Purpose: The purpose of this systematic review is to describe the complications and downsides of robotic systems in total knee arthroplasty (TKA).Methods: A comprehensive search according to the PRISMA guidelines was performed across PubMed, MEDLINE, Cochrane Central Register of Controlled Trials, Scopus, and Google Scholar from inception until December 2021. All articles of any study design directly reporting on complications and downsides of the robotic system in TKA were considered for inclusion. Risk of bias assessment was performed for all included studies using the Cochrane risk of bias and MINORS score.Results: A total of 21 studies were included, consisting of 4 randomized controlled trials, 7 prospective studies and 10 retrospective studies. Complications of the robotic system were pin‐hole fracture, pin‐related infection, iatrogenic soft tissue and bony injury, and excessive blood loss. While, downsides were longer operative duration, higher intraoperative cost, learning curve and aborting a robotic TKA due to different reasons. Iatrogenic injuries were more common in the active robotic system and abortion of the robotic TKA was reported only with active robotic TKA.Conclusion: Robotic TKA is associated with certain advantages and disadvantages. Therefore, surgeons need to be familiar with the system to use it effectively. Widespread adoption of the robotic system should always be evidence‐based.Level of evidence: IV.

Purpose: This study aimed to systematically evaluate the clinical, functional, and radiological outcomes, complications, and rate of return to sports among patients with RAMP lesion of the medial meniscus encountered during anterior cruciate ligament (ACL) reconstruction.Methods: A systematic review was conducted based on the PRISMA guidelines. Two independent reviewers searched the PubMed, Scopus, Embase, and Cochrane Library databases using the terms “ACL” or “anterior cruciate ligament,” and “RAMP lesion.” The outcome measures extracted from the studies were the Short Form‐12 (SF‐12) in its mental and physical component (MCS and PCS), Lysholm score, Subjective IKDC, Marx Score, WOMAC Score, Tegner, Radiological changes, complications, failures and/or revision surgery, and rate of return to sports.Results: The cohort of patients consisted of 1,243 participants with a mean age of 28.6 ± 2.6. The mean postoperative follow‐up was 40.9 ± 6.3 months. A total of 1145 (92.1%) RAMP lesions were repaired with concomitant ACL reconstruction, while only 98 (7.9%) lesions were left untreated (or treated with abrasion only). The Lysholm score was used in 6 studies (in one only at final follow‐up), with a significant improvement in all the studies (Lysholm_pre 60.03 ± 6.12; Lysholm_post 89.9 ± 5.0). Eight studies out of nine reported Subjective IKDC score, and a significant improvement was noted in all cases (IKDC_pre 56.2 ± 5.8. IKDC_post 84.9 ± 3.7). Of 18 (1.4%) complications reported, 15 (1.2%) were related to RAMP/ACL surgery, and of the remaining three (0.2%) two (0.2%) were hematomas and one (0.1%) a contralateral ACL lesion. Of the 106 (8.5%) revision surgeries required, 5 (0.4%) were in non‐treated lesions [two (0.2%) ACL re‐ruptures and three (0.2%) medial meniscus re‐injury]. In treated patients, the revision occurred for the following reasons: 75 (6.0%) meniscectomy, 14 (1.1%) meniscal suture revisions, 11 (0.9%) ACL failures and one (0.1%) arthrolysis.Conclusions: It is not yet clear if, in all cases of ACL reconstruction in which a medial meniscal RAMP lesion is encountered, the lesion needs to undergo surgical repair. Accordingly, it is recommended that in the repair of all unstable medial meniscal RAMP lesions during an ACL reconstruction in cases associated with a stable RAMP lesion, the surgeon may decide on repair based on the patient profile.Level of evidence: Level IV.

Purpose: The purpose of this study was to evaluate the differences in the patient‐reported functional outcomes, and graft failure in revision ACL reconstruction using quadriceps tendon (QT), Hamstring tendon (HT) and bone‐patellar tendon‐bone (BPTB) autografts.Methods: Between 2010 and 2020, 97 patients who underwent revision ACL reconstruction (40 patients received a QT, 26 an HT and 31 a BPTB graft) met the inclusion criteria. Pre‐injury and at 2‐year postoperatively patients were evaluated for patient‐reported functional outcomes; Lysholm knee score, Tegner activity level and VAS (visual analogue scale) for pain; and graft failure. Patient‐reported outcomes and graft failure were compared between the QT, HT and BPTB groups. The patients with graft failure were not included for outcome analysis at 2‐years of follow‐up.Results: All three revision groups with QT, HT and BPTB autograft did not differ significantly in terms of age, sex, time from injury to surgery, concomitant injuries and single‐stage or double‐stage procedures (n.s.). No significant difference was found in the pre‐injury patient‐reported outcome; Lysholm knee score, Tegner activity and VAS for pain (n.s.) between the three groups. At the 2‐year follow‐up functional outcomes improved in all three groups and all the patients returned to pre‐injury activity level; however, no significant difference was found in functional outcomes at the 2‐year follow‐up between the three groups (n.s.). Graft failure occurred in 4 (10%), 5 (19%) and 3 (10%) patients of QT, HT and BPTB groups, respectively. However, the rate of failure did not differ significantly between groups.Conclusion: All three autografts (QT, HT and BPTB) demonstrated satisfactory patient‐reported outcomes in revision ACL reconstruction. Compared with QT and BPTB grafts, HT graft showed a higher tendency for failure rates. With the increasing incidence of revision ACL reconstruction, surgeons should be aware of all the available graft options. The findings of this study will assist the surgeons in the graft selection for revision ACL reconstruction.Level of evidence: Level III.

Purpose: The purpose of this systematic review is to report complications, graft failure, fixation methods, rehabilitation protocol, clinical and patient‐reported outcomes, and return to sports with the use of quadriceps tendon graft with the bone block (QT‐B) and without bone block (QT‐S).Methods: According to the PRISMA guidelines a comprehensive search was performed across PubMed/MEDLINE, Scopus, EMBASE, and Cochrane Library databases from inception until April 2022. Only prospective studies using quadriceps tendon autograft with a minimum of 20 patients were considered for inclusion. The outcome measures extracted from the studies were the KT‐1000, Lysholm score, Subjective and Objective IKDC, Tegner, Marx Score, complications, failures and/or revision surgery, and rate of return to sports. Cochrane risk of bias and MINORS tool were used for the risk of bias assessment of all included studies.Results: A total of 13 studies were included, consisting of 5 randomized controlled trials, 6 cohort studies, 1 case–control and 1 case series. A total of 484 patients received QT‐S in 6 studies of which 224 (46.2%) were males and 212 (43.8%) females with a mean age of 21.5 ± 7.5 (range 14–58). While 243 patients received QT‐B in 7 studies of which 167 (68.7%) were males and 76 (31.3%) females with a mean age of 28.9 ± 4.5 (range: 18–49). The studies analyzed had a mean MINORS score of 14.6 (range, 12–19). Both QT‐B and QT‐S for ACL reconstruction reported satisfactory results in terms of patient‐reported outcome measures. Although, a slightly higher anterior laxity was found with the QT‐S than with the QT‐B.Conclusion: Quadriceps tendon with a bone block (QT‐B) or without bone block (QT‐S) for ACL reconstruction is supported by current literature. Both grafts are safe and viable options for ACL reconstruction with comparable clinical outcomes, complications and revision rates.Level of evidence: Level IV.Registration: PROSPERO‐CRD42022347134; https://www.crd.york.ac.uk/prospero/

Purpose: The purpose of this study was to synthesize and quantitatively assess the outcomes of ACL Revision using a quadriceps tendon (QT) graft and to compare them with those of ACL Revisions performed with hamstring tendons (HT) graft.Methods: A comprehensive search based on the PRISMA protocol was performed across PubMed, Scopus, Embase, and Cochrane Library from inception until February 2022. Clinical studies reporting the outcomes of ACL Revision with QT autograft were included. Subjective and Objective IKDC, Tegner activity level, Lysholm knee score, KOOS score, VAS for pain, knee laxity (KT‐1000/2000 arthrometer, Lachman test, and pivot‐shift test), and graft failure were assessed. A systematic review and meta‐analysis were performed and a quality assessment of the included studies was carried out with the MINORS score.Results: Seven studies met the selection criteria and were included in the systematic review for the qualitative synthesis of data. A pooled mean of all the variables was provided for the 7 studies, while 3 studies included a control group of ACL Revision with HT and were included in a meta‐analysis. A total of 420 participants with a mean age of 28.9 ± 10.5 years and a mean postoperative follow‐up of 39.3 ± 16.4 months were assessed. Of these, 277 patients underwent ACL Revision with QT and 143 patients underwent ACL Revision with HT. In the QT group, average graft failure was 9.8% compared to 17.4% in the HT group. KOOS Sport and pivot‐shift test showed better postoperative outcomes in QT than HT, although it was not statistically significant (p = 0.052).Conclusion: The QT autograft was associated with an improved trend of rotatory laxity, PROMs and failure rate compared to HT autograft after revision ACL reconstruction. The QT autograft for revision ACL reconstruction is supported by the current literature. It is a viable graft that should be considered for both primary and revision ACL reconstruction.Level of evidence: Level IV.