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Generalised joint hypermobility increases ACL injury risk and is associated with inferior outcome after ACL reconstruction: A systematic review

Review article
Authors David Sundemo
Eric Hamrin Senorski
Louise Karlsson
Alexandra Horvath
B. Juul-Kristensen
Jón Karlsson
Olufemi R Ayeni
Kristian Samuelsson
Published in BMJ Open Sport and Exercise Medicine
Volume 5
Issue 1
ISSN 2055-7647
Publication year 2019
Published at Institute of Neuroscience and Physiology, Department of Health and Rehabilitation
Institute of Clinical Sciences, Department of Orthopaedics
Language en
Keywords anterior cruciate ligament injury, anterior cruciate ligament reconstruction, generalised joint hypermobility, generalized joint hypermobility, hyperextension, laxity
Subject categories Orthopedics


Objectives To investigate the association between generalised joint hypermobility (GJH) and ACL injury risk. Secondary aims involved evaluating associations between GJH and postoperative outcome (including graft-failure risk, knee laxity and patient-reported outcome). Furthermore, we aimed to compare the performance of different grafts in patients with GJH. Methods Databases MEDLINE/PubMed, EMBASE and the Cochrane Library were searched, including 2760 studies. Two reviewers independently screened studies for eligibility. A modified version of the MINORS score was applied for quality appraisal. Studies assessing GJH while reporting the risk of ACL injury and/or postoperative outcome were included. Results Twenty studies were included, using several different methods to determine GJH. There was consistent evidence showing that GJH is a risk factor for unilateral ACL injury in males, while in females, the results were conflicting. There was limited evidence associating GJH with increased knee laxity 5 years postoperatively. There was consistent evidence of inferior postoperative patient-reported outcome in patients with GJH. Moreover, there was limited yet consistent evidence indicating that patellar-tendon autografts are superior to hamstring-tendon autografts in patients with GJH in terms of knee laxity and patient-reported outcome. There was insufficient evidence to draw conclusions regarding the outcomes of bilateral ACL injury and graft failure. Conclusions In men, GJH was associated with an increased risk of unilateral ACL injury. Moreover, GJH was associated with greater postoperative knee laxity and inferior patient-reported outcome. Based on the available evidence, a patellar-tendon autograft appears to be superior to a hamstring-tendon autograft in patients with GJH. However, the included studies were heterogeneous and there is a need for consensus in the assessment of GJH within sports medicine. © Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

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