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Xiaofeng Deng, Haoran Xu, Xiaoxia Hao, Jiawei Liu, Xingru Shang, and Tao Xu

  • Osteoarthritis (OA) is a chronic degenerative disease, which can cause a series of symptoms including pain and functional limitation, thus severely decreasing quality of life.

  • OA pathogenesis can be categorized into four levels, including risk factors, potential mechanisms, intraarticular degeneration phenotype, and substantive histological changes.

  • Moderate exercise can alleviate OA at all levels of pathogenesis, while excessive exercise may have adverse effects.

  • Based on rat-related original research, the parameters of moderate exercise and the effect of improving osteoarthritis have been comprehensively summarized.

  • Based on the extensive randomized controlled trial studies, results show various moderate exercises can improve the symptom and prognosis of OA in clinical settings.

  • This review gives an overview of the pathogenesis of OA and the mechanisms as well as clinical examples of moderate exercise treatment, aimed at providing rationale and evidence for moderate exercise in the treatment of OA to facilitate the provision of appropriate exercise therapy for OA patients.

Tianping Zhou, Yihong Xu, Aiai Zhang, Lan Zhou, Qing Zhang, Zhou Ji, and Weidong Xu


  • The aim of this study is to comprehensively analyze the publications of anterior cruciate ligament reconstruction (ACLR) research and display the current research status in this field.


  • Articles regarding ACLR research published before October 7, 2021, were downloaded from the Web of Science Core Collection. Excel 2016 and Bibliometric website were used to analyze the annual article trends and international cooperation network. CiteSpace V and VOSviewer were used to perform co-occurrence and citation analyses for journals, institutions, authors, cocitation authors and keywords. Burst keyword detection was also performed with CiteSpace V.


  • A total of 12 223 ACLR articles were identified. The American Journal of Sports Medicine (1636 publications, 92,310 citations), the Pennsylvania Commonwealth System of Higher Education (624 publications, 25,304 citations) and Freddie H. Fu (321 publications, 15,245 citations) were journals, institutions and authors with the most publications and citations, respectively. Patellar tendon was the keyword with the most occurrences (1618 times) and return to sport was the keyword with the most burst strength (burst strength: 46.99).


  • ACLR-related publications showed a rapid increasing trend since 1990. A large number of articles have been published by authors from different institutions and countries, some of which have gained great academic influence. Based on keyword analysis, patellar tendon is identified as the research hotspot and return to sport is identified as the current research frontier.

E. Carlos Rodríguez-Merchán, Hortensia De la Corte-Rodríguez, Carlos A. Encinas-Ullán, and Primitivo Gómez-Cardero

  • The main complications of surgical reconstruction of multiligament injuries of the knee joint are residual or recurrent instability, arthrofibrosis, popliteal artery injury, common peroneal nerve injury, compartment syndrome, fluid extravasation, symptomatic heterotopic ossification, wound problems and infection, deep venous thrombosis, and revision surgery.

  • Careful surgical planning and execution of the primary surgical reconstruction of multiligament injuries of the knee joint can minimize the risk of the aforementioned complications.

  • Careful postoperative follow-up is required to detect complications. Early recognition and prompt treatment are of paramount importance.

  • To obtain good results in the revision surgery of failed multiligamentary knee reconstructions, it is crucial to perform a thorough and exhaustive evaluation to detect all the causes of failure.

  • Addressing all associated injuries during revision surgery will lead to the best possible subjective and objective results, although functional outcomes are often modest.

  • However, advanced age and high-energy injuries have been associated with the poorest functional outcomes after revision surgery of failed multiligament injuries of the knee joint.

Cite this article: EFORT Open Rev 2021;6:973-981. DOI: 10.1302/2058-5241.6.210057

Joanna Baawa-Ameyaw, Ricci Plastow, Fahima Aarah Begum, Babar Kayani, Hyder Jeddy, and Fares Haddad

  • Graft selection for anterior cruciate ligament reconstruction (ACLR) is important for optimizing post-operative rehabilitation, facilitating return to full sporting function and reducing the risk of complications.

  • The most commonly used grafts for ACLR include hamstring tendon autografts, bone–patellar tendon–bone autografts, quadriceps tendon autografts, allografts and synthetic grafts.

  • This instructional review explores the existing literature on clinical outcomes with these different graft types for ACLR and provides an evidence-based approach for graft selection in ACLR.

  • The existing evidence on the use of extra-articular tenodesis to provide additional rotational stability during ACLR is also revisited.

Cite this article: EFORT Open Rev 2021;6:808-815. DOI: 10.1302/2058-5241.6.210023

Vicente Carlos da Silva Campos, Francisco Guerra Pinto, Diogo Constantino, Renato Andrade, and João Espregueira-Mendes

  • Complete access to the posterior medial compartment of the knee may represent a technical challenge during arthroscopy in patients with a tight tibiofemoral joint space.

  • Medial collateral release reduces direct iatrogenic cartilage damage in the medial compartment of the knee through manipulation with instruments.

  • We recommend performing medial collateral release in surgeries that access the posteromedial compartment (e.g. partial meniscectomy for ruptures of the posterior horn of medial meniscus or posterior root repairs) when the patient has a tight tibiofemoral joint space.

  • There are two main techniques to perform medial collateral release: inside-out and outside-in. Regardless of the technique used, releasing medial ligament structures is a safe and effective method to be used in the diagnosis and treatment of injuries to the medial compartment.

Cite this article: EFORT Open Rev 2021;6:669-675. DOI: 10.1302/2058-5241.6.200128

Francisco Figueroa, David Figueroa, Sven Putnis, Rodrigo Guiloff, Patricio Caro, and João Espregueira-Mendes

  • Limited knowledge of the anatomy and biomechanics of the posterolateral corner (PLC) of the knee, coupled with poor patient outcomes with non-operative management, resulted in the PLC often being labelled as the ‘dark side’ of the knee. In the last two decades, extensive research has resulted in a better understanding of the anatomy and function of the PLC, and has led to the development of anatomic reconstructions that have resulted in improved patient outcomes.

  • Despite considerable attention in the clinical orthopaedic literature (nearly 400 articles published in the last decade), a standardized algorithm for the diagnosis and treatment of the PLC is still lacking, and much controversy remains.

  • Considering the literature review, there is not a reconstruction technique that clearly prevails over the others. As anatomic, biomechanical, and clinical knowledge of PLC injuries continues to progress, finding the balance between re-creating native anatomy and safely performing PLC reconstruction provides a big challenge. Treatment decisions should be made on a case-by-case basis.

Cite this article: EFORT Open Rev 2021;6:676-685. DOI: 10.1302/2058-5241.6.200096

Riccardo D’Ambrosi, Katia Corona, Germano Guerra, Simone Cerciello, Chiara Ursino, Nicola Ursino, and Michael Hantes

  • The posterior oblique ligament (POL) is the predominant ligamentous structure on the posterior medial corner of the knee joint. A thorough understanding of the anatomy, biomechanics, diagnosis, treatment and rehabilitation of POL injuries will aid orthopaedic surgeons in the management of these injuries.

  • The resulting rotational instability, in addition to valgus laxity, may not be tolerated by athletes participating in pivoting sports. The most common mechanism of injury – accounting for 72% of cases – is related to sports activity, particularly football, basketball and skiing. Moreover, three different injury patterns have been reported: those associated with injury to the capsular arm of the semimembranosus (SM), those involving a complete peripheral meniscal detachment and those involving disruption of the SM and peripheral meniscal detachment.

  • The hallmark of an injury related to POL lesions is the presence of anteromedial rotatory instability (AMRI), which is defined as ‘external rotation with anterior subluxation of the medial tibial plateau relative to the distal femur’.

  • In acute settings, POL lesions can be easily identified using coronal and axial magnetic resonance imaging (MRI) where the medial collateral ligament (MCL) and POL appear as separate structures. However, MRI is not sensitive in chronic cases.

  • Surgical treatment of the medial side leads to satisfactory clinical results in a multi-ligamentous reconstruction scenario, but it is known to be associated with secondary stiffness.

  • In young patients with high functional demands, return to sports is allowed no earlier than 9–12 months after they have undergone a thorough rehabilitation programme.

Cite this article: EFORT Open Rev 2021;6:364-371. DOI: 10.1302/2058-5241.6.200127

Yusuf Omar Qalib, Yicun Tang, Dawei Wang, Baizhou Xing, Xingming Xu, and Huading Lu

  • Ramp lesion of the medial meniscus used to be completely disregarded in the past.

  • Ramp lesion has been now put under the spotlight by orthopaedic and sport medicine surgeons and requires attention.

  • It is closely associated with anterior cruciate ligament injury. Major risk factors include chronic laxity, lateral meniscal lesion, anterior cruciate ligament reconstruction revision, anterolateral ligament tear concomitant with anterior cruciate ligament injury, time from injury, pre-operative side-to-side laxity > 6 mm, age < 30 years old, male sex, etc.

  • Radiologists attempt to create diagnostic criteria for ramp lesion using magnetic resonance imaging. However, the only definite method to diagnose ramp lesion is still arthroscopy. Various techniques exist, among which posteromedial approach is the most highly recommended.

  • Various treatment options are available. The success rate of ramp repair is very high. Major complications are uncommon.

Cite this article: EFORT Open Rev 2021;6:372-379. DOI: 10.1302/2058-5241.6.200126

Francisco Figueroa, David Figueroa, Rafael Calvo, Alex Vaisman, and João Espregueira-Mendes

  • Hamstring autograft use has been linked to an increased risk of infection after anterior cruciate (ACL) reconstruction compared to other grafts. The absolute reason for this remains unclear, with contamination after harvesting and preparation of the graft being the most accepted hypothesis.

  • Using the rationale that a contaminated graft could be the main factor in postoperative septic arthritis and in an effort to maximize the antibiotic efficacy of the graft, the Vancomycin presoaking technique was developed. It has shown success in decreasing the infection rate in ACL reconstruction. In recent years, an important number of research articles using this protocol have appeared, but the technique is still not widely implemented.

  • Recent literature shows that Vancomycin presoaking of the graft has shown a successful decrease in the infection rate after hamstring autograft ACL reconstruction. It has also shown efficacy decreasing the infection rate in other types of grafts (patellar tendon, quadriceps tendon, allograft) and also in patients with concomitant ligament procedures or open surgeries.

  • Despite the positive effects of Vancomycin presoaking reducing the infection rate after ACL reconstruction, the lack of prospective randomized control trials and the heterogeneity of the different studies mean it is not feasible to recommend Vancomycin presoaking of the graft universally for every ACL reconstruction patient.

Cite this article: EFORT Open Rev 2021;6:211-216. DOI: 10.1302/2058-5241.6.200059

Alberto Grassi, Nicola Pizza, Gian Andrea Lucidi, Luca Macchiarola, Massimiliano Mosca, and Stefano Zaffagnini

  • The popliteal hiatus is a complex region, formed by the confluence of various structures connecting the meniscus, popliteal tendon, tibia and fibula.

  • The main structures that can be found are the three popliteomeniscal fascicles (anterior, postero-inferior and postero-superior), the lateral and posterior meniscotibial ligaments, the popliteofibular ligament and the meniscofibular fascicle.

  • These structures can be identified in most cases using magnetic resonance imaging, and their ‘static’ assessment can be performed.

  • Arthroscopic assessment is useful in identifying and testing ‘dynamically’ the integrity of the structures around the popliteal hiatus.

  • Injuries or abnormalities of the popliteal hiatus and its structures could result in meniscal hypermobility and subluxation; however, these injuries are often unrecognized.

  • Possible abnormalities in this region, apart from the well-known bucket-handle meniscal tear, are the Wrisberg Type III discoid meniscus, and meniscal fascicles tears.

Cite this article: EFORT Open Rev 2021;6:61-74. DOI: 10.1302/2058-5241.6.200089