Purpose: The metaverse and extended reality (XR), which includes augmented reality (AR), virtual reality (VR) and mixed reality (MR), are transforming orthopaedic surgery by enhancing training, procedural accuracy and rehabilitation. However, a literature review of these new virtual tools is lacking. The purpose of this narrative review is to summarise available evidence about the metaverse and discuss current and future clinical applications.Methods: A narrative review of the current literature was performed for studies evaluating XR tools and their respective clinical and educational utility. Studies from all orthopaedic subspecialties were eligible for inclusion. The XR tools evaluated in each study were categorised according to the reality spectrum and future research or clinical applications were discussed.Results: XR is a technological spectrum that includes AR, VR and MR to create immersive and interactive surgical training environments. VR‐based simulators may improve surgical education by allowing trainees to refine their skills in a risk‐free setting. AR may enhance intraoperative guidance and has been studied within orthopaedics to improve implant positioning accuracy and reduce complications in procedures including arthroscopy and total joint arthroplasty. In rehabilitation, AR and VR have been implemented to facilitate patient engagement and adherence, promoting functional recovery through gamified therapy and remote telerehabilitation.Conclusions: There has been a paradigm shift in orthopaedic care in which digital tools are integrated with patient care to optimise patient outcomes. However, challenges to the widespread implementation of promising XR technology include high costs, steep learning curves and limited clinical validation. Ethical concerns, including data security and patient privacy, further complicate its use in clinical settings. Future research must focus on cost‐effectiveness, standardisation and improving accessibility to ensure seamless integration into clinical practice.Level of Evidence: Level V.

Background: Postoperative infection following anterior cruciate ligament reconstruction (ACLR) is a rare yet severe complication that can compromise patient outcomes, leading to prolonged recovery, graft failure, and knee dysfunction. Although infection rates are reported to be less than 2%, it remains essential to implement strategies to reduce infection risk and improve surgical outcomes. Methods: This review explores current evidence on the prevention of infections in ACLR, emphasizing the importance of timely antibiotic prophylaxis and vancomycin presoaking of grafts, which has been associated with a substantial reduction in infection rates. Results: Empirical antibiotic therapy should be started immediately after joint aspiration when infection is suspected. Treatment must prioritize culture-specific antibiotic regimens to optimize patient outcomes. Surgical intervention with arthroscopic debridement and irrigation needs to occur as soon as the diagnosis of infection is made. Often, this is performed with a focus on retaining the graft in order to preserve knee stability, if possible. Careful intraoperative management, along with the aid of infectious disease specialists, is paramount to help optimize outcomes following infection after ACLR. Conclusions: This review emphasizes the need for treatment protocols and highlights areas for future research to establish clear guidelines on infection after ACLR, especially with decisions of graft retention versus removal.

This study aimed to determine the trends and indications for anterolateral complex augmentation during anterior cruciate ligament reconstruction (ACL-R) among international orthopedic sports surgeons. An electronically distributed survey was sent out to international surgeons with high-volume experience in complex ligament reconstructions and revision surgery attending the 2024 Freddie Fu Panther Sports Medicine Symposium. The survey was sent prior to the meeting with questions related to the use of lateral extra-articular tenodesis (LET) or anterolateral ligament reconstruction (ALL-R) during ACL-R. Sessions pertaining to anterolateral complex augmentation were held during the symposium to inform about current clinical practices among attendees. A total of 49 surgeons were identified from 5 different geographic regions prior to the meeting date and were sent an electronic survey, of which 48 responded (98% response rate). Among the surgeons who reported performing anterolateral complex augmentation procedures (n = 45), a total of 39 (87%) respondents reported using only the LET technique, 2 (4%) reported using only the ALL-R technique, and 4 (9%) reported using both techniques during ACL-R. The most common indication for anterolateral complex augmentation was a high-grade pivot shift, which 39 of 43 (91%) respondents ranked in their top 3 indications. In the setting of primary ACL-R, respondents added LET when using hamstring tendon autograft in 38% of cases on average compared with 34% of cases when using either bone-patellar tendon-bone autograft or quadriceps tendon autograft. In the setting of revision ACL-R, LET was added in an average of 68% of cases for a first-time revision ACL-R and in 84% of cases for a multiple-revision ACL-R. The most common indication for ACL-R with anterolateral complex augmentation was a high-grade pivot shift and most respondents preferred LET over ALL-R. Respondents performed LET in a comparable percentage of cases of primary ACL-R using hamstring tendon, bone-patellar tendon-bone, and quadriceps tendon autografts, and this number increased with the number of revision ACL-Rs. Based on the results of this survey, surgeons may consider adding LET in cases of revision ACL-R or in patients with a high-grade pivot shift. Level V.