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ObjectiveClinicians treating patients with patellofemoral pain (PFP) rely on consensus statements to make the best practice recommendations in the absence of definitive evidence on how to manage PFP. However, the methods used to generate and assess agreement for these recommendations have not been examined. Our objective was to map the methods used to generate consensus-based recommendations for PFP and apply four novel questions to assess the rigour of consensus development.DesignScoping review.Data sourcesWe searched Medline, SPORTDiscus, CINAHL and Embase from inception to May 2022 to identify consensus-derived statements or practice guidelines on PFP. The Joanna Briggs Institute Manual for Evidence Synthesis was followed to map the existing evidence. We measured the consensus methods based on four sets of questions addressing the panel composition, application of the consensus method chosen, agreement process and the use of evidence mapping.Eligibility criteriaAll consensus statements or clinical guidelines on PFP were considered.ResultsTwenty-two PFP consensus statements were identified. Panel composition: 3 of the 22 (14%) consensus groups reported the panellists’ experience, 2 (9%) defined a desired level of expertise, 10 (45%) reported panellist sex and only 2 (9%) included a patient. Consensus method: 7 of 22 (32%) reported using an established method of consensus measurement/development. Agreement process: 10 of 22 (45%) reported their consensus threshold and 2 (9%) acknowledged dissenting opinions among the panel. Evidence mapping: 6 of 22 (27%) reported using systematic methods to identify relevant evidence gaps.ConclusionsPFP consensus panels have lacked diversity and excluded key partners including patients. Consensus statements on PFP frequently fail to use recognised consensus methods, rarely describe how ‘agreement’ was defined or measured and often neglect to use systematic methods to identify evidence gaps.

ObjectiveAssess the association between combined hormonal contraceptives (CHC) use and musculoskeletal tissue pathophysiology, injuries or conditions.DesignSystematic review with semiquantitative analyses and certainty of evidence assessment, guided by the Grading of Recommendations Assessment, Development and Evaluation approach.Data SourcesMEDLINE, EMBASE, CENTRAL, SPORTDiscus, CINAHL searched from inception to April 2022.EligibilityIntervention and cohort studies that assessed the association between new or ongoing use of CHC and an outcome of musculoskeletal tissue pathophysiology, injury or condition in postpubertal premenopausal females.ResultsAcross 50 included studies, we assessed the effect of CHC use on 30 unique musculoskeletal outcomes (75% bone related). Serious risk of bias was judged present in 82% of studies, with 52% adequately adjusting for confounding. Meta-analyses were not possible due to poor outcome reporting, and heterogeneity in estimate statistics and comparison conditions. Based on semiquantitative synthesis, there is low certainty evidence that CHC use was associated with elevated future fracture risk (risk ratio 1.02–1.20) and total knee arthroplasty (risk ratio 1.00–1.36). There is very low certainty evidence of unclear relationships between CHC use and a wide range of bone turnover and bone health outcomes. Evidence about the effect of CHC use on musculoskeletal tissues beyond bone, and the influence of CHC use in adolescence versus adulthood, is limited.ConclusionGiven a paucity of high certainty evidence that CHC use is protective against musculoskeletal pathophysiology, injury or conditions, it is premature and inappropriate to advocate, or prescribe CHC for these purposes.PROSPERO registration numberThis review was registered on PROSPERO CRD42021224582 on 8 January 2021.

The goal of the OPTIKNEE consensus is to improve knee and overall health, to prevent osteoarthritis (OA) after a traumatic knee injury. The consensus followed a seven-step hybrid process. Expert groups conducted 7 systematic reviews to synthesise the current evidence and inform recommendations on the burden of knee injuries; risk factors for post-traumatic knee OA; rehabilitation to prevent post-traumatic knee OA; and patient-reported outcomes, muscle function and functional performance tests to monitor people at risk of post-traumatic knee OA. Draft consensus definitions, and clinical and research recommendations were generated, iteratively refined, and discussed at 6, tri-weekly, 2-hour videoconferencing meetings. After each meeting, items were finalised before the expert group (n=36) rated the level of appropriateness for each using a 9-point Likert scale, and recorded dissenting viewpoints through an anonymous online survey. Seven definitions, and 8 clinical recommendations (who to target, what to target and when, rehabilitation approach and interventions, what outcomes to monitor and how) and 6 research recommendations (research priorities, study design considerations, what outcomes to monitor and how) were voted on. All definitions and recommendations were rated appropriate (median appropriateness scores of 7–9) except for two subcomponents of one clinical recommendation, which were rated uncertain (median appropriateness score of 4.5–5.5). Varying levels of evidence supported each recommendation. Clinicians, patients, researchers and other stakeholders may use the definitions and recommendations to advocate for, guide, develop, test and implement person-centred evidence-based rehabilitation programmes following traumatic knee injury, and facilitate data synthesis to reduce the burden of knee post-traumatic knee OA.

ObjectiveTo identify and quantify potential risk factors for osteoarthritis (OA) following traumatic knee injury.DesignSystematic review and meta-analyses that estimated the odds of OA for individual risk factors assessed in more than four studies using random-effects models. Remaining risk factors underwent semiquantitative synthesis. The modified GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach for prognostic factors guided the assessment.Data sourcesMEDLINE, EMBASE, CENTRAL, SPORTDiscus, CINAHL searched from inception to 2009–2021.EligibilityRandomised controlled trials and cohort studies assessing risk factors for symptomatic or structural OA in persons with a traumatic knee injury, mean injury age ≤30 years and minimum 2-year follow-up.ResultsAcross 66 included studies, 81 unique potential risk factors were identified. High risk of bias due to attrition or confounding was present in 64% and 49% of studies, respectively. Ten risk factors for structural OA underwent meta-analysis (sex, rehabilitation for anterior cruciate ligament (ACL) tear, ACL reconstruction (ACLR), ACLR age, ACLR body mass index, ACLR graft source, ACLR graft augmentation, ACLR+cartilage injury, ACLR+partial meniscectomy, ACLR+total medial meniscectomy). Very-low certainty evidence suggests increased odds of structural OA related to ACLR+cartilage injury (OR=2.31; 95% CI 1.35 to 3.94), ACLR+partial meniscectomy (OR=1.87; 1.45 to 2.42) and ACLR+total medial meniscectomy (OR=3.14; 2.20 to 4.48). Semiquantitative syntheses identified moderate-certainty evidence that cruciate ligament, collateral ligament, meniscal, chondral, patellar/tibiofemoral dislocation, fracture and multistructure injuries increase the odds of symptomatic OA.ConclusionModerate-certainty evidence suggests that various single and multistructure knee injuries (beyond ACL tears) increase the odds of symptomatic OA. Risk factor heterogeneity, high risk of bias, and inconsistency in risk factors and OA definition make identifying treatment targets for preventing post-traumatic knee OA challenging.

ObjectiveTo determine sex-based differences in risk of a second ACL injury (overall and by laterality) following primary ACL reconstruction in athletes who are attempting to return to sport.DesignSystematic review with meta-analysis.Data sourcesSystematic search of five databases conducted in August 2019.Eligibility criteria for selecting studiesStudies reporting sex-based differences in the incidence of second ACL injury in athletes attempting to return-to-sports and who were followed for at least 1 year following primary ACL reconstruction.ResultsNineteen studies were included in this review, with seven studies excluded from the primary meta-analysis due to high risk of bias. The remaining 12 studies (n=1431 females, n=1513 males) underwent meta-analysis, with all 19 studies included in a sensitivity analysis. Total second ACL injury risk was 21.9% (females: 22.8%, males: 20.3%). Females were found to have 10.7% risk of an ipsilateral ACL injury and 11.8% risk of a contralateral ACL injury. Males were found to have 12.0% risk of an ipsilateral ACL injury and 8.7% risk of a contralateral ACL injury. No statistically significant differences were observed for total second ACL injury risk (risk difference=−0.6%, 95% CI −4.9 to 3.7, p=0.783, I2=41%) or contralateral ACL injury risk (risk difference=1.9%, 95% CI −0.5% to 4.4%, p=0.113, I2=15%) between sexes. Females were found to have a 3.4% absolute risk reduction in subsequent ipsilateral ACL injury risk compared with males (risk difference=−3.4%, 95% CI −6.7% to −0.02%, p=0.037, I2=35%).ConclusionBoth sexes have >20% increased risk of experiencing a second ACL injury. Any difference in the absolute risk of either a subsequent ipsilateral or contralateral ACL injury between sexes appears to be small.RegistrationPROSPERO (CRD42020148369)