Anterior cruciate ligament (ACL) reconstruction is a common orthopedic procedure, but graft failure remains a significant complication, particularly in young and active individuals. Understanding the multifactorial etiology of failure and optimizing revision strategies are crucial for improving outcomes. A structured narrative review of the literature was conducted, including studies published from January 2000 to May 2024. Databases searched included PubMed/MEDLINE, Embase, and Google Scholar. Eligible studies addressed definitions, etiology, classification, and surgical management of ACL reconstruction failure. Data were synthesized qualitatively, integrating evidence on technical, biological, and traumatic causes, as well as neuromuscular and psychosocial factors influencing functional outcomes. ACL reconstruction failure is primarily caused by technical errors, particularly tunnel malposition (60–70% of cases), followed by traumatic (15–25%) and biological (10–15%) mechanisms. Failure timing provides diagnostic clues: early (12 months) to trauma or degeneration. Revision strategies include individualized graft selection, anatomical tunnel placement, repair of associated lesions, and consideration of biomechanical abnormalities. Overall success rates of revision procedures average 70–75%, with lower outcomes in adolescents and high-demand athletes. Emerging techniques, including lateral extra-articular tenodesis and biologic augmentation, may enhance revision outcomes, although long-term evidence remains limited. ACL reconstruction failure is a multifactorial event requiring thorough preoperative assessment, precise surgical planning, and individualized management. Addressing technical, biological, and neuromuscular factors, alongside patient-specific considerations, is essential to optimize functional outcomes and reduce failure rates. Future research should focus on standardized reporting, multicenter prospective studies, and advanced surgical planning tools to further improve revision success.

Introduction: Achieving personalized alignment in total knee arthroplasty (TKA) with conventional instrumentation remains challenging. This study validates a novel trigonometric formula that calculates the exact lateralization needed for the tibial extramedullary guide based on preoperative weight-bearing X-rays. Methods: We retrospectively analysed 196 patients who underwent TKA between November 2018 and June 2023. Inclusion criteria: patients with preoperative weight-bearing AP lower limb X-rays aged 18 or older. Exclusion criteria: previous total hip arthroplasty, those without consent. The formula LAT = LENG(S) × sin α angle calculated tibial guide lateralization, where LAT was the lateralization distance, LENG(S) was the tibial length from radiographs, and α angle was the tibial coronal correction angle. The true radiographic lateralization was measured to validate the formula’s accuracy and defined a “safety zone” representing acceptable surgical margins to validate the formula’s accuracy and defined a “safety zone” representing acceptable surgical margins. The Intraclass Correlation Coefficient (ICC) was used to test for the measurement consistency among observers. 95% Clopper-Pearson Confidence Interval was calculated for the frequency of lateralization falling within a “safety zone”. A T-test compared LAT measurements with true radiographic lateralization. Results: ICC showed that 97.2% of lateralization measurements fell within the defined “safety cone” (95% CI 93.9–98.9%). Inter-observer reliability was high (ICC 0.91). No differences were found between the formula-derived measurements and the true radiographic lateralization. The 95% Clopper-Pearson Confidence Interval was 93.9–98.9%. LAT was found to fall outside the safety cone with a total mean of 2.3° (range 1–5) in 2.8% of the cases, with a mean error in the degree of proximal tibial cut of -0.67° (range − 1 - +1). No association between CPAK and cases within or outside the safety cone was found (χ²= 5.014, p = 0.658). Conclusions: This validated trigonometric formula enables surgeons to accurately calculate tibial guide lateralization for personalized alignment using only conventional instrumentation and standard radiographs. The method’s 97.2% accuracy within safe surgical margins supports its use as a reliable preoperative planning tool for personalized TKA alignment without requiring specialized software or robotic assistance.

Lateral femoral neck and peritrochanteric fractures are common and clinically challenging injuries, particularly in the elderly population, with significant implications for morbidity, mortality, and functional recovery. Traditional classification systems are widely used to guide treatment, yet their reproducibility and clinical applicability remain debated. Increasing attention has been directed toward trabecular architecture and its role in fracture behavior and reduction strategies. This review aims to summarize current evidence on classification systems, trabecular-based fracture patterns, pre-operative reduction techniques, and fixation strategies. A narrative review was conducted using PubMed/MEDLINE, Embase, and Scopus databases up to May 2026. Original studies, reviews, and biomechanical investigations focusing on proximal femur fracture classification, reliability, trabecular alignment, reduction techniques, and fixation methods were included. Data were qualitatively analyzed, with emphasis on interobserver reliability, biomechanical implications, and clinical outcomes. Conventional classification systems, including anatomical, Evans–Jensen, and AO/OTA frameworks, demonstrated variable and generally moderate reproducibility, with reported interobserver agreement ranging from approximately κ = 0.30 to 0.60. Emerging evidence highlights the importance of trabecular architecture, distinguishing intradigital fractures—confined within trabecular pathways and relatively stable—from extradigital fractures, which disrupt load-bearing structures and are associated with increased mechanical instability and higher failure rates. Biomechanical and clinical studies indicate that inadequate reduction with trabecular misalignment significantly increases the risk of varus collapse and implant cut-out. Reduction strategies tailored to fracture pattern, such as internal rotation for intradigital fractures and external or combined maneuvers for extradigital patterns, improve alignment and load transfer. In terms of fixation, dynamic hip screws remain effective in stable fractures, whereas cephalomedullary nails demonstrate superior performance in unstable patterns, with lower reoperation rates reported (approximately 5–8% vs. 10–15%). Management of lateral femoral neck and peritrochanteric fractures should extend beyond traditional classification systems to incorporate trabecular biomechanics. Restoration of trabecular alignment, alongside established parameters such as neck–shaft angle and tip–apex distance, is critical for optimizing outcomes. Further prospective studies are needed to validate trabecular-based classifications and standardize reduction strategies.

Background: Anterior cruciate ligament (ACL) reconstruction is a common orthopedic procedure, but graft failure remains a significant complication, particularly in young and active individuals. Understanding the multifactorial etiology of failure and optimizing revision strategies are crucial for improving outcomes. Methods: A structured narrative review of the literature was conducted, including studies published from January 2000 to May 2024. Databases searched included PubMed/MEDLINE, Embase, and Google Scholar. Eligible studies addressed definitions, etiology, classification, and surgical management of ACL reconstruction failure. Data were synthesized qualitatively, integrating evidence on technical, biological, and traumatic causes, as well as neuromuscular and psychosocial factors influencing functional outcomes. Results: ACL reconstruction failure is primarily caused by technical errors, particularly tunnel malposition (60–70% of cases), followed by traumatic (15–25%) and biological (10–15%) mechanisms. Failure timing provides diagnostic clues: early (< 3 months) failures often relate to fixation or infection, mid-term (3–12 months) to technical errors, and late (>12 months) to trauma or degeneration. Revision strategies include individualized graft selection, anatomical tunnel placement, repair of associated lesions, and consideration of biomechanical abnormalities. Overall success rates of revision procedures average 70–75%, with lower outcomes in adolescents and high-demand athletes. Emerging techniques, including lateral extra-articular tenodesis and biologic augmentation, may enhance revision outcomes, although long-term evidence remains limited. Conclusions: ACL reconstruction failure is a multifactorial event requiring thorough preoperative assessment, precise surgical planning, and individualized management. Addressing technical, biological, and neuromuscular factors, alongside patient-specific considerations, is essential to optimize functional outcomes and reduce failure rates. Future research should focus on standardized reporting, multicenter prospective studies, and advanced surgical planning tools to further improve revision success.