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The 3 primary factors involved with preservation of the knee joint include joint alignment, meniscal status, and ligament stability (in particular that of the anterior cruciate ligament [ACL]). These factors are interdependent and result in knee joint homeostasis when all factors are stable. When a deficiency exists in one of the factors, it will affect the others. For example, the ACL and posterior horn of the medial meniscus both act as restraints to anterior tibial translation. Thus, medial meniscal deficiency increases the risk for failure of ACL reconstruction, and chronic ACL insufficiency increases the risk for medial meniscus tears. Furthermore, all 3 of the factors of joint preservation have an impact on the articular cartilage status of the knee joint. Studies have shown that cartilage-preservation procedures do not result in optimal outcomes if there is joint malalignment, meniscal deficiency, or ligament deficiency. When evaluating patients with knee cartilage pathology, surgeons should be aware of the various factors involved in knee joint preservation and, if surgery is indicated, all factors should be addressed in order to support a successful result. [ABSTRACT FROM AUTHOR]

Valgus instability can occur after total knee arthroplasty (TKA) due to traumatic medial collateral ligament (MCL) injury, component malpositioning, or progressive ligamentous laxity. Although revision TKA with exchange of the polyethylene to a varus–valgus-constrained liner can reduce laxity due to MCL insufficiency, isolated liner exchange in the setting of collateral ligament insufficiency may lead to greater strain at the cement–bone or implant–cement interface and possibly a greater rate of aseptic loosening. Anatomic MCL reconstruction can be performed in conjunction with liner exchange to restore stability and reduce strain compared with liner exchange alone. The purpose of this Technical Note is to describe a technique for MCL reconstruction and liner exchange for treatment of valgus instability after TKA. [Display omitted] [ABSTRACT FROM AUTHOR]

To compare the biomechanical properties of the knotted versus knotless transosseous-equivalent (TOE) techniques for rotator cuff repair (RCR). A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines using PubMed, Embase, and the Cochrane Library to identify studies that compared the biomechanical properties of knotted and knotless TOE RCR techniques. The search phrase used was as follows: (Double Row) AND (rotator cuff) AND (repair) AND (biomechanical). Evaluated properties included ultimate load to failure, cyclic displacement, stiffness, footprint characteristics, and failure mode. Eight studies met the inclusion criteria, including a total of 67 specimens in each group. Of 6 studies reporting on ultimate load to failure, 4 found tendons repaired with the knotted TOE technique to experience significantly higher ultimate load to failure compared with knotless TOE repairs (knotted range, 323.5-549.0 N; knotless range, 166.0-416.8 N; P <.05). Of 6 studies reporting on failure stiffness, 2 found knotted TOE repairs to have significantly higher failure stiffness compared with knotless TOE repairs (knotted range, 30.0-241.8 N/mm; knotless range, 28.0-182.5 N/mm; P <.05), whereas 1 study found significantly higher failure stiffness in knotless TOE repairs compared with knotted TOE repairs (P =.039). Cyclic gap formation favored the knotted TOE group in 2 of 3 studies (knotted range, 0.6-5.2 mm; knotless range, 0.4-9.1 mm; P <.05). The most common mode of failure in both groups was suture tendon tear. On the basis of the included cadaveric studies, rotator cuff tendons repaired via the knotted TOE technique display superior time-zero biomechanical properties, including greater ultimate load to failure, compared with rotator cuffs repaired via the knotless TOE technique. Suture tearing through the tendon remains a common failure method for both techniques. The results of this systematic review provide helpful insight into the biomechanical differences between 2 popular techniques for RCR. Although these results should be carefully considered by surgeons who are using either of these techniques in the operating room, they should not be mistaken for direct clinical applicability because cadaveric studies may not directly correlate to clinical outcomes. [ABSTRACT FROM AUTHOR]

Partial meniscectomy or failed meniscus repair can lead to pain, dysfunction, and cartilage degradation due to increased contact forces. Meniscus transplantation can lead to favorable outcomes and cartilage preservation with careful patient selection. Limited data exist on segmental meniscus allograft transplantation, with promising results using synthetic grafts and early animal and biomechanical studies on segmental allograft transplantation, showing similar results to full meniscus allograft transplantation. This article presents a technique for arthroscopic segmental medial meniscus allograft transplant and a brief review of the literature. [Display omitted] [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study is (1) to determine if, when optimizing modern techniques, medial opening-wedge osteotomies can effectively maintain tibial slope and (2) to determine how different magnitude coronal plane corrections affect tibial slope.Methods: Proximal tibial osteotomies (PTOs) were performed on 10 fresh-frozen cadaveric knees leaving a consistent lateral hinge, using either a 5-mm or a 10-mm trapezoidal wedged osteotomy plate. Techniques including posterior plate placement; a trapezoidal, sloped plate; and knee hyperextension were used during plate fixation to help close the anterior osteotomy gap. Medial coronal proximal tibia angle and posterior tibial slope were measured preosteotomy, after a 5-mm implant, and after a 10-mm implant using true anteroposterior and lateral fluoroscopic images. Three independent observers performed all radiographic measurements, and intraclass correlation coefficients were calculated.Results: The 5-mm and 10-mm osteotomy plates increased the coronal medial proximal tibia angle by a mean of 3.4° (range, 3.0°-3.7°) and 7.3° (range, 6.7°-7.7°), respectively. The 5-mm and 10-mm trapezoidal wedged osteotomy plates decreased the posterior tibial slope by a mean of 0.9° (range, 0.5°-1.2°) and 0.3° (range, 0°-0.6°), respectively. Intraobserver reliability was found to be high for both the coronal medial proximal tibia angle (intraclass correlation coefficient [ICC] = 0.897 [0.821-0.946]) and the tibial slope measurements (ICC = 0.761 [0.672-0.826]).Conclusions: When optimizing the medial opening-wedge proximal tibial osteotomy, including utilization of a sagittally oriented hinge, placement of a trapezoidal plate posteriorly, and fixation with knee hyperextension, posterior tibial slope can be maintained regardless of the degree of coronal correction.Clinical Relevance: Tibial slope has a significant effect on cruciate ligament stress and a better understanding of coronal plane correction, and its effect on tibial slope is critical when performing proximal tibia osteotomies. [ABSTRACT FROM AUTHOR]

Ruptures of the patellar tendon are rare but potentially devastating injuries reported to occur most commonly in active males in their third and fourth decades of life. Repair failure rates have been reported to range between 2% and 50% based on surgical technique used. There are several inherent challenges associated with revision patellar tendon repair, including quadriceps atrophy, contracture, tissue loss, excessive scarring, and improper patella height. There remains no consensus regarding ideal revision patellar tendon repair technique. The purpose of this Technical Note is to describe our preferred method for revision patellar tendon repair using suture anchors and allograft augmentation with adjustable loop suspensory fixation. On the basis of recent studies, we have carefully chosen our fixation and augmentation methods that have shown biomechanical promise, while allowing the surgeon to carefully titrate the patellar tendon length and accommodate for some patellar tendon tissue loss. [ABSTRACT FROM AUTHOR]

The article focuses on the knee cartilage repair and restoration, and includes complications associated with the same; use of magnetic resonance imaging and arthroscopically for diagnosing the same; surgical techniques used for the same; and surgical procedures for focal cartilage defects .

The article discusses the process of Allografts surgery by Osteochondral followed by shell, and paste.

Background The purpose of this study is to help define the indications for rotator cuff repair by identifying predictors of failure of nonoperative treatment. Methods A prospective, multicenter, cohort study design was used. All patients with full-thickness rotator cuff tears on magnetic resonance imaging were offered participation. Baseline data from this cohort were used to examine risk factors for failing a standard rehabilitation protocol. Patients who underwent surgery were defined as failing nonoperative treatment. A Cox proportional hazards model was fit to determinethe baseline factors that predicted failure. The dependent variable was time to surgery. The independent variables were tear severity and baseline patient factors: age, activity level, body mass index, sex, Single Assessment Numeric Evaluation score, visual analog scale score for pain, education, handedness, comorbidities, duration of symptoms, strength, employment, smoking status, and patient expectations. Results Of the 433 subjects in this study, 87 underwent surgery with 93% follow-up at 1 year and 88% follow-up at 2 years. The median age was 62 years, and 49% were female patients. Multivariate modeling, adjusted for the covariates listed previously, identified patient expectations regarding physical therapy ( P  < .0001) as the strongest predictor of surgery. Higher activity level ( P  = .011) and not smoking ( P  = .023) were also significant predictors of surgery. Conclusion A patient's decision to undergo surgery is influenced more by low expectations regarding the effectiveness of physical therapy than by patient symptoms or anatomic features of the rotator cuff tear. As such, patient symptoms and anatomic features of the chronic rotator cuff tear may not be the best features to use when deciding on surgical intervention. [ABSTRACT FROM AUTHOR]

Hypothesis: The purpose of this cross-sectional study is to determine whether the duration of symptoms influences the features seen in patients with atraumatic, full-thickness rotator cuff tears. Our hypothesis is that an increasing duration of symptoms will correlate with more advanced findings of rotator cuff tear severity on magnetic resonance imaging, worse shoulder outcome scores, more pain, decreased range of motion, and less strength. Methods: We enrolled 450 patients with full-thickness rotator cuff tears in a prospective cohort study to assess the effectiveness of nonoperative treatment and factors predictive of success. The duration of patient symptoms was divided into 4 groups: 3 months or less, 4 to 6 months, 7 to 12 months, and greater than 12 months. Data collected at patient entry into the study included (1) demographic data, (2) history and physical examination data, (3) radiographic imaging data, and (4) validated patient-reported measures of shoulder status. Statistical analysis included a univariate analysis with the Kruskal-Wallis test and Pearson test to identify statistically significant differences in these features for different durations of symptoms. Results: A longer duration of symptoms does not correlate with more severe rotator cuff disease. The duration of symptoms was not related to weakness, limited range of motion, tear size, fatty atrophy, or validated patient-reported outcome measures. Conclusions: There is only a weak relationship between the duration of symptoms and features associated with rotator cuff disease. [Copyright &y& Elsevier]

Purpose: To assess the effectiveness of a specific nonoperative physical therapy program in treating atraumatic full-thickness rotator cuff tears using a multicenter prospective cohort study design. Materials and methods: Patients with atraumatic full-thickness rotator cuff tears who consented to enroll provided data via questionnaire on demographics, symptom characteristics, comorbidities, willingness to undergo surgery, and patient-related outcome assessments (Short Form 12 score, American Shoulder and Elbow Surgeons score, Western Ontario Rotator Cuff score, Single Assessment Numeric Evaluation score, and Shoulder Activity Scale). Physicians recorded physical examination and imaging data. Patients began a physical therapy program developed from a systematic review of the literature and returned for evaluation at 6 and 12 weeks. At those visits, patients could choose 1 of 3 courses: (1) cured (no formal follow-up scheduled), (2) improved (continue therapy with scheduled reassessment in 6 weeks), or (3) no better (surgery offered). Patients were contacted by telephone at 1 and 2 years to determine whether they had undergone surgery since their last visit. A Wilcoxon signed rank test with continuity correction was used to compare initial, 6-week, and 12-week outcome scores. Results: The cohort consists of 452 patients. Patient-reported outcomes improved significantly at 6 and 12 weeks. Patients elected to undergo surgery less than 25% of the time. Patients who decided to have surgery generally did so between 6 and 12 weeks, and few had surgery between 3 and 24 months. Conclusion: Nonoperative treatment using this physical therapy protocol is effective for treating atraumatic full-thickness rotator cuff tears in approximately 75% of patients followed up for 2 years. [Copyright &y& Elsevier]

Purpose: The purpose of this systematic review is to evaluate the current literature in an effort to investigate sleep quality and disturbances and the association with clinical outcomes of patients undergoing shoulder surgery.Methods: A systematic review of the PubMed, Embase, and Cochrane Library databases was performed according to PRISMA guidelines. All English-language literature reporting clinical outcomes and sleep quality and disturbance following shoulder surgery was reviewed by two independent reviewers. Outcomes assessed included patient-reported outcomes (PROs) and sleep quality. Specific PROs included the Pittsburgh Sleep Quality Index (PSQI), Visual Analog Scale (VAS) for pain, Simple Shoulder Test (SST), University of California Los Angeles (UCLA) Shoulder Rating Scale, and American Shoulder and Elbow Surgeons Score (ASES). Study methodology was assessed using the Modified Coleman Methodology Score. Descriptive statistics are presented.Results: Sixteen studies (11 level IV, 2 level III, 3 level II) with a total of 2748 shoulders were included (age, 12-91 years; follow-up, 0.25-132 months). A total of 2198 shoulders underwent arthroscopic rotator cuff repair (RCR), 131 shoulders underwent arthroscopic capsular release, 372 shoulders underwent total shoulder arthroplasty, 18 shoulders underwent comprehensive arthroscopic management, and 29 shoulders underwent sternoclavicular joint procedures. All shoulder surgeries improved self-reported sleep and PROs from pre-operatively to post-operatively. In RCR patients, PSQI scores were significantly associated with VAS scores, SST scores (r = 0.453, r = -0.490, p<0.05, respectively), but not significantly associated with UCLA Shoulder rating scale or the ASES scores (r = 0.04, r = 0.001, p>0.05, respectively). In TSA patients, PSQI scores were significantly associated with ASES scores (r = -0.08, p<0.05). All 4 RCR studies and 1 TSA study utilizing PSQI found significant improvements in mean PSQI scores within 6-24 months (p<0.05).Conclusions: Surgical intervention for rotator cuff tear and glenohumeral osteoarthritis significantly improves self-reported sleep in patients with shoulder pain. However, there remains a dearth of available studies assessing the effects of surgical intervention for adhesive capsulitis, sternoclavicular joint instability, and sternoclavicular osteoarthritis on sleep. Future studies should utilize sleep-specific PROs and quantitative measures of sleep to further elucidate the relationship between sleep and the effect of shoulder surgery. [ABSTRACT FROM AUTHOR]

Abstract: Suspensory cortical fixation is commonly used for distal biceps tendon repair and reconstruction with one of several commercially available devices. The single-incision approach typically used with these devices is believed to have a lower incidence of heterotopic ossification than the dual-incision technique, but the true incidence of heterotopic ossification is unknown. The role of chemotherapeutic or radiation prophylaxis is undefined. We have identified 4 cases of extensive heterotopic ossification after biceps fixation with a suspensory button and single-incision approach. Surgeons should be aware of this potential complication when using suspensory cortical buttons for distal biceps fixation. [Copyright &y& Elsevier]

The anterior cruciate ligament (ACL) is a complex structure consisting of 2 functionally independent anatomic bundles, the anteromedial and posterolateral bundles. Anatomic and biomechanical studies have demonstrated distinctive functions for each of these bundles at various degrees of flexion. ACL reconstructions have traditionally focused solely on the reconstruction of the anteromedial bundle, with little consideration for the posterolateral bundle. Recent reports have appeared describing various techniques for anatomic ACL reconstruction in an attempt to recreate the native anatomy. We present an arthroscopic technique of anatomic, double-bundle ACL reconstruction using tibialis anterior tendon allografts. This technique restores the anatomic footprint of the native ACL on both the tibia and the femur. We believe that focusing reconstructive techniques on recreating both bundles of the ACL more closely recreates the biomechanical function of the native ligament. [Copyright &y& Elsevier]

Anterior cruciate ligament (ACL) ruptures are some of the most common knee injuries seen by sports medicine physicians. However, given the complex anatomy and function of the ACL, reconstruction of this ligament is anything but straightforward. The last decade has seen much advancement in ACL reconstruction, with an improved knowledge of the biology and biomechanics of graft incorporation, new choices for graft material and graft fixation devices, and more accelerated rehabilitation protocols. Although there are numerous studies in the literature on ACL reconstruction, there is yet to be a consensus among surgeons on the “best” graft choice and the “optimal” fixation device. This is generally attributed to the small sample size in most studies, which prohibits a definite conclusion of superiority of one technique over another. Additionally, it is difficult to directly compare the results from one study to another because there is tremendous heterogeneity between studies. This review is intended to examine the anatomy, biomechanics, surgical considerations, and clinical outcomes after ACL reconstruction that have been highlighted in the literature during the past 10 years. [Copyright &y& Elsevier]

Background Orthopedic surgeons are among the highest prescribers of narcotic pills, and no guidelines currently exist for appropriate management of postoperative pain within this field. The purpose of this study was to gain understanding of the current pain management strategies used perioperatively and postoperatively among orthopedic shoulder surgeons. Methods Members of the American Shoulder and Elbow Surgeons were e-mailed an online survey regarding methods for managing pain in the perioperative and postoperative setting for total shoulder arthroplasty, labral and capsular stabilization procedures, and rotator cuff repair. Postoperative narcotic prescribing amounts were converted into oral morphine equivalents. Results The survey response rate was 25.8% (170/658), with >90% of surgeons reporting use of a standard pain management regimen in the perioperative and postoperative periods. A regional nerve block was used on the operative day by >80% of surgeons for all 3 procedures. Short-acting narcotics are prescribed for postoperative pain control by >85% of surgeons, with long-acting narcotics provided by <14%. More than 400 oral morphine equivalents of short-acting narcotic are prescribed by shoulder surgeons. Referral to a pain specialist or primary care physician is made after 12 weeks by 92.3% of surgeons if patients continue to require narcotic painkillers. Conclusion The majority of shoulder surgeons use a standard pain management protocol in perioperative and postoperative settings. Regimens frequently include a regional nerve block, nonsteroidal anti-inflammatory drugs, and short-acting oral narcotics. Findings from this study provide guidelines on standard pain management strategies for common shoulder operations based on expert opinion. [ABSTRACT FROM AUTHOR]

Background Orthopedic surgeons are among the highest prescribers of narcotic pills, and no guidelines currently exist for appropriate management of postoperative pain within this field. The purpose of this study was to gain understanding of the current pain management strategies used perioperatively and postoperatively among orthopedic shoulder surgeons. Methods Members of the American Shoulder and Elbow Surgeons were e-mailed an online survey regarding methods for managing pain in the perioperative and postoperative setting for total shoulder arthroplasty, labral and capsular stabilization procedures, and rotator cuff repair. Postoperative narcotic prescribing amounts were converted into oral morphine equivalents. Results The survey response rate was 25.8% (170/658), with >90% of surgeons reporting use of a standard pain management regimen in the perioperative and postoperative periods. A regional nerve block was used on the operative day by >80% of surgeons for all 3 procedures. Short-acting narcotics are prescribed for postoperative pain control by >85% of surgeons, with long-acting narcotics provided by <14%. More than 400 oral morphine equivalents of short-acting narcotic are prescribed by shoulder surgeons. Referral to a pain specialist or primary care physician is made after 12 weeks by 92.3% of surgeons if patients continue to require narcotic painkillers. Conclusion The majority of shoulder surgeons use a standard pain management protocol in perioperative and postoperative settings. Regimens frequently include a regional nerve block, nonsteroidal anti-inflammatory drugs, and short-acting oral narcotics. Findings from this study provide guidelines on standard pain management strategies for common shoulder operations based on expert opinion. [ABSTRACT FROM AUTHOR]