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. 2025 Aug 13;6(8):933–943. doi: 10.1302/2633-1462.68.BJO-2025-0080.R1

Allografts in primary anterior cruciate ligament reconstruction

a scoping review of the literature highlighting reporting standards

Khalid Al-Hourani 1,✉, Saran Singh Gill 2, Bhargava Ram Govardhana 3, Eoghan Hurley 4, Shehzaad Khan 1, Alastair Davidson 1, Xinning Li 5, Iain R Murray 6, Fares S Haddad 7,8,9
PMCID: PMC12343146  PMID: 40796153

Abstract

Aims

To conduct a scoping review into the use of allograft in primary anterior cruciate ligament (ACL) reconstruction, and to ascertain the variability in reporting outcomes in the literature.

Methods

The study was conducted in line with the Preferred Reporting Items for Systematic reviews and Meta-Analayses (PRISMA), and also used Arksey and O’Malley’s established five-stage process for scoping reviews in order to map the literature for allograft use in primary ACL reconstruction. Following screening to identify eligible studies, data were extracted and mapped to provide a descriptive and thematic analysis.

Results

A total of 421 studies were identified from the initial search, with 77 studies eligible for final scoping review published from January 1993 to December 2024. The majority of studies were published from the USA and China (56/77, 72.3%). Nine studies (9/77, 11.7%) were level1 evidence. Key variables such as graft diameter (27/77, 33.8%), graft processing (27/77, 35.1%), and cost of graft (3/77, 3.9%) were significantly under-reported. For clinical outcomes, the Lachman score (45/77, 57.1%), pivot shift grade (45/77, 58.4%), and graft re-rupture rate (42/77, 54.5%) were highest reported. For functional outcomes, two predominant scores were recorded, the International Knee Documentation Committee score (52/77, 67.5%) and the Tegner-Lysholm knee score (48/77, 62.3%). A total of 30 functional outcomes were recorded, spanning all studies.

Conclusion

This scoping review identified 77 studies which analyzed allografts in primary ACL reconstruction. There is great variability in the reporting standards, with significant under-reporting of important variables. Further research is required to develop standardized reporting criteria in order to accurately reflect the outcomes of allografts in primary ACL reconstruction.

Cite this article: Bone Jt Open 2025;6(8):933–943.

Keywords: Allograft, ACL, Outcomes, Scoping, Review, Knee, primary anterior cruciate ligament reconstruction, clinical and functional outcomes, functional outcomes, Graft diameter, re-rupture, International Knee Documentation Committee score, anterior cruciate ligament (ACL) reconstructions, Lysholm knee score, autografts

Introduction

Over 18,000 anterior cruciate ligament (ACL) reconstructions were undertaken in the UK in 2024, with this being the commonest soft-tissue knee operation performed annually.1 However, there remains considerable contention regarding the use of allografts in primary ACL reconstruction (ACLR), as historically they have been considered inferior to autografts.2 The higher revision rate when using allografts has been particularly pronounced in younger individuals;3 however, modern sterilization, preparation, and storage techniques seem to have reduced this risk.4

Allografts remain a viable option in the surgeon’s armamentarium, and this is especially the case in North America, where significantly more allografts are utilized for primary ACL reconstruction compared to the UK (40% vs 1%, respectively).5,6 This is likely due to several advantages over autografts, namely the lack of patient donor site morbidity, graft predictability (length, diameter, quality, and dimensions), positive effect on theatre efficiency given shorter operating time required, and allograft mechanical properties which have been shown to be similar to or exceeding that of the native ligament.7

A recent editorial shed further light on the available literature when considering allografts in comparison to autografts, and questioned whether data could be reliably interpreted given the heterogeneity in reporting variables and outcomes on preliminary review.8 The aim of this study is to provide a methodologically robust scoping review to map the available literature surrounding allograft use in primary ACL reconstruction. This review should further inform evidence-based practice, and systematically identify the gaps in reporting criteria for future research.

Methods

The five-stage scoping review process proposed by Arksey and O’Malley9 was adopted, with the recommended adaptations by the Joanna Briggs Institute incorporated.10 This protocol has been previously published by Makaram et al.11 This study was conducted in line with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines.12 The five-stage process was conducted as follows.

Stage 1: Determining the research question

The authors aimed for a broad research question in order to capture as much data as possible in relation to the aim. The research question formulated was therefore: what studies have been published with regard to outcomes of allograft use in primary ACL reconstruction? This would allow capture of the population, variables, and outcomes required to address the aim of the study.

Stage 2: Identifying relevant studies

Inclusion and exclusion criteria to delineate eligible studies are summarized in Table I. The following databases were searched from inception to 1 August 2024: MEDLINE, EMBASE, PubMed, Scopus, Web of Science, and CENTRAL. Grey literature sources such as OpenGrey were reviewed, but did not yield any relevant results. Additional articles were sought by reviewing the reference lists on applicable articles. The primary search strategy was constructed using MEDLINE and subsequently adapted to suit the other databases. The search included terms (and variants of these) for the following keywords: (ACL OR "Anterior Cruciate Ligament") AND Surgery AND Allograft AND Knee. A PRISMA flow diagram is presented in Figure 1. After removal of duplicates, three authors (KAH, SSG, BRG) independently screened the remaining titles and abstracts against the earlier defined eligibility criteria. Differences were resolved by consensus.

Table I.

Inclusion and exclusion criteria for the scoping review.

Inclusion criteria Exclusion criteria
No limitations regarding location or setting of studies Technical tips, narrative reviews, commentaries and editorials
All studies must be related to autografts Articles that are not available in English
All studies must refer to primary ACL repair Articles that do not have accessible full texts
All patients must be skeletally mature, or adults
Studies must be focused on humans
Primary studies, systematic reviews, meta-analyses
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ACL, anterior cruciate ligament.

Fig. 1.

Flowchart showing the step-by-step process used to determine study eligibility. A flow diagram outlines the process of selecting studies for eligibility. It begins with an initial pool of records identified through database searching. After removing duplicates, the remaining records are screened. Records that do not meet inclusion criteria are excluded, and the full texts of the remaining articles are assessed for eligibility. Some full-text articles are excluded with reasons provided. The final box shows the number of studies included in the analysis.

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Flow diagram of the selection process for study eligibility.

Stage 3: Study selection

After removal of duplicates, two authors (SSG, BRG) independently screened the remaining titles and abstracts against the earlier defined eligibility criteria. A third senior reviewer (KAH) then completed the screening process, with a random selection of 10% of the articles remaining after initial duplicates had been removed in order to validate concordance with the inclusion/exclusion decision-making. Differences were resolved by consensus after full-text review.

Stage 4: Charting the data

Data were extracted and tabulated by two reviewers (SSG, BRG), who analyzed all included studies. Any discrepancies were resolved via consensus following consultation with a senior author (KAH), who also checked 10% of the eligible articles for accuracy of data extraction. Data from each study were charted, and these were tabulated into both a priori categories and emerging themes to include: study characteristics (study type, level of evidence, country, and year), patient demographics, variables reported (including data on graft type, cost, processing, sterilization, and storage), and outcomes reported (functional and clinical). This was charted into a heat map for ease of analysis and to give a gross impression of the results.

Stage 5: Collating, summarizing, and reporting results

Analysis and summary of data were grouped into two domains: 1) descriptive analysis, outlining basic data pertaining to study characteristics as outlined in stage 4; and 2) thematic summary, as per the a priori categories in stage 4 and their relation to the aim of the study and the broad research question posed in stage 1. These were mapped out accordingly into four main themes: patient demographics, study independent variables, patient-reported outcomes, and clinical outcome reporting.

Results

Descriptive analysis

A total of 5,259 studies were identified from six different databases (EMBASE, MEDLINE, PubMed, Scopus, Web of Science, and CENTRAL) (Figure 1). From these, 2,196 studies were isolated after removing duplicates, and were screened using a title and abstract keyword search, through which 1,775 studies were excluded. The remaining 421 studies were then subjected to full-text screening, 344 of which were excluded for reasons such as irrelevance, language, and lack of full-text accessibility. Following the screening process, 77 studies were identified as eligible to be included in final analysis.

The studies span from 1993 to 2024, with 68/77 (88.3%) published in the last 20 years and 41/77 (53.2%) published in the last ten years (Figure 2). The most common years of publication, with 7/77 (9.1%) studies from each, were 2015 and 2016. The least common years of publication were 1993, 1998, 2000, 2001, 2003, 2004, 2008, and 2014, with one study from each. There were no included studies from 1994, 1995, 1999, 2002, or 2006.

Fig. 2.

Bar chart showing the number of included studies published each year, from 1993 to 2024. A vertical bar chart displays the distribution of included studies by year of publication, from 1993 to 2024. Each bar represents a different year, with the height corresponding to the number of studies published in that year. The chart shows variation in publication volume over time, with some years having noticeably more studies than others, indicating trends in research activity related to the study topic.

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Included studies by year of publication.

Studies were identified from 14 countries, with 40/77 (51.9%) from the USA, 16/77 (20.8%) from China, and the remaining 21/77 (27.3%) from other countries, including Belgium, Bulgaria, Canada, Hungary, Iran, Italy, the Netherlands, Poland, South Korea, Switzerland, Turkey, and the UK (Figure 3).

Fig. 3.

Bar chart showing the number of included studies from each country. A horizontal bar chart presents the number of included studies categorized by country of origin. Each bar represents a different country, with the length of the bar indicating the number of studies contributed by that country. The chart reveals that some countries have contributed significantly more studies than others, highlighting geographical trends in research output.

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Included studies by country of origin.

Out of the included studies, 60/77 (77.9%) were primary studies and 17/77 (22.1%) were secondary studies (Figure 4). Out of the primary studies, 12/60 (20.0%) were cross-sectional studies, 30/60 (50.0%) were longitudinal studies, and 18/60 (30%) were experimental studies. Of the secondary studies included, 16/17 (94.1%) were review articles and 1/17 (5.9%) was an expected-value decision analysis.

Fig. 4.

Diagram showing the classification of research designs used in the included studies. A hierarchical diagram presents the taxonomy of research designs found in the included studies. At the top level, research designs are broadly categorized. These categories branch into more specific types of study designs, with each level representing a further refinement or subtype. The structure illustrates how various study designs are related and grouped, providing a visual overview of methodological diversity within the included research.

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Taxonomy of research design for included studies.

Level of evidence (LoE) was determined in accordance with the Oxford Centre for Evidence Based Medicine Levels of Evidence.13 The distribution of studies by LoE can be seen in Figure 5. There were 9/77 (11.7%) studies at Level I, 26/77 (33.8%) studies at Level II, 31/77 (40.3%) studies at Level III, 9/77 (11.7%) studies at Level IV, and 2/77 (2.6%) studies at Level V.

Fig. 5.

Bar chart showing the number of included studies grouped by level of evidence. A vertical bar chart illustrates the distribution of included studies according to their level of evidence. Each bar represents a different evidence level, such as Level I, Level II, and Level III, with the height of each bar indicating the number of studies in that category. The chart shows that one level has a notably higher number of studies than the others, highlighting the predominance of that evidence level in the included research.

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Included studies by level of evidence.

Given the heterogeneity in study parameters as described above, and the remit of this scoping review, no formal quality assessment of the studies was attempted, as this fell outside of the remit of the aim and broad research question.

Thematic analysis

A representative bubble heat map for patient demographics is shown in Figure 6. The most frequently reported demographics were participant age and duration of follow-up, documented in 67/77 studies (87.0%) and 64/77 studies (83.1%), respectively. Mean patient age was 29.4 years (18 to 54). Participant sex appeared in 60/77 studies (77.9%), with a mean 70.6% being male and the remainder female (33 to 100). The mechanism of injury and associated sport was rarely reported, in just 15/77 studies (19.5%). Information on time since injury was covered in 30/77 studies (39.9%), while details on prior knee injury and time since surgery were each reported in 28/77 studies (36.4%). BMI was noted in 9/77 studies (11.7%), and height and weight were both reported in 3/77 studies (4%) (Figure 6). Of all the studies, 53/77 (68.8%) focused on soft-tissue allografts, with the remaining 24/77 studies (31.2%) focusing on bone-tendon-bone allografts.

Fig. 6.

Bubble chart showing how frequently different demographic characteristics were reported across studies. A bubble chart displays the frequency with which various demographic characteristics were reported in the included studies. Each row represents a different demographic category, such as age, sex, or BMI, while each column corresponds to a specific reporting context or study grouping. The size of each bubble indicates how many studies reported that demographic detail, with larger bubbles representing higher reporting frequency and smaller bubbles indicating fewer or no reports. The chart visually emphasizes which demographics were most and least commonly included in the research.

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Bubble heatmap representing the most commonly reported demographics. This ranges from a small red circle (denoting no studies reporting), to a larger green circle (denoting greater number of studies reporting).

Of the 77 studies, only three (3/77, 3.9%), reported on the procedural cost of the allograft (Figure 7). Cole et al14 analyzed 122 primary ACL reconstructions, comparing soft-tissue tendo-achilles allograft with bone-tendon-bone patellar tendon autograft, and observed a lower mean charge of USD$4,622 (3,874 to 6,100) for the allograft compared to USD$5,694 (4,355 to 9,691) for the autograft procedure. Cole et al14 observed that while the unit cost of the allograft was higher (USD$415), this was offset by increased operating time and cost, additional anaesthesia, and the increased hospital stay for an open procedure. When comparing soft-tissue allograft to soft-tissue autograft, however, the same with regard to procedural cost has not been found to be true. Cooper and Kaeding,15 in their study of 98 primary ACL reconstructions, showed that a tibialis anterior allograft ACL reconstruction was found to be on average USD$1,123 higher in cost, largely owing to the unit cost of the allograft itself (USD$1,296).

Fig. 7.

Bubble chart showing how frequently different independent variables were reported across studies. A bubble chart displays the frequency with which various independent variables were reported in the included studies. Each row represents a different variable, such as surgical technique or graft type, while each column corresponds to a specific reporting context or study grouping. The size of each bubble indicates how many studies reported that variable, with larger bubbles representing higher reporting frequency and smaller bubbles indicating fewer or no reports. The chart visually highlights which independent variables were most and least commonly included in the research.

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Bubble heatmap representing the most commonly reported study independent variables. This ranges from a small red circle (denoting no studies reporting), to a larger green circle (denoting greater number of studies reporting). BTB, bone-patellar tendon-bone.

The graft diameter was reported in 27/77 studies (33.8%). The mean graft diameter across all reporting studies was 9.81 mm (7.0 to 15). Rai et al,16 in a retrospective series of 222 patients comparing hamstring tendon autograft with tibiais anterior allograft, analyzed graft re-rupture rate and observed that while graft type was not a significant risk factor for this outcome, a minimum graft diameter of 8 mm was recommended regardless of graft type. Kurtoğlu et al17 analyzed 51 patients who underwent ACLR with soft-tissue allograft > 10 mm (21/51 patients), comparing this to soft-tissue autografts < 8 mm diameter (30/51 patients), and noted no difference in clinical outcomes including graft re-rupture at final follow-up. Graft diameter was also not significant in a further study by Issın et al18, comparing 27 four-strand hamstring autograft ACLRs to 36 tibialis anterior double-strand allograft ACLRs. There was no difference in mean diameter of grafts (8.5 mm autograft vs 7.8 mm allograft), and at final follow-up no clinical or functional difference between the groups. In the main, graft diameter did not seem to be a contributory variable in the studies included.

A total of 37 studies (37/77, 48.1%) reported storage method, with 26 (26/37, 70.3%) being fresh-frozen. Fresh-freezing as a storage method has previously been shown to have a deleterious effect on allograft mechanical properties, particularly following thawing, compared to freshly harvested donor allograft.19 One study by Edgar et al20 examined 84 ACLR patients (47/84 allograft reconstructions). The allografts were cryopreserved, and compared to autografts at three- and six-year follow-up there was no clinical difference in laxity between the groups. The remaining studies, while reporting storage method, did not report on whether this was standardized across their allograft group.

A total of 27 studies (27/77, 35.1%) reported irradiation method and even fewer studies (16/77, 20.8%) reported on actual irradiation dose used for the allografts. The type of irradiation used was uniform across all studies, being γ irradiation, however the majority of studies used high dose > 1.8 Mrad (11/16, 68.8%). Maletis et al4 assessed a cohort of over 14,000 ACLR cases. They observed a comparable revision rate for non mechanically processed, < 1.8 Mrad allografts compared to hamstring autografts (2.1% vs 2.3%, respectively) and a comparable revision rate to bone-tendon-bone autografts (2.1% vs 1.9%, respectively). Entirely non-irradiated grafts with chemical-only processing exhibited a higher revision rate overall compared to autograft of any type. Tejwani et al21 analyzed 5,968 allograft ACLR patients, concluding a higher revision rate for allografts used with irradiation > 1.8 Mrad when compared with other processing methods.

The Lachman score (45/77, 57.1%), pivot shift grade (45/77, 58.4%), and graft re-rupture rate (42/77, 54.5%) were reported the most across the studies included (Figure 8). A key clinical outcome such as return to work/sport was inadequately reported (11/77, 14.3%) and this was similar for all remaining clinical outcomes. Similarly for functional outcomes, two scores were widely reported, namely the International Knee Documentation Committee (IKDC)22 score (52/77, 67.5%) and the Tegner-Lysholm knee score (48/77, 62.3%).23 Scores pertaining to pain or activities of daily living were under-reported, e.g. visual analogue scale-pain (5/77, 6.5%) and 36-Item Short-Form Health Survey questionnaire (SF-36) scores (3/77, 2.6%).24

Fig. 8.

Bubble chart showing how frequently different clinical outcomes were reported across studies. A bubble chart displays the frequency with which various clinical outcomes were reported in the included studies. Each row represents a different outcome, such as osteoarthritis, imaging results, or range of motion, while each column corresponds to a specific reporting context or study grouping. The size of each bubble indicates how many studies reported that outcome, with larger bubbles representing higher reporting frequency and smaller bubbles indicating fewer or no reports. The chart visually highlights which clinical outcomes were most and least commonly included in the research.

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Bubble heatmap representing the most commonly reported clinical outcomes. This ranges from a small red circle (denoting no studies reporting), to a larger green circle (denoting greater number of studies reporting). OA, osteoarthritis; ROM, range of motion; XR, X-ray.

Of the studies included in this scoping review, nine were Level I studies which reported on clinical or functional outcomes of allograft primary ACL reconstruction. Yoo et al,25 in a 2017 prospective randomized study involving 184 patients, analyzed the outcomes when comparing hamstring autograft reconstruction with tibialis anterior allograft. Overall, 51/184 (27.7%) underwent second-look arthroscopy. At final clinical follow-up, there was no difference in range of motion (ROM), Lachman’s grade, pivot shift grade, or postoperative degree of arthritis development. However, there was a difference at second-look arthroscopy whereby there seemed to be greater synovial coverage of ACL autograft reconstructions compared to allograft. A further prospective randomized study involving 106 patients (53 hamstring autografts versus 53 bone-patellar tendon-bone allografts) followed up for a mean of 81 months. Jia and Sun26 also showed that no difference seemed to exist in clinical outcomes including ROM, Lachman’s grade, or pivot shift grade. Jia and Sun26 also included assessment of functional outcome IKDC score, noting a similar improvement in postoperative score and final absolute postoperative score between both groups. However, there was a significantly higher rate of tibial tunnel widening visible in the allograft group. Bottoni et al27 conducted a further prospective randomized study, with 99 patients receiving either a hamstring autograft or a tibialis posterior allograft, with ten-year follow-up. Allografts were chemically processed without irradiation, and at latest follow-up there was a 26.5% revision surgery rate compared to 8.3% in the autograft group. However, of those that did not require revision surgery, there was no difference noted in clinical outcome, including graft integrity and graft laxity, or in subjective/objective knee functional outcomes, including IKDC and Tegner-Lysholm scores. Functional outcome reporting is represented in Figure 9.

Fig. 9.

Bubble chart showing how frequently different patient-reported outcomes were reported across studies. A bubble chart displays the frequency with which various patient-reported outcomes were included in the studies. Each row represents a different outcome measure, such as functional scores or return to sport, while each column corresponds to a specific reporting context or study grouping. The size of each bubble reflects how many studies reported that outcome, with larger bubbles indicating higher reporting frequency and smaller bubbles indicating fewer or no reports. The chart highlights which patient-reported outcomes were most and least commonly assessed.

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Bubble heatmap representing the most commonly reported patient-reported outcomes. This ranges from a small red circle (denoting no studies reporting), to a larger green circle (denoting greater number of studies reporting). IKDC, International Knee Documentation Score; GRS, Global Rating Score; RTS, Return to sport; SF-36, Short Form-36 score.

Discussion

Scoping reviews are designed to identify the types of available evidence in a given field, identify the given key characteristics related to the concept at hand, highlight potential knowledge gaps, clarify concepts in the literature, and provide a precursor to systematic reviews.28 This scoping review employed rigorous methodology in order to map the data, identify gaps in the literature, and highlight controversies regarding this debatable issue in primary ACL reconstruction surgery. A key message of this study is the considerable lack of standardized reporting of variables and outcomes in the literature. It is the first study to provide a broad and contextual overview of the literature regardless of the quality, encompassing studies since inception. As a result of this, however, it is difficult to discuss individual controversies in the data, which are better served as part of a systematic review and meta-analysis, provided data heterogeneity would allow for this. A further limitation includes the inability to accurately assess data heterogeneity and provide greater granularity for specific datasets such as soft-tissue allograft characteristics (type of graft, diameter, type of storage/preservation), which can vary considerably within studies.

A common theme throughout the literature was a lack of standardized reporting standards. This includes reporting of variables and outcomes. As a result, the authors of this paper would suggest the need for standardized minimum reporting criteria through an international consensus statement of experts in order to accurately assess the validity of studies. Furthermore, there is a need for an up-to-date systematic review and network meta-analysis, considering that previous reviews of this nature are outdated.29,30 This is particularly the case given that several Level I prospective randomized studies have been published since these systematic reviews were published. There is a clear need for future studies to incorporate more rigorous subjective and objective assessment of functional scores, particularly those encompassing more holistic health concepts such as role limitations from a mental, emotional, and physical viewpoint: for example, the SF-36 score. It is also clear that sex and race may be associated with health disparities, and it is vital that improved diversity demographics are incorporated for patients with allograft primary ACLR.5 Finally, the use of allografts in primary ACLR remains debatable. In order to address this, and until more definitive data are available, a further expert consensus statement is warranted to identify the role of allografts in primary ACLR.

This scoping review identified 77 studies which analyzed allografts in primary ACL reconstruction. There was great variability in the reporting standards, including the variables associated, as well as clinical and functional outcomes. This variability does not allow for accurate conclusions to be drawn about the utility of allograft use. Further research is required to develop standardized reporting criteria in order to accurately reflect the outcomes of allografts in primary ACL reconstruction.

Take home message

- Great variability exists in reporting standards for allograft use in primary anterior cruicate ligament (ACL) reconstruction.

- Significant under-reporting of key variables exist in the literature to allow accurate comparison of data regarding allograft use in primary ACL reconstruction.

- Standardized reporting criteria are necessary to allow for accurate reporting of outcomes in future studies.

Author contributions

K. Al-Hourani: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Supervision, Writing – original draft, Writing – review & editing

S. S. Gill: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Writing – original draft

B. R. Govardhana: Data curation, Formal analysis, Investigation, Methodology, Resources

E. Hurley: Conceptualization, Methodology, Writing – review & editing

S. Khan: Conceptualization, Investigation, Validation, Writing – review & editing

A. Davidson: Conceptualization, Writing – review & editing

X. Li: Conceptualization, Writing – review & editing, Resources, Validation, Visualization, Writing – original draft

I. R. Murray: Conceptualization, Methodology, Visualization, Writing – review & editing

F. S. Haddad: Conceptualization, Supervision, Writing – original draft, Writing – review & editing

Funding statement

The author(s) received no financial or material support for the research, authorship, and/or publication of this article.

ICMJE COI statement

K. Al-Hourani reports consulting fees and payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Meril Life, unrelated to this study. F. S. Haddad reports multiple research study grants from Stryker, Smith & Nephew, Corin, International Olympic Committee, and the NIHR, royalties or licenses from Smith & Nephew, Stryker, Corin, and MatOrtho, consulting fees from Stryker, payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Stryker, Smith & Nephew, Zimmer, AO Recon, and Mathys, and support for attending meetings and/or travel from Stryker, Mathys, AO Recon, and The Bone & Joint Journal, all of which are unrelated to this study. F. S. Haddad is also Editor in Chief of The Bone & Joint Journal, President of the International Hip Society, Vice President of the European Hip Society, and an ISTA board member. S. Khan is a surgical advisor for Orthonika Limited. X. Li is a consultant for FH Ortho. I. R. Murray reports consulting fees from Stryker, and payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Arthrex and Smith & Nephew, all of which are unrelated to this study.

Data sharing

All data generated or analyzed during this study are included in the published article and/or in the supplementary material.

Social media

Follow K. Al-Hourani on LinkedIn at http://linkedin.com/in/khalid-al-hourani-md-phd-ba5a4676

Follow S. Khan on Instagram @sportskneedoc

Follow F. S. Haddad on X @bjjeditor

© 2025 Al-Hourani et al. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives (CC BY-NC-ND 4.0) licence, which permits the copying and redistribution of the work only, and provided the original author and source are credited. See https://creativecommons.org/licenses/by-nc-nd/4.0/

Contributor Information

Khalid Al-Hourani, Email: kalhourani@doctors.org.uk.

Saran Singh Gill, Email: saran.gill21@imperial.ac.uk.

Bhargava Ram Govardhana, Email: bhargava.govardhana@new.ox.ac.uk.

Eoghan Hurley, Email: eoghan.hurley@duke.edu.

Shehzaad Khan, Email: shehzaad.khan1@nhs.net.

Alastair Davidson, Email: alastair.davidson@nhs.net.

Xinning Li, Email: xinning.li@gmail.com.

Iain R. Murray, Email: Iain.Murray@ed.ac.uk.

Fares S. Haddad, Email: fsh@fareshaddad.net.

Data Availability

All data generated or analyzed during this study are included in the published article and/or in the supplementary material.

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Associated Data

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Data Availability Statement

All data generated or analyzed during this study are included in the published article and/or in the supplementary material.

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