SummaryObjective: Anterior cruciate ligament (ACL) injury has a devastating impact on physical and psychological disability. Rates of ACL rupture are significantly greater in females than males during the same sports. Hormonal mechanisms have been proposed but are complex and poorly understood. This systematic review evaluates the effects of menstrual cycle on: 1) lower-limb biomechanics, 2) neuromuscular control, and 3) ACL injury risk. Methods: The MEDLINE, CINAHL, SPORTSDiscus, Web of Science, and Google Scholar databases were searched from inception to August 2016 for studies investigating the effects of the menstrual cycle on lower-limb biomechanics, neuromuscular control, and ACL injury risk in females. Three independent reviewers assessed each paper for inclusion and two assessed for quality. Results: Seventeen studies were identified. There is strong evidence that: 1) greatest risk of ACL injury is within the pre-ovulatory phase of the menstrual cycle, and 2) females with greater ACL laxity in the pre-ovulatory phase experience greater knee valgus and greater tibial external rotation during functional activity. Conclusion: Females are at greatest risk of ACL injury during the pre-ovulatory phase of the menstrual cycle through a combination of greater ACL laxity, greater knee valgus, and greater tibial external rotation during functional activity. Level of evidence: Ib.

Objective: Anterior cruciate ligament (ACL) injury has a devastating impact on physical and psychological disability. Rates of ACL rupture are significantly greater in females than males during the same sports. Hormonal mechanisms have been proposed but are complex and poorly understood. This systematic review evaluates the effects of menstrual cycle on: 1) lower-limb biomechanics, 2) neuromuscular control, and 3) ACL injury risk. Methods: The MEDLINE, CINAHL, SPORTSDiscus, Web of Science, and Google Scholar databases were searched from inception to August 2016 for studies investigating the effects of the menstrual cycle on lower-limb biomechanics, neuromuscular control, and ACL injury risk in females. Three independent reviewers assessed each paper for inclusion and two assessed for quality. Results: Seventeen studies were identified. There is strong evidence that: 1) greatest risk of ACL injury is within the pre-ovulatory phase of the menstrual cycle, and 2) females with greater ACL laxity in the pre-ovulatory phase experience greater knee valgus and greater tibial external rotation during functional activity. Conclusion:Females are at greatest risk of ACL injury during the pre-ovulatory phase of the menstrual cycle through a combination of greater ACL laxity, greater knee valgus, and greater tibial external rotation during functional activity. Level of evidence: Ib.

Splenic ectopic pregnancy is extremely rare but carries a high risk of uncontrollable life-threatening bleeding. Our aim is to try to diagnose those cases earlier and to include splenic preservation as good alternative for selected cases. Extensive review of the literature has been performed. Thirty-one case reports were identified, of which 4 have been excluded because they were not written in English. A 36-year-old woman presented to the Emergency Department with haemorrhagic shock. Despite the levonorgestrel intrauterine system (LNG-IUS) being in situ for 4 months, urinary and serum tests were both positive for pregnancy, and an ultrasound scan revealed haemoperitoneum suggestive of a ruptured ectopic pregnancy. An emergency Pfannenstiel laparotomy was performed and a diagnosis of spontaneous tubal abortion was made and the abdomen was subsequently closed. Following a period of cardiovascular instability on the Intensive Care Unit postoperatively, an urgent CT scan was performed which revealed bleeding from the spleen. A midline laparotomy was performed by the general surgeon, which involved resection of the gestational sac and splenorrhaphy. Twenty-seven cases were reviewed, and 73% of them presented as an emergency and 21 cases (81%) had been managed with splenectomy. CT scan had been used in eight of the previous case reports of splenic ectopic pregnancy with 100% diagnostic accuracy rate. Non-tubal ectopic pregnancies are very rare. Splenorrhaphy is a safe alternative to splenectomy in cases of splenic ectopic pregnancy. CT abdomen and pelvis with intravenous contrast can be very helpful in relatively stable patients with a vaginal ultrasound demonstrating an empty uterus, no clear adnexal masses or free fluid.

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