the transtibial group than the anteromedial portal and outside-in groups (p < 0.001 each), but all mean tunnel lengths in the three groups exceeded 30 mm. The only significant difference was the coronal graft- bending angle in the anteromedial portal and outside-in groups (23.5° vs 29.8°, p = 0.012).

Compared with the transtibial technique, the anteromedial portal and outside-in techniques may reduce the graft-bending stress at the opening of the femoral tunnel. Despite the femoral tunnel length being shorter in the anteromedial portal and outside-in techniques than in the transtibial technique, a femoral tunnel length of more than 30 mm in the anteromedial portal and outside-in techniques may be sufficient for the graft to heal.

Cite this article: Bone Joint J 2014;96-B:743–51.

Recent reports have suggested an increase in the number of anterior cruciate ligament (ACL) injuries in children, although their true incidence is unknown.

The prognosis of the ACL-deficient knee in young active individuals is poor because of secondary meniscal tears, persistent instability and early-onset osteoarthritis. The aim of surgical reconstruction is to provide stability while avoiding physeal injury. Techniques of reconstruction include transphyseal, extraphyseal or partial physeal sparing procedures.

In this paper we review the management of ACL tears in skeletally immature patients.

Cite this article: Bone Joint J 2013;95-B:1562–9.

Medial patellofemoral ligament (MPFL) reconstruction is used to treat patellar instability and recurrent patellar dislocation. Anatomical studies have found the MPFL to be a double-bundle structure. We carried out a meta-analysis of studies reporting outcomes of patellofemoral reconstruction using hamstring tendon autograft in a double-bundle configuration and patellar fixation via mediolateral patellar tunnels.

A literature search was undertaken with no language restriction in various databases from their year of inception to July 2012. The primary outcome examined was the post-operative Kujala score. We identified 320 MPFL reconstructions in nine relevant articles. The combined mean post-operative Kujala score was 92.02 (standard error (se) 1.4, p = 0.001) using a fixed effects model and 89.45 (se 37.9, p = 0.02) using random effect modelling. The reported rate of complications with MPFL reconstruction was 12.5% (40 of 320) with stiffness of the knee being the most common. High-quality evidence in assessing double-bundle MPFL reconstruction is lacking. The current literature consists of a mixture of prospective and retrospective case series. High-quality randomised trials evaluating this procedure are still awaited.

Cite this article: Bone Joint J 2013;95-B:900–5.

The use of platelet-rich plasma (PRP) as an adjuvant to tissue repair is gaining favour in orthopaedic surgery. Tunnel widening after anterior cruciate ligament (ACL) reconstruction is a recognised phenomenon that could compromise revision surgery. The purpose of this study was to determine whether PRP might prevent tunnel widening in ACL reconstruction.

Patients undergoing ACL reconstruction using a hamstring graft were randomly allocated either to have PRP introduced into the tunnels peri-operatively or not. CT scanning of the knees was carried out on the day after surgery and at three months post-operatively and the width of the tunnels was measured. Patients were also evaluated clinically at three months, when laxity was also measured.

Each group comprised 25 patients, and at three months post-operatively all were pain-free with stable knees, a negative Lachman test and a good range of movement. Arthrometric results had improved significantly in both groups (p < 0.001). Despite slightly less tunnel widening in the PRP group, there was no significant difference between the groups at the femoral opening or the mid-tunnel (p = 0.370 and p = 0.363, respectively) nor at the tibial opening or mid-tunnel (p = 0.333 and p = 0.177, respectively).

We conclude that PRP has no significant effect in preventing tunnel widening after ACL reconstruction.

Cite this article: Bone Joint J 2013;95-B:65–9.

The technical advances in arthroscopic surgery of the hip, including the improved ability to manage the capsule and gain extensile exposure, have been paralleled by a growth in the number of conditions that can be addressed. This expanding list includes symptomatic labral tears, chondral lesions, injuries of the ligamentum teres, femoroacetabular impingement (FAI), capsular laxity and instability, and various extra-articular disorders, including snapping hip syndromes. With a careful diagnostic evaluation and technical execution of well-indicated procedures, arthroscopic surgery of the hip can achieve successful clinical outcomes, with predictable improvements in function and pre-injury levels of physical activity for many patients.

This paper reviews the current position in relation to the use of arthroscopy in the treatment of disorders of the hip.

Cite this article: Bone Joint J 2013;95-B:10–19.

Incomplete avulsion of the proximal hamstrings can be a severely debilitating injury that causes weakness, pain while sitting and inability to run. The results of the surgical treatment of 23 consecutive patients with such injuries at least two years after surgery are described. The surgery consisted of the repair of the hamstrings directly onto the ischial tuberosity. At review, using a visual analogue scale (VAS, 0 to 100), pain while sitting improved from a mean of 40 (0 to 100) to 64 (0 to 100) (p = 0.024), weakness from a mean of 39 (0 to 90) to 76 (7 to 100) (p = 0.0001) and the ability to run from a mean of 24 (0 to 88) to 64 (0 to 95) (p = 0.0001). According to a VAS, satisfaction was rated at a mean of 81 (0 to 100) and 20 patients (87%) would have the same procedure again. Hamstring strength measured pre- and post-operatively had improved significantly from a mean of 64% (0% to 95%) to 88% (50% to 114%) compared with the normal side.

Most of these patients with symptomatic incomplete hamstring avulsions unresponsive to conservative treatment had an improved outcome after surgical repair.

The purpose of this study was to report the outcome of ‘isolated’ anterior cruciate ligament (ACL) ruptures treated with anatomical endoscopic reconstruction using hamstring tendon autograft at a mean of 15 years (14.25 to 16.9). A total of 100 consecutive men and 100 consecutive women with ‘isolated’ ACL rupture underwent four-strand hamstring tendon reconstruction with anteromedial portal femoral tunnel drilling and interference screw fixation by a single surgeon. Details were recorded pre-operatively and at one, two, seven and 15 years post-operatively. Outcomes included clinical examination, subjective and objective scoring systems, and radiological assessment. At 15 years only eight of 118 patients (7%) had moderate or severe osteo-arthritic changes (International Knee Documentation Committee Grades C and D), and 79 of 152 patients (52%) still performed very strenuous activities. Overall graft survival at 15 years was 83% (1.1% failure per year). Patients aged < 18 years at the time of surgery and patients with > 2 mm of laxity at one year had a threefold increase in the risk of suffering a rupture of the graft (p = 0.002 and p = 0.001, respectively). There was no increase in laxity of the graft over time. ACL reconstructive surgery in patients with an ‘isolated’ rupture using this technique shows good results 15 years post-operatively with respect to ligamentous stability, objective and subjective outcomes, and does not appear to cause osteoarthritis

This annotation considers the place of extra-articular reconstruction in the treatment of anterior cruciate ligament (ACL) deficiency. Extra-articular reconstruction has been employed over the last century to address ACL deficiency. However, the technique has not gained favour, primarily due to residual instability and the subsequent development of degenerative changes in the lateral compartment of the knee. Thus intra-articular reconstruction has become the technique of choice. However, intra-articular reconstruction does not restore normal knee kinematics. Some authors have recommended extra-articular reconstruction in conjunction with an intra-articular technique.

The anatomy and biomechanics of the anterolateral structures of the knee remain largely undetermined. Further studies to establish the structure and function of the anterolateral structures may lead to more anatomical extra-articular reconstruction techniques that supplement intra-articular reconstruction. This might reduce residual pivot shift after an intra-articular reconstruction and thus improve the post-operative kinematics of the knee.

Abnormal knee kinematics following reconstruction of the anterior cruciate ligament may exist despite an apparent resolution of tibial laxity and functional benefit. We performed upright, weight-bearing MR scans of both knees in the sagittal plane at different angles of flexion to determine the kinematics of the knee following unilateral reconstruction (n = 12). The uninjured knee acted as a control. Scans were performed pre-operatively and at three and six months post-operatively. Anteroposterior tibial laxity was determined using an arthrometer and patient function by validated questionnaires before and after reconstruction. In all the knees with deficient anterior cruciate ligaments, the tibial plateau was displaced anteriorly and internally rotated relative to the femur when compared with the control contralateral knee, particularly in extension and early flexion (mean lateral compartment displacement: extension 7.9 mm (sd 4.8), p = 0.002 and 30° flexion 5.1 mm (sd 3.6), p = 0.004). In all ten patients underwent post-operative scans. Reconstruction reduced the subluxation of the lateral tibial plateau at three months, with resolution of anterior displacement in early flexion, but not in extension (p = 0.015). At six months, the reconstructed knee again showed anterior subluxation in both the lateral (mean: extension 4.2 mm (sd 4.2), p = 0.021 and 30° flexion 3.2 mm (sd 3.3), p = 0.024) and medial compartments (extension, p = 0.049).

Our results show that despite improvement in laxity and functional benefit, abnormal knee kinematics remain at six months and actually deteriorate from three to six months following reconstruction of the anterior cruciate ligament.