Background and ObjectiveMultiligament knee injuries (MLKIs), although rare in athletes, can present distinct challenges beyond the high-energy trauma commonly seen in the general population. The combination of anterior cruciate ligament (ACL) injury with other major knee stabilizers creates substantial treatment challenges as most athletes experience pressure to return to top-level sports quickly, while maintaining joint stability over a long career. This narrative review summarizes the epidemiology and biomechanics of common injury patterns, classification systems, surgical decision-making and rehabilitation strategies for managing multiple ligament knee injuries in athletes.MethodsA narrative literature review was conducted using PubMed and MEDLINE databases, targeting English-language studies from 2000 to 2024. Relevant studies were identified through keyword searches including “multiligament knee injury”, “ACL reconstruction”, “athlete”, “return to play”, and “concomitant ligament injury”. Studies focused on biomechanics, surgical technique, rehabilitation, biologic augmentation, and performance outcomes were included.Key Content and FindingsMLKIs are recognized with an increasing incidence in athletes; however, they are not well studied in the literature outside of traumatic, typically high energy settings. In athletes, management becomes more complex as surgical intervention must be considered in tandem with return-to-play (RTP) necessitating individualized planning. Underlying knee biomechanics can help identify potential risk for specific injury patterns. Surgical reconstruction with autograft in a single staged procedure is preferred due to possible lower risk for re-rupture and potentially quicker return to sport; however, graft selection based on number of ligaments involved and timing of surgery remain points of controversy. Importantly, avoiding tunnel collision during MLKI reconstruction adds a unique challenge and requires thoughtful surgical preoperative planning. Appropriate rehabilitation is critical as well to allow RTP at the same level. Generally, early range of motion with progressive weight bearing is recommended with an additive potential for standardized testing to evaluate for RTP. As MLKI research continues to progress, identifying optimal graft selection, timing of reconstruction, and rehabilitation protocols with a potential role for biologics will improve athletes’ successful RTP.ConclusionsMLKIs in athletes present unique challenges that extend beyond those seen in high-energy trauma cases. Coordinating surgical management with RTP goals requires individualized planning and thoughtful rehabilitation. Ongoing research is needed to refine graft selection, surgical timing, and recovery protocols. In this narrative review, we aim to review the literature, highlight treatment gaps and future areas of research, and provide general treatment recommendations to optimize outcomes in this population.

Background and ObjectiveCartilage lesions of the knee occur frequently and can cause debilitating symptoms such as pain, swelling, locking, clicking, or catching. In some lesions, both the cartilage and underlying subchondral bone are affected, which may require treatment of both the osseous and cartilaginous units. The objective of this review was to assess the available evidence of advanced treatments for osteochondral lesions in the knee.MethodsA literature search was conducted in the electronic databases of PubMed, Embase and Cochrane Library for a narrative review on studies reporting outcomes of osteochondral knee treatments. Studies were included if they reported outcomes at minimum 1-year follow-up and had minimum 5 patients, and biomechanical, translational and basic science studies were excluded.Key Content and FindingsIn addition to chondroplasty and microfracture, four major advanced osteochondral restoration procedures aimed at treating injuries to the osteochondral unit were identified in the literature, which consisted of surgical internal fixation of either acute osteochondral fragments or osteochondritis dissecans (OCD) lesions, osteochondral autograft transplantation (OAT), osteochondral allograft (OCA) transplantation and biphasic scaffold implantation. Internal fixation of acute osteochondral patellofemoral fractures has been found to have superior outcomes compared to fragment removal, but does require concomitant patellar stabilization. Fixation of OCD also leads to good outcomes without superiority for fixation method. Osteochondral autograft is an excellent treatment option for smaller defects and has a high rate of return to sport. OCA outcomes are excellent with good survival rates although reoperations can frequently occur. Finally, biphasic scaffolds are relatively recent and can be used in both more acute as well as more degenerative settings and the short-term outcomes are promising.ConclusionsOsteochondral injury in the knee requires unique treatment options as both the underlying bone and cartilage need to be treated, due to their poor healing capacity and significant cause of morbidity. Several treatment options exist and the overall outcomes of these treatments are satisfactory in improving patient-reported outcomes, and most patients can return to activities.

Patellofemoral instability (PFI) is a relatively common injury in the young, athletic population and remains a significant source of knee pain and functional limitation. It most frequently affects athletes who participate in sports that involve repetitive jumping, cutting, and pivoting motions, such as basketball, soccer, and volleyball. During the competitive season, managing this condition becomes particularly challenging. Athletes are often eager to return to play, while clinicians must weigh the risks of early return against the need for sufficient recovery to prevent re-injury. As a result, in-season management continues to be a topic of ongoing discussion and debate. This review explores the comprehensive evaluation and treatment of PFI, with a focus on both non-surgical and surgical options. Non-surgical management, including rehabilitation and activity modification, is typically favored for first-time dislocations or in the absence of significant anatomical abnormalities. Surgical intervention is considered in cases of recurrent instability or when structural issues are identified. In addition to physical treatment, rehabilitation plays a central role in restoring strength, stability, and neuromuscular control. Equally important is psychological readiness, which is increasingly recognized as a critical factor in safely returning athletes to sport. A well-rounded approach that addresses both physical and mental recovery is essential for optimal outcomes.

Surgical site infections (SSIs) are common complications after joint arthroplasty, leading to increased morbidity and healthcare costs. Traditional models, like the National Nosocomial Infections Surveillance (NNIS) system, have limitations in predicting SSI risk due to a lack of patient-specific factors. This study aimed to create and validate a predictive model focusing on hypoproteinemia to enhance SSI risk assessment in joint surgery patients. A retrospective cohort study of 726 patients undergoing joint arthroplasty between 2020 and 2022 was conducted. Data included demographics, laboratory values, and surgical details. Univariate and multivariate analyses identified key predictors, including hypoproteinemia, to develop a predictive nomogram. Model validation was performed using receiver operating characteristic curves, calibration, and decision curve analysis (DCA), comparing it to the NNIS model. Hypoproteinemia was a significant independent predictor of SSI, with the new model outperforming the NNIS system (area under the curve: 0.829 vs. 0.534). Calibration analysis showed excellent agreement between predicted and observed probabilities, with a mean absolute error of 0.009. DCA further confirmed the model's clinical utility, showing a higher net benefit across various thresholds compared to traditional approaches. Hypoproteinemia is a critical risk factor for SSI in joint arthroplasty. The new predictive model offers improved risk stratification, supporting a more personalized approach to perioperative management in orthopedic surgery.

Growing evidence suggests that many non-contact mechanical fatigue-related anterior cruciate ligament (ACL) injuries are related to the accumulated microtrauma that leads to sudden failure. These factors may play a critical role in enhancing both sports performance and adherence to ACL injury prevention programs among youth and adolescent athletes. This clinical practice review synthesizes existing literature on sustainable performance plan principles that integrate active rest and recovery, with an emphasis on boredom mitigation and self-control development. A comprehensive literature search was conducted using PubMed, Web of Science, and OVID MEDLINE databases to identify key themes presented in the following sub-sections: The elite training industry and rise of specialization; Lessons from sports diversity and delayed specialization; Developing more than muscles; Mitigating boredom, developing self-control; Active rest and recovery; Culture, context, and compliance; and Blending performance training and injury prevention. By fostering engagement and adherence among all stakeholders, sustainable performance plans that incorporate boredom mitigation, self-control development, and structured active rest and recovery may enhance compliance with neuromuscular training programs aimed at reducing non-contact ACL injury risk in youth and adolescent athletes. Further research is needed to assess the most effective strategies for integrating these principles into existing training models.

The evaluation of both femoral and tibial torsional profiles remains a challenge in the orthopedic practice since there is no agreement on the most precise and reliable measurement method and technique. The aim of this review is to collect and critically report the most relevant and up-to-date evidence on the radiological techniques available to determine lower limb torsional deformities and to discuss the advantages and limitations of each technique to better define their optimal field of application. Literature research on PubMed, Embase, and Google Scholar databases was performed, utilizing the following search string: "torsion" AND ("lower limb" OR "femur" OR "tibia"). Relevant clinical and preclinical studies evaluating different radiological techniques to assess lower limb torsional deformities, and possibly comparing them, were collected and critically reviewed. Computed tomography (CT) is still considered the best method to measure both femoral and tibial torsional angles. Its main limitation, the radiation exposure, has been recently addressed with ultra-low dose protocols that were proven to be as accurate as standard protocols. On the other hand, magnetic resonance imaging (MRI) offers a nonionizing, radiation-free option that is now considered almost equivalent to CT. However, MRI consists in a long and expensive procedure that can be hindered by issues linked to metal implants, patient's positioning and measurement variabilities. Lastly, three-dimensional (3D) reconstructions derived from low-dose biplanar radiographies (LD-BRs) have been proposed as a low-radiating, quick and reliable solution to overcome the limitations of both MRI and CT scans. To date, CT has still to be considered the gold standard for the radiological assessment of lower limb torsional deformities. Nonetheless, MRI and LD-BR have been proven to be valid and reliable alternatives, especially in specific clinical settings.

Angiotensin II receptor blockers (ARBs) are commonly prescribed for hypertension and heart failure, and have well-described antifibrotic properties throughout medical literature. The etiology and pathogenesis of fibrosis is biologically complex with a multitude of factors playing a role in the process. Consequently, pathologic fibrosis may be significant within orthopaedics contributing to post-operative stiffness and, ultimately, negative patient outcomes. The pharmacology of ARBs has been described to combat fibrosis in preclinical settings, while the literature of ARBs antifibrotic properties in relation to orthopaedics remains scarce. However, fibrosis is one of the primary factors contributing to tissue healing and functional recovery in the field of orthopaedic surgery. Fibrosis has specifically been described in relation to shoulder surgery, knee arthroplasty and hip arthroscopy. As such, outcomes of various orthopaedic surgeries are dependent upon a balance between tissue healing and stiffness, both of which may be mediated by a fibrotic response. Importantly, ARBs have recently emerged as a potential therapy to combat fibrosis-mediated stiffness in orthopaedic surgery patients. Thus, the following review article seeks to highlight the basic and clinical science of ARBs with emphasis on their implications and indications for orthopaedic surgery and musculoskeletal medicine.

Injury to the anterior cruciate ligament (ACL) is a devastating injury to athletes of all ages. The current gold standard treatment following complete rupture of the ACL is reconstruction of the torn ligament with autograft or allograft tendon. Commonly used tendon grafts include patellar tendon, hamstring tendon, and quadriceps tendon. Although ligaments and tendons have similar collagen and proteoglycan compositions, they maintain a unique composition and arrangement of cells to serve their unique biomechanical needs. Therefore, following ACL reconstruction (ACLR), the implanted tendon tissue undergoes a process of remodeling which is termed "ligamentization". The process of ligamentization is divided into three main phases, which include the early healing phase, the proliferative phase, and the maturation phase. Following the process of ligamentization, the graft tissue closely mimics the appearance of ligament tissue on an ultrastructural level. Successful outcome following ACLR is contingent upon adequate remodeling of the tissue as well as healing of the graft within the bone tunnels in the femur and tibia. Choice of graft has individual implications regarding their associated risk of complications, failure, and infection. The purpose of this review is to summarize the process of ligamentization and graft healing and to discuss how graft type influences the rate and types of complications, failures, and infections.

Due to growing numbers of primary total hip replacement (THR), the revision THR burden is also increasing. Common indications for revision are osteolysis, infection, instability, and mechanical failure of implants, which can cause acetabular bone loss. Massive acetabular bone defects and pelvic discontinuity are extremely challenging problems. Many techniques have been utilized to address bone loss while maintaining a stable revision THR. Structural allografts, cemented prosthesis, reconstruction cages, and custom triflanged implants have all been used successfully albeit with relatively high complications rates. We have tried to highlight emerging trends to utilize Custom Made Monoflange or Triflange Acetabular Components to reconstruct massive acetabular defects with favourable midterm implant survival, better functional outcomes, relatively lesser complications, and almost similar cost of prosthesis as compared to conventional reconstruction techniques. However, long-term data and study is still recommended to draw a definitive conclusion. In this narrative review article, we searched PubMed and Cochrane for studies on managing acetabular bone loss in revision THR with a focus on recent literature for mid to long-term outcomes and compared results from various studies on different reconstruction methods. Hemispherical cementless acetabular prosthesis with supplemental screws are commonly utilized to manage mild to moderate acetabular bone loss. Recent trends have shown much interest and paradigm shift in patient specific custom triflange acetabular components (CTAC) for reconstructing massive acetabular defects and pelvic discontinuity. Studies have reported high patient satisfaction, improved patient reported daily functioning, high mid-term implant survival, similar complications, and encouraging all cause re-revision rate. However, more prospective and quality studies with larger sample sizes are needed to validate the superiority of CTACs over conventional acetabular implants. There is no consensus regarding the best option for reconstructing massive acetabular defects. Thorough preoperative workup and planning is an absolute requirement for successful revision THR. While most of the moderate acetabular bone loss can be managed with cementless hemispherical acetabular shells with excellent long-term outcomes, reconstructing massive acetabular bone defects in revision THR remains a challenge. Depending on the size and location of the defect, various constucts have demonstrated long-term success as discussed in this review, but complications are not negligible. CTACs provide a treatment for massive bone loss that may be otherwise difficult to achieve anatomic stability with other constructs. Although long-term data is sparse, the cost and complication rate is comparable to other reconstruction methods.

Proximal femoral replacement due to revision hip arthroplasty or catastrophic proximal femur fracture fixation failures with considerable proximal femur bone loss can lead to a substantial loss of function of the soft tissue around the hip and the abductor muscles in particular. Surgical techniques of gluteus medius repair and/or abductor mechanism reattachment/reconstruction are widely debated in the literature, but it is quite rarely dealt with in the context of megaprosthesis and femoral reconstruction, particularly in non-oncologic patients. The aim of this study is to present a narrative review of the literature on techniques for abductor reattachment in proximal femoral replacement for non-oncological reconstructions. MEDLINE, Embase, and Cochrane databases were searched by two researchers independently from inception until February 1st, 2023 (923 for MEDLINE and 963 for Embase; Cochrane is a composite of multiple databases and thus does not report a standard inception date). Articles examining proximal femoral reconstruction with megaprosthesis or allograft prosthesis were included. Studies concerning cadaver and oncologic patients were excluded. If the researchers failed to find an agreement on whether to include a study, the senior researcher would make a final decision in such cases. Data were extracted and stored, and qualitative synthesis was performed. A total of 1,157 articles from MEDLINE, 11,187 articles from Embase, and 0 articles from Cochrane were identified. Of 12,344 articles, the structured screening process revealed 10 eligible trials. Four different types of abductor musculature reconstruction/reinsertion were identified. Multiple and complex revision hip arthroplasties as well as multiple surgical procedures for proximal femur fracture fixations failures may have a great impact on proximal femur bone stock condition and soft tissue preservation requiring the use of a proximal femur megaprosthesis. In such cases, the abductor mechanism reconstruction and/or reattachment is achievable with different techniques that can be resumed in four different groups: direct suture to the prosthesis, trochanteric sleeve osteotomy, muscle-to-muscle suture, and synthetic tube augmentation suture.