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The etiology of anterior cruciate ligament (ACL) reconstruction failure is often multifactorial, and the role of subclinical bacterial colonization in ACL reconstruction failure has not been fully elucidated. Although the presence of bacterial metabolism in and of itself does not indicate true clinical infection, low-grade infections may contribute to ACL reconstruction graft failure. Bacterial biofilms on soft tissue grafts are shown to change the crimp patterns of collagen and lower graft load to failure. In addition, bacterial DNA has been reported in 80-87% of failed ACL grafts during revision surgery compared to only 20% of primary ACL grafts. Also, higher bacterial DNA concentration is associated with tibial tunnel widening. Further study is needed to establish if any causal relationship between bacterial colonization and ACL graft failure exists. But it does seem that the circumstantial evidence is pointing to such a relationship. [ABSTRACT FROM AUTHOR]

To determine whether preoperative psychological status before outpatient knee surgery is influenced by athletic status, symptom chronicity, or prior surgical history. International Knee Documentation Committee subjective scores (IKDC-S), Tegner Activity Scale scores, and Marx Activity Rating Scale scores were collected. Psychological and pain surveys included the McGill pain scale, Pain Catastrophizing Scale, Tampa Scale for Kinesiophobia 11, Patient Health Questionnaire 9, Perceived Stress Scale, New General Self-Efficacy Scale, and Life Orientation Test–Revised for optimism. Linear regression was used to determine the effects of athlete status, symptom chronicity (>6 months or ≤6 months), and history of prior surgery on preoperative knee function, pain, and psychological status after matching for age, sex, and surgical procedure. In total, 497 knee surgery patients (247 athletes, 250 nonathletes) completed a preoperative electronic survey. All patients were age 14 years and older and had knee pathology requiring surgical treatment. Athletes were younger than nonathletes on average (mean [SD], 27.7 [11.4] vs 41.6 [13.5] years; P <.001). The most frequently reported level of play among athletes was intramural or recreational (n = 110, 44.5%). Athletes had higher preoperative IKDC-S scores (mean [SE], 2.5 [1.0] points higher; P =.015) and lower McGill pain scores compared to nonathletes (mean [SE] 2.0 [0.85] points lower; P =.017). After matching for age, sex, athlete status, prior surgery, and procedure type, having chronic symptoms resulted in higher preoperative IKDC-S (P <.001), pain catastrophizing (P <.001), and kinesiophobia scores (P =.044). Athletes demonstrate no difference in symptom/pain and function scores preoperatively when compared to nonathletes of similar age, sex, and knee pathology, as well as no difference in multiple psychological distress outcomes measures. Patients with chronic symptoms have more pain catastrophizing and kinesiophobia, while those who have had prior knee surgeries have slightly higher preoperative McGill pain score. Level III, cross-sectional analysis of prospective cohort study data. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study is to determine the efficacy of amniotic suspension allograft (ASA) compared to hyaluronic acid (HA) and saline at up to 12 months of follow-up through the use of patient-reported outcomes, immunoglobulin levels, and anti-human leukocyte antigen (HLA) levels.Methods: Within this multicenter study, 200 patients were randomized 1:1:1 to a single intra-articular injection of saline, HA, or ASA. Patient-reported outcomes, including Knee Injury and Osteoarthritis Outcome Score (KOOS) and visual analog scale (VAS) score, were collected at multiple time points (baseline, 1 week, 6 weeks, 3 months, 6 months) out to 12 months to assess improvements in pain and function. Radiographs at baseline and 12 months were taken to determine radiographic changes, while blood was collected at baseline, 6 weeks, and 6 months to determine changes in immunoglobulins and anti-HLA levels. Statistical analyses were performed using last observation carried forward and mixed effects model for repeated measures.Results: Treatment with ASA resulted in significant improvements in KOOS and VAS scores that were maintained through 12 months (P < .05). Treatment with ASA resulted in a 63.2% responder rate at 12 months using the Outcome Measures in Arthritis Clinical Trials-Osteoarthritis Research Society International simplified definition. There were no significant differences between groups for radiographic measures in the index knee, immunoglobulins, C-reactive protein, or anti-HLA serum levels (P > .05). The number and type of adverse events (AEs) reported for ASA were comparable to the HA injection group, while no treatment-emergent AEs were reported for the saline group.Conclusions: This randomized controlled trial of ASA vs HA and saline for the treatment of symptomatic knee osteoarthritis demonstrated clinically meaningful improved outcomes with ASA over the controls out to 12 months postinjection. No concerning immunologic or adverse reactions to the ASA injection were identified with regards to severe AEs, immunoglobulin, or anti-HLA levels.Level Of Evidence: Level I, randomized controlled multicenter trial. [ABSTRACT FROM AUTHOR]

Purpose: To analyze the trends in operative experience, specifically procedures of the shoulder, hip and knee, of fellows graduating from Accreditation Council for Graduate Medical Education orthopaedic sports medicine fellowships between 2011 and 2016.Methods: The 2011-2016 Accreditation Council for Graduate Medical Education orthopaedic surgery sports medicine fellow case logs were retrieved for analysis. Trends in the mean case volume for procedures of the shoulder, hip, and knee were analyzed. Linear regression was used to identify significant changes in trends over time for each surgical case/procedure. Variation in case volume between fellows in the lowest (10th) and highest (90th) centile was assessed for first and last year of the study.Results: The average number of total procedures per fellow minimally decreased by 3.5% from 2011 to 2016 (726 to 701 cases) (P < .001). The mean total number of hip procedures significantly increased by 155% from 24.9 to 63.5 (P = .049). There were no significant differences in the mean total number of shoulder (P = .88) and knee procedures (P = .54). Arthroscopic hip procedures had the largest increase from 2011 to 2016 (14.1 to 57.8 [+310%], P = .049). There was greater than 2-fold difference in total procedural volume between fellows in the 10th and 90th percentile for 2011 and 2016, with the greatest variation (64-fold) for arthroscopic hip procedures.Conclusions: In this study there was a 2.6-fold increase in hip procedures, largely driven by a 310% rise in arthroscopic hip cases. The average procedural volume per fellow minimally decreased, with no change in the mean number of shoulder and knee procedures.Clinical Relevance: Understanding variability in case exposure among orthopaedic sports medicine fellowships is important for programs to ensure that fellows are appropriately exposed to all facets of sports medicine procedures. [ABSTRACT FROM AUTHOR]

Purpose: To analyze the clinical outcomes and survivorship of meniscal horizontal cleavage tear (HCT) repairs with hopes of guiding future treatment decisions.Methods: Standard systematic review methodology was used. A comprehensive search of PubMed was conducted on June 1, 2019. The inclusion criteria were articles that were published in English, involved human subjects, and reported on at least 1 outcome after repair of HCTs. The exclusion criteria included technique guides and reviews, studies without full text available, and studies with HCT outcomes not separated from other repair groups. Effect heterogeneity was determined using the I2 measure. Forest plots were created in addition to a random-effects model to show the results.Results: The systematic review yielded 19 studies evaluating 289 knees in a total of 273 patients. At most recent follow-up, there was a high probability of return to sport (93.1% [67 of 72]). Overall, 74% of patients (67 of 90) were symptom free at last follow-up, and 80% expressed satisfaction with their overall result (80 of 100). The most frequently reported subjective outcome was the Lysholm score, which improved from a preoperative study range of 48 to 79 (I2 = 20.7%, P = .283) to a postoperative study range of 56 to 99 (I2 = 49%, P = .081). The next most commonly reported was the International Knee Documentation Committee subjective score, which improved from a preoperative study range of 16 to 49 (I2 = 47.7%, P = .125) to a postoperative study range of 72 to 95 (I2 = 0%, P = .660). An overall 11.7% reported risk of reoperation was found, with most cases involving revision meniscectomy. Rates of complications beyond fixation failure were overall very low, with infrequent reports of septic arthritis and transitory dysesthesia.Conclusions: The short- to intermediate-term results of repair of HCTs are comparable to prior studies. Survivorship is comparable to repairs of other types of meniscal tears with high rates of return to sport and low complication rates.Level Of Evidence: Level IV, systematic review of Level I-IV studies. [ABSTRACT FROM AUTHOR]

Purpose: To determine whether subjective knee function or risk of repair failure differ between men and women at mean 5 years following meniscal repair with or without concomitant anterior cruciate ligament reconstruction.Methods: A total of 235 patients (97 women, 138 men; mean age, 29.1 years; standard deviation, 11.3) were assessed for meniscus repair failure and postoperative knee function at mean 5.8 years follow-up. Knee symptoms were assessed with International Knee Documentation Committee Subjective (IKDC-S) scores. Postoperative activity scores were assessed with Marx activity score. Independent effects of patient age and activity level on meniscus failure risk and patient-reported outcomes were determined by multivariate analysis with adjustment for age, body mass index, anterior cruciate ligament status, tear pattern, and number of implants used at the time of surgery.Results: Failures occurred in 18.9% of men and 21.0% of women with no difference in mean time to failure (P = .75) or risk of failure for men vs women (P = .57) in the univariate analysis. Male sex was not an independent risk factor for failure after adjustment for patient age, body mass index, concomitant anterior cruciate ligament status, tear pattern, or number of implants used (P = .16). Marx activity scores at follow-up were higher among men in multivariate analysis (P = .009). Men and women had similar IKDC-S scores at follow-up in the unadjusted (P = .25) and multivariate analyses (P = .21).Conclusions: Following meniscus repair, both sexes report similar subjective knee function, though men have higher self-reported activity scores. Meniscus repair failure risk does not differ between men or women at mid-term follow up.Level Of Evidence: Level III, retrospective case-control study. [ABSTRACT FROM AUTHOR]

Purpose: To compare meniscal repair failure rates in patients aged 40 years or older versus patients younger than 40 years.Methods: A total of 276 patients underwent meniscal repair surgery by a single sports medicine fellowship-trained surgeon between 2006 and 2012 and were eligible for study inclusion. Patients were followed up for meniscal repair failure, defined as meniscectomy, repeated meniscal repair, or total knee arthroplasty. Logistic regression analysis was used to determine the risk of failure while controlling for potential confounding variables including body mass index, sex, anterior cruciate ligament status, time from injury to surgery, number of implants used, tear pattern, and chondral status at the time of the repair.Results: Among the 276 eligible patients, 221 (80%) were successfully contacted for follow-up at an average of 5 years after surgery. Of these patients, 56 were aged 40 years or older (mean, 47.2 years; standard deviation [SD], 5.3 years) and 165 were younger than 40 years (mean, 24.7 years; SD, 6.7 years). The overall meniscal repair failure rate over a 5-year period was 20%. Among patients aged 40 years or older, the failure risk was 18% versus 21% in patients younger than 40 years. After adjustment for confounding variables, age of 40 years or older was not associated with increased failure risk (adjusted odds ratio, 0.83; 95% confidence interval, 0.36-1.81; P = .65). The mean time to failure tended to be shorter in older patients, at 16.9 months (SD, 10.2 months) versus 28.5 months in the group younger than 40 years (SD, 23.3 months) (P = .04).Conclusions: Age of 40 years or older is not associated with an increased risk of meniscal repair failure at 5 years, although a shorter time to failure was noted in this age cohort.Level Of Evidence: Level III, retrospective comparative study. [ABSTRACT FROM AUTHOR]

Purpose: To determine whether bacterial DNA will be detectable by polymerase chain reaction (PCR) in torn graft tissue at the time of revision anterior cruciate ligament reconstruction (ACLR).Methods: A total of 31 consecutive revision ACLR cases from 1 center from 2014-2016 were recruited. No patients had clinical signs of infection on presentation. Torn graft tissue was obtained in revision cases and subjected to clinical culture and PCR analysis with a universal bacterial primer. Fluorescence microscopy was used to confirm the presence of a biofilm. We obtained negative control samples of water open to air on the field and excess primary ACLR graft tissue, as well as torn native ligament, to evaluate for PCR positivity due to environmental contamination.Results: Clinical cultures were positive (coagulase-negative Staphylococcus) in 1 revision case (3%, 1 of 31). Bacterial DNA was detectable in most revision ACLR cases (87.0%, 27 of 31), and there was a low rate of PCR positivity in negative control samples of water open to air (0%, 0 of 3), excess primary ACLR graft tissue after passage (20%, 1 of 5), or native torn ligament (20%, 1 of 5). Bacterial biofilm presence on failed graft tissue as well as monofilament suture was visually confirmed with fluorescence microscopy.Conclusions: Bacterial DNA is frequently present in failed ACLR grafts, with high rates of DNA detection by PCR but low culture positivity.Level Of Evidence: Level IV, case series. [ABSTRACT FROM AUTHOR]

Purpose: To compare the risk of anterior cruciate ligament reconstruction failure in patients who undergo anterior cruciate ligament reconstruction with either autograft tissue or hybrid grafts.Methods: A systematic search was performed on February 28, 2018, on PubMed, Scopus, Arthroscopy, and Cochrane Library. Included studies were clinical outcome studies of primary anterior cruciate ligament reconstructions that compared failure risk for hybrid grafts versus autografts. Baseline and outcomes data were extracted, and reporting quality was assessed via modified Coleman criteria. A random effects meta-analysis was conducted for both randomized and nonrandomized studies.Results: Nine studies were identified with a mean of 40.1 months of follow-up. The mean Coleman methodology score was 66.5 (standard deviation, 12.8). One randomized study (Level II evidence) was identified with no difference in failure rates (0% for both groups, 8-mm minimum graft diameter for all patients). Eight nonrandomized studies (all Level III evidence) were identified with no difference in failure risk for hybrid grafts versus autograft (pooled odds ratio, 1.29; 95% confidence interval, 0.57-2.92; P = .55; I2 = 34%). Mean graft diameters were significantly larger in hybrid groups (range, 8.5-9.9 mm) than in autograft groups (range, 6.4-8.8 mm) in nonrandomized studies (mean difference, 0.5-2.5 mm; P ≤ .003). There was no evidence of small study bias or bias owing to reporting quality, and adjustment for length of follow-up, mean patient age, percentage of male patients, year of publication, or reporting quality did not improve statistical heterogeneity.Conclusions: Based on the current literature, although it may be theoretically detrimental to add allograft to a small-diameter autograft, it cannot be definitively shown based on the findings of this review with meta-analysis. Currently, it remains unclear that there is an advantage or disadvantage to hybridization of small autograft with allograft, although randomized studies of patients with small (<8-mm) autograft diameters are lacking.Level Of Evidence: Level III, systematic review of Level II and III studies. [ABSTRACT FROM AUTHOR]

Purpose: To systematically review multiligament knee injury (MLKI) outcome studies to determine overall rates of return to work or sport after MLKI and risk factors for lack of return to work or sport after MLKI.Methods: A search was performed of MLKI outcome studies from 1950 to March 1, 2017. Ninety-two studies were identified. All included reported return to work, return to sport, or Tegner activity scores. Rates of return to work or sport were determined for overall population and by obesity status, injury severity, and presence of peroneal nerve or vascular injury.Results: A total of 524 patients (21 studies) were included. Return to high-level sport was low (22%-33%). Return to any level of sport was 53.6% overall (178/332), with a higher rate reported in studies with all surgical patients (59.1%, 114/193 patients) versus studies with mixed surgical and nonoperative treatment (46.0%, 64/139 patients) (P = .02). Rate of return to work with little or no modifications was 62.1% (146/200) and return to any work was 88.4% (190/215). Obese patients had lower postoperative Tegner scores than a general population (obese: mean 1.7 ± 1.2; nonobese: mean 4.5 ± 1.0; P < .001). Among studies without Schenck grade IV and V injuries, return to work with no or minimal modifications (100%, 12/12 patients) was higher than studies including grade IV and V patients (66.0%, 70/106 patients) (P = .017). Return to any work was higher in studies without vascular injuries (96.3%, 105/109) versus those including them (80.2%, 85/106) (P < .001).Conclusions: Return to sport after MLKI occurs in approximately 60% of surgically treated patients, though return to high-level sport is lower. Return to work is frequently possible after MLKI though it may require workplace or job duty modifications. Obesity, nonoperative treatment, higher injury severity, and vascular injury are associated with poorer functional outcomes.Level Of Evidence: Level IV, systematic review of level III and IV studies. [ABSTRACT FROM AUTHOR]

Purpose: To determine whether graft selection or patient age affects the following after isolated medial patellofemoral ligament (MPFL) reconstruction: (1) rates of recurrent instability, (2) rates of postoperative complications (other than instability), and (3) subjective symptom improvement.Methods: A systematic search identified studies reporting outcomes for isolated MPFL reconstruction. Rates of recurrent instability, subjective Kujala knee function scores, and complications were tabulated. Symptom improvement was defined as change in Kujala score (preoperative evaluation to final follow-up).Results: Forty-five studies were included with 27 documented cases of recurrent instability among 1,504 patients (1.8%); instability rates ranged from 0% to 20.0% overall; among autograft in adults, 0% to 11.1% (1.4%, 18/1,260); among autograft in adolescents, 0% to 20% (10.0%, 8/80); among allograft, 0% (0/65 cases); and among synthetic, 0% to 3.3% (1.3%, 1/76). Among autograft choices in adults, rates of recurrent instability were low; recurrence with gracilis ranged from 0% to 11.1% (0.9%, 1/116); with semitendinosus, 0% to 6.3% (0.6%, 4/676); with quad or patellar tendon, 0% (0/65); and with adductor tendon, 5.6% to 8.3% (6.7%, 2/30). Complication rates ranged from 0% to 34.4%. All included studies reported significant improvement in Kujala scores after surgery (P < .01). There was significant heterogeneity in effect size and evidence of reporting bias among small studies, precluding reliable pooled analysis of treatment effect.Conclusions: Autograft is not superior to allograft or synthetic grafts for isolated reconstruction of the MPFL, and rates of recurrent instability are generally low. Isolated MPFL reconstruction can provide significant symptom relief regardless of graft selection, although there is a bias toward reporting better than expected results among smaller studies. Pediatric patients and patients treated with adductor tendon autograft have higher recurrent instability rates. While caution should be used in making definitive recommendations secondary to the small number of allograft and synthetic studies, selection of graft type based on surgeon preference, comfort, and prior experience remains appropriate.Level Of Evidence: Level IV, systematic review of Level I to IV studies. [ABSTRACT FROM AUTHOR]

Purpose: To analyze failure rate in 2-year increments to determine if graft choice changed over time and graft failure rate.Methods: A prospective 2002-2008 database was used to identify risk factors for anterior cruciate ligament (ACL) retear. Subjects who had primary ACL retear with no history of contralateral surgery and 2-year follow-up were included. Subjects who underwent a multiligament reconstruction were excluded. Graft type, age, sex, smoking status, body mass index, Marx activity level at index surgery, medial and lateral meniscus status at time of ACL retear, sport played after ACL reconstruction, and clinical site were evaluated. Analysis was repeated using 2002-2003 (early) and 2007-2008 (late) 2-year databases. Analysis of variance with post hoc analysis was performed to detect significant differences in age and Marx score by graft type over time.Results: Two-year follow-up for graft failure was obtained on 2,497 of 2,692 (93%) subjects. There were 112 of 2,497 (4.5%) ACL retears identified at 2-year follow-up. The only predictor that changed between early/late periods was allograft use. Allograft odds ratio decreased from 13.1 to 9.5 (P < .01). Allografts were used in older patients (31-40 years) and with lower Marx scores (10-8) from early to late periods. The mean age of subjects who received bone-patellar tendon-bone autografts did not significantly change over time (22.8-23.5). The mean age of subjects who received hamstring autografts fell (27.9-25.5). The mean age of subjects who received allografts rose significantly (31.3-39.8, P < .01). The mean Marx score of subjects who received bone-patellar tendon-bone and hamstring autografts did not significantly change over time. The mean Marx score of subjects who received allografts decreased significantly (P < .01).Conclusions: After early recognition, allograft use in young active patients was a risk factor for retear; graft choice by surgeons changed in the late period to use of allografts in older and less-active patients, which correlated with a significant decrease in retear risk.Level Of Evidence: Level III, case control study. [ABSTRACT FROM AUTHOR]

Purpose: To compare the efficacy of common invasive and noninvasive patellar tendinopathy (PT) treatment strategies.Methods: A systematic search was performed in PubMed, Google Scholar, CINAHL, UptoDate, Cochrane Reviews, and SPORTDiscus. Fifteen studies met the following inclusion criteria: (1) therapeutic outcome trial for PT, and (2) Victorian Institute of Sports Assessment was used to assess symptom severity at follow-up. Methodological quality and reporting bias were evaluated with a modified Coleman score and Begg's and Egger's tests of bias, respectively.Results: A total of 15 studies were included. Reporting quality was high (mean Coleman score 86.0, standard deviation 9.7), and there was no systematic evidence of reporting bias. Increased duration of symptoms resulted in poorer outcomes regardless of treatment (0.9% decrease in improvement per additional month of symptoms; P = .004). Eccentric training with or without core stabilization or stretching improved symptoms (61% improvement in the Victorian Institute of Sports Assessment score, 95% confidence interval [CI] 53% to 69%). Surgery in patients refractory to nonoperative treatment also improved symptoms (57%, 95% CI 52% to 62%) with similar outcomes among arthroscopic and open approaches. Results from shockwave (54%, 95% CI 22% to 87%) and platelet-rich plasma (PRP) studies (55%, 95% CI 5% to 105%) varied widely though PRP may accelerate early recovery. Finally, steroid injection provided no benefit (20%, 95% CI -20% to 60%).Conclusions: Initial treatment of PT can consist of eccentric squat-based therapy, shockwave, or PRP as monotherapy or an adjunct to accelerate recovery. Surgery or shockwave can be considered for patients who fail to improve after 6 months of conservative treatment. Corticosteroid therapy should not be used in the treatment of PT.Level Of Evidence: Level IV, systematic review of Level II-IV studies. [ABSTRACT FROM AUTHOR]

Hybrid anterior cruciate ligament grafts augmenting a small-diameter hamstring tendon autograft with nonirradiated allografts can be used with good results in adults. In teens, however, outcomes of hybrid grafts have not been well defined, and other solutions to small hamstring grafts including graft folding, contralateral autograft augmentation, or selection of a different autograft source could be considered. [ABSTRACT FROM AUTHOR]

Purpose: To perform a systematic review of the use of autologous chondrocyte implantation (ACI) in the adolescent knee.Specific Aims: (1) quantify clinical outcomes of ACI in adolescent knees, (2) identify lesion and patient factors that correlate with clinical outcome, and (3) determine the incidence of complications of ACI in adolescents.Methods: PubMed, MEDLINE, SCOPUS, CINAHL, and Cochrane Collaboration Library databases were searched systematically. Outcome scores recorded included the International Knee Documentation Committee score, the International Cartilage Repair Society score, the Knee Injury and Osteoarthritis Outcome Score, the visual analog scale, the Bentley Functional Rating Score, the Modified Cincinnati Rating System, Tegner activity Lysholm scores, and return athletics. Outcome scores were compared among studies based on proportion of adolescents achieving specific outcome quartiles at a minimum 1-year follow-up. Methodologic quality of studies was evaluated by Coleman Methodology Scores (CMSs).Results: Five studies reported on 115 subjects who underwent ACI with periosteal cover (ACI-P; 95, 83%), ACI with type I/type III collagen cover (ACI-C; 6, 5%), or matrix-induced ACI (MACI; 14, 12%). Mean patient age was 16.2 years (range, 11 to 21 years). All studies were case series. Follow-up ranged from 12 to 74 months (mean, 52.3 months). Mean defect size was 5.3 cm(2) (range, 0.96 to 14 cm(2)). All studies reported improvement in clinical outcomes scores. Graft hypertrophy was the most common complication (7.0%). The mean preoperative clinical outcome percentage (based on percentage of outcome scale used) was 37% (standard deviation [SD], 18.9%) and the mean postoperative clinical outcome percentage was 72.7% (SD, 16.9%). The overall percentage increase in clinical outcome scores was 35.7% (SD, 14.2%). Mean CMS was 47.8 (SD, 8.3).Conclusions: Cartilage repair in adolescent knees using ACI provides success across different clinical outcomes measures. The only patient- or lesion-specific factor that influenced clinical outcome was the shorter duration of preoperative symptoms.Level Of Evidence: Level IV, systemic review of Level I-IV studies. [ABSTRACT FROM AUTHOR]

Purpose: To analyze the effect of gracilis harvest on hamstring strength, patient-reported outcomes, and anterior knee laxity after anterior cruciate ligament (ACL) reconstruction.Methods: A systematic review of the literature was performed to identify studies comparing the results of semitendinosus (ST) versus semitendinosus-gracilis (ST-G) harvest for ACL reconstruction. A meta-analysis using a random effects model was performed to determine overall pooled estimates of effect for the influence of additional gracilis harvest on hamstring strength, patient-reported outcomes, and anterior knee laxity after ACL reconstruction.Results: Twelve studies were identified and included in the review. ST-G harvest was noted to decrease hamstring isokinetic strength at 60° per second by 3.85% relative to isolated ST harvest (P = .01). Decreased isometric strength was also noted in the ST-G harvest group at both 90° of flexion (mean difference: 5.55%; P = .03) and 105° to 110° of flexion (mean difference: 13.68%; P = .003). Active knee flexion angle loss was also noted to be greater in the ST-G harvest group (mean difference: 3.91°; P = .006). No differences were found in isokinetic strength at 180° to 240° per second (mean difference: 3.20%; P = .08), patient-reported outcome scores (mean difference: 1.87 points; P = .06), or anterior knee laxity (mean difference: 0.03 mm; P = .78) based on gracilis harvest.Conclusions: The addition of gracilis harvest to an isolated ST harvest for ACL reconstruction results in statistically significant, but likely not clinically relevant differences in isokinetic and isometric hamstring strength as well as patient-reported outcomes. Hamstring strength deficits may be larger at higher flexion angles.Level Of Evidence: Level III, systematic review of level I-III studies. [ABSTRACT FROM AUTHOR]

Purpose: To describe the outcomes of bone-patellar tendon-bone (BPTB) and soft-tissue allografts in anterior cruciate ligament (ACL) reconstruction with respect to graft failure risk, physical examination findings, instrumented laxity, and patient-reported outcomes.Methods: A search of the PubMed, Scopus, CINAHL (Cumulative Index to Nursing and Allied Health Literature) Complete, Cochrane Collaboration, and SPORTDiscus databases was performed. English-language studies with outcome data on primary ACL reconstruction with nonirradiated BPTB and soft-tissue allografts were identified. Outcome data included failure risk, physical examination findings, instrumented laxity measurements, and patient-reported outcome scores.Results: Seventeen studies met the inclusion criteria. Of these studies, 11 reported on BPTB allografts exclusively, 5 reported on soft-tissue allografts exclusively, and 1 compared both types. The comparative study showed no difference in failure risk, Lachman grade, pivot-shift grade, instrumented laxity, or overall International Knee Documentation Committee score between the 2 allograft types. Data from all studies yielded a failure risk of 10.3% (95% confidence interval [CI], 4.5% to 18.1%) in the soft-tissue group and 15.2% (95% CI, 11.3% to 19.6%) in the BPTB group. The risk of a Lachman grade greater than 5 mm was 6.4% (95% CI, 1.7% to 13.7%) in the soft-tissue group and 8.6% (95% CI, 6.3% to 11.2%) in the BPTB group. The risk of a grade 2 or 3 pivot shift was 1.4% (95% CI, 0.3% to 3.3%) in the soft-tissue group and 4.1% (95% CI, 1.9% to 7.2%) in the BPTB group.Conclusions: One comparative study showed no difference in results after ACL reconstruction with nonirradiated BPTB and soft-tissue allografts. Inclusion of case series in the analysis showed qualitatively similar outcomes with the 2 graft types. [ABSTRACT FROM AUTHOR]

Purpose: (1) To investigate the pattern and diameter of the iatrogenic defect that meniscal repair devices impose on meniscal tissue and (2) to determine whether repair-induced defect patterns or diameters differ across devices.Methods: Sixty-one fresh frozen human cadaveric menisci were used (n = 9; eliminated). All-inside devices (n = 9) included ULTRA FAST-FIX, FAST-FIX 360, Depuy Mitek 0° and 12° TRUESPAN, ConMed Sequent, Zimmer Biomet JuggerStitch, Stryker IvyAIR, Arthrex FiberStitch and Meniscal Cinch II. Inside-out needles (n = 4) included ConMed HiFi, Depuy Mitek ORTHOCORD, Arthrex-2-0 FiberWire, and Stryker SharpShooter. Following India Ink staining, implant devices were inserted into cadaveric menisci. Samples were fixed in formalin solution and imaged with a high-resolution camera. Defects were classified by qualitative evaluation. Defect and needle diameter were quantified with software assistance. Statistical analysis was performed using analysis of variance testing.Results: We analyzed 644 iatrogenic defects with mean defect diameter of 1.96 mm (standard deviation 0.86). For all-inside devices, defect patterns (n = 436) were 15.6% linear, 38.1% semilunar, 46.3% stellate, while inside-out devices (n = 208) were 95.7% stellate, 4.3% linear, and 0.0% semilunar. All-inside devices had mean defect diameter of 2.46 mm, while inside-out meniscus needles had mean 0.90 mm defect diameter (P < .001). FasT-FIX 360, ULTRA-FAST-FIX, and Arthrex Meniscal Cinch II induced smaller diameter defects than other all-inside devices (F = 20.2, P < .05). Strong positive correlation was found comparing outer needle diameter and mean defect diameters across all devices (R2 = 0.9447).Conclusions: Needles utilized in meniscal implant systems produce the following basic defect patterns: stellate (62.3%), semilunar (25.8%), and linear (11.9%). A strong positive correlation was found between mean defect size and outer needle diameter across all devices. Inside-out double-armed flexible needles produced significantly smaller defects than all-inside devices. Of the all-inside devices, ULTRA FAST-FIX, FAST-FIX 360, and Arthrex Meniscal Cinch II produced smaller defects on average.Clinical Relevance: While the true clinical impact of these findings cannot be drawn from the present study, this investigation provides necessary context to better understand reported similarities and differences in healing rates and outcomes between inside-out and all-inside repair techniques. [ABSTRACT FROM AUTHOR]

Purpose The goal of this review was to quantify the risk of perioperative and early postoperative complications of tibial tubercle osteotomy (TTO) with different techniques. Methods A systematic review of multiple databases was performed to identify studies that reported complications of TTO. Complications were defined as any adverse outcome, including osteotomy site nonunion, fracture, infection, wound complications, neurovascular complications, deep vein thrombosis (DVT), and pulmonary embolism (PE). Major complications were defined as nonunion, fracture, infections/wound complications requiring return to the operating room, and DVT or PE. The risk of subsequent hardware removal was also quantified. Results The 19 identified studies included a total of 787 TTOs: 472 direct medialization procedures (Elmslie-Trillat technique), 193 anteromedialization procedures (Fulkerson technique), and 102 procedures in which the tibial tubercle was completely detached for medialization or distalization, or a combination. The overall complication risk was 4.6%. The risk of complications was higher when the tibial tubercle was completely detached (10.7%) than with Elmslie-Trillat (3.3%) or Fulkerson (3.7%) procedures ( P = .004). The overall risk of major complications was 3.0%. Hardware removal was performed in 36.7% of osteotomies and was less frequent with the Elmslie-Trillat technique (26.8%) than with the Fulkerson technique (49.0%) or complete tubercle detachment (48.3%) ( P < .001). Conclusions Tibial tubercle osteotomy is a complex surgical procedure with a significant risk of complications. Osteotomies that involve complete detachment of the tubercle have an increased risk of complications compared with those in which a distal cortical hinge is maintained. Level of Evidence Level IV, systematic review of Level IV studies. [ABSTRACT FROM AUTHOR]

Purpose To investigate the association of smoking with rotator cuff (RTC) disease and shoulder dysfunction, defined as poor scores on shoulder rating scales. Methods A systematic review was performed using a search strategy based on “shoulder AND [smoke OR smoking OR nicotine OR tobacco].” English-language clinical or basic science studies testing the association of smoking and shoulder dysfunction on shoulder rating scales or disease of the soft tissue of the shoulder were included. Level V evidence studies and articles reporting only on surgery outcomes, subjective symptoms, adhesive capsulitis, or presence of fracture or oncologic mass were excluded. Results Thirteen studies were included, comprising a total of 16,172 patients, of whom 6,081 were smokers. All 4 clinical studies addressing the association between smoking and patient-reported shoulder symptoms and dysfunction in terms of poor scores on shoulder rating scales (i.e., Simple Shoulder Test; University of California, Los Angeles shoulder scale; and self-reported surveys) confirmed this correlation with 6,678 patients, of whom 1,723 were smokers. Two of four studies documenting provider-reported RTC disease comprised 8,461 patients, of whom 4,082 were smokers, and found a time- and dose-dependent relation of smoking with RTC tears and a correlation of smoking with impingement syndrome. Smoking was also reported in 4 other articles to be associated with the prevalence of larger RTC tears or tears with pronounced degenerative changes in 1,033 patients, of whom 276 were smokers, and may accelerate RTC degeneration, which could result in tears at a younger age. In addition, 1 basic science study showed that nicotine increased stiffness of the supraspinatus tendon in a rat model. Conclusions Smoking is associated with RTC tears, shoulder dysfunction, and shoulder symptoms. Smoking may also accelerate RTC degeneration and increase the prevalence of larger RTC tears. These correlations suggest that smoking may increase the risk of symptomatic RTC disease, which could consequently increase the need for surgical interventions. Level of Evidence Level IV, systematic review of Level II through IV studies. [ABSTRACT FROM AUTHOR]

Purpose: This study aimed to determine the ability of patients to return to activity after medial patellofemoral ligament (MPFL) reconstruction or repair for patellar instability. Methods: A systematic review was performed using multiple databases. Studies reporting outcomes with Tegner scores after repair or reconstruction of the MPFL were included. Surgical technique, Tegner scores, and episodes of recurrent patellar instability were recorded. Results: Ten articles with a total of 402 patients were included. The mean preoperative Tegner score was 4.7 (2.9 to 7.5). The mean postoperative Tegner score was 5.8 (4.0 to 7.7). Forty-nine patients (12.2%) had a recurrent episode of instability, 11 of whom required additional corrective procedures. There was a statistically significant larger failure rate among those who underwent MPFL repair (26.9%) than those who underwent reconstruction (6.6%) or medial retinacular repair/plication (16.5%). Conclusions: Recurrent dislocation was higher in patients who underwent MPFL repair rather than reconstruction. However, repair and reconstruction had similar Tegner scores. Repair or reconstruction of the soft tissue structures contributing to patellofemoral instability is successful in returning patients to preinjury activity levels. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to evaluate the effect of graft size on patient-reported outcomes and revision risk after anterior cruciate ligament (ACL) reconstruction. Methods: A retrospective chart review of prospectively collected cohort data was performed, and 263 of 320 consecutive patients (82.2%) undergoing primary ACL reconstruction with hamstring autograft were evaluated. We recorded graft size; femoral tunnel drilling technique; patient age, sex, and body mass index at the time of ACL reconstruction; Knee Injury and Osteoarthritis Outcome Score (KOOS) and International Knee Documentation Committee score preoperatively and at 2 years postoperatively; and whether each patient underwent revision ACL reconstruction during the 2-year follow-up period. Revision was used as a marker for graft failure. The relation between graft size and patient-reported outcomes was determined by multiple linear regression. The relation between graft size and risk of revision was determined by dichotomizing graft size at 8 mm and stratifying by age. Results: After we controlled for age, sex, operative side, surgeon, body mass index, graft choice, and femoral tunnel drilling technique, a 1-mm increase in graft size was noted to correlate with a 3.3-point increase in the KOOS pain subscale (P = .003), a 2.0-point increase in the KOOS activities of daily living subscale (P = .034), a 5.2-point increase in the KOOS sport/recreation function subscale (P = .004), and a 3.4-point increase in the subjective International Knee Documentation Committee score (P = .026). Revision was required in 0 of 64 patients (0.0%) with grafts greater than 8 mm in diameter and 14 of 199 patients (7.0%) with grafts 8 mm in diameter or smaller (P = .037). Among patients aged 18 years or younger, revision was required in 0 of 14 patients (0.0%) with grafts greater than 8 mm in diameter and 13 of 71 patients (18.3%) with grafts 8 mm in diameter or smaller. Conclusions: Smaller hamstring autograft size is a predictor of poorer KOOS sport/recreation function 2 years after primary ACL reconstruction. A larger sample size is required to confirm the relation between graft size and risk of revision ACL reconstruction. Level of Evidence: Level III, retrospective comparative study. [Copyright &y& Elsevier]

Purpose: To determine whether the basic science evidence supports the use of continuous passive motion (CPM) after articular cartilage injury in the knee. Methods: A systematic review was performed identifying and evaluating studies in animal models that focused on the basic science of CPM of the knee. Databases included in this review were PubMed, Biosis Previews, SPORTDiscus, PEDro, and EMBASE. All functional, gross anatomic, histologic, and histochemical outcomes were extracted and analyzed. Results: Primary outcomes of CPM analyzed in rabbit animal models (19 studies) included histologic changes in articular cartilage (13 studies), biomechanical changes and nutrition of intra-articular tissue (3 studies), and anti-inflammatory biochemical changes (3 studies). Nine studies specifically examined osteochondral defects, 6 of which used autogenous periosteal grafts. Other pathologies included were antigen-induced arthritis, septic arthritis, medial collateral ligament reconstruction, hemarthrosis, and chymopapain-induced proteoglycan destruction. In comparison to immobilized knees, CPM therapy led to decreased joint stiffness and complications related to adhesions while promoting improved neochondrogenesis with formation and preservation of normal articular cartilage. CPM was also shown to create a strong anti-inflammatory environment by effectively clearing harmful, inflammatory particles from within the knee. Conclusions: Current basic science evidence from rabbit studies has shown that CPM for the knee significantly improves motion and biological properties of articular cartilage. This may be translated to potentially improved outcomes in the management of articular cartilage pathology of the knee. Clinical Relevance: If the rabbit model is relevant to humans, CPM may contribute to improved knee health by preventing joint stiffness, preserving normal articular tissue with better histologic and biologic properties, and improving range of motion as compared with joint immobilization and intermittent active motion. [Copyright &y& Elsevier]

Purpose: Our purpose was to determine patient-cited reasons for lack of return to sport after anterior cruciate ligament reconstruction. Methods: All patients who underwent primary or revision anterior cruciate ligament reconstruction by 2 surgeons from 2007 to 2008 (N = 171) were contacted for a telephone interview. Patients who did not return to preinjury levels by self-assessment were then asked to cite contributing factors from a predetermined list. These included non–knee-related life events, persistent knee symptoms, fear of reinjury (kinesiophobia), and choice-related options (such as lack of interest or time). Results: Of the 135 patients who completed the interview, 62 (46%) reported a return to preinjury activity levels (returners) whereas 73 (54%) did not (non-returners). Returners (26.4 ± 10.9 years) were younger than non-returners (30.0 ± 9.8 years) (P = .04). Persistent knee symptoms (68%) and kinesiophobia (52%) were more commonly cited as reasons for not returning to sport than non–knee-related life events (29%), including children, job/education, or health problems (P < .001 for symptoms and P = .004 for kinesiophobia). Among non-returners who cited knee symptoms, 50% concurrently cited kinesiophobia and 24% cited life events. Conclusions: A lack of return to preinjury activity levels is common after anterior cruciate ligament reconstruction. A majority of patients who do not return to their preinjury activities cite persistent knee symptoms, particularly pain, as a contributing factor, and only a minority of patients cite job and family demands or a lack of interest. Finally, fear of reinjury was cited by half of the patients who did not return to sport. Level of Evidence: Level III, retrospective comparative study. [Copyright &y& Elsevier]

Purpose: To compare clinical outcomes of patients undergoing isolated patellofemoral autologous chondrocyte implantation (ACI) and ACI combined with patellofemoral realignment. Methods: A systematic review was performed by use of PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines/checklist. We searched PubMed, CINAHL (Cumulative Index to Nursing and Allied Health Literature), SportDiscus, and the Cochrane Central Register of Controlled Trials databases from 1946 through February 2012 to determine whether a difference exists in outcomes of combined ACI and osteotomy versus isolated ACI (minimum 2 years'' follow-up). Studies were included only if outcomes were reported separately for both isolated ACI and combined ACI and osteotomy. All ACI generations were eligible for inclusion. Patellofemoral osteotomies eligible for inclusion were anteriorization, medialization, or anteromedialization. All patient-, limb-, and defect-specific characteristics were assessed. All reported clinical scores, radiographic and histologic outcomes, and complications/reoperations were analyzed. Risk of bias was assessed within all studies. Results: Eleven studies (10 Level III or IV evidence) (366 subjects) were included. Of the defects treated, 78% were located on the patella and 22% on the trochlea. The mean subject age was 33.3 years. Twenty-three percent of subjects underwent concomitant osteotomy. The mean length of follow-up was 4.2 years. Significant (P < .05) improvements in patients undergoing both isolated ACI and combined ACI and osteotomy for patellofemoral chondral defects were observed in all studies. Three studies directly compared isolated ACI and combined ACI and osteotomy, with significantly (P < .05) greater improvements shown in patients undergoing combined osteotomy and ACI (International Knee Documentation Committee subjective score, Lysholm score, Knee Injury and Osteoarthritis Outcome Score, Tegner score, modified Cincinnati score, Short Form 12 score, and Short Form 36 score). There was no significant difference between groups in the rate of postoperative complications overall. Conclusions: This review showed statistically significant improvements in patients undergoing both isolated ACI and ACI combined with osteotomy for patellofemoral chondral defects in all studies. When individual studies compared these 2 groups (3 studies), significantly greater improvements in multiple clinical outcomes in subjects undergoing ACI combined with osteotomy were observed. There was no significant difference in the rate of total complications between groups. Level of Evidence: Level IV, systematic review of studies with minimum Level IV evidence, retrospective case series. [Copyright &y& Elsevier]

Purpose: Chondral defects within the patellofemoral compartment are common and lack the ability to heal on their own. Early detection of these lesions with a noninvasive modality would be beneficial in delaying or preventing their possible progression to osteoarthritis. We hypothesized that magnetic resonance imaging (MRI) is a sensitive, specific, and accurate imaging modality for the detection of patellofemoral chondral defects with substantial interobserver reliability and that MRI has a higher sensitivity, specificity, and accuracy for detecting patellar defects than trochlear defects. Methods: A systematic review of multiple medical databases was performed by use of the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) protocol. Analysis of studies that reported diagnostic performance of MRI in the assessment of patellofemoral chondral defects (patella and trochlea), using arthroscopy as the reference gold standard, was performed. Sensitivity, specificity, accuracy, and interobserver reliability were reported. Significant heterogeneity across studies precluded meta-analysis. Results: MRI was more sensitive in detection of patellar (87%) versus trochlear (72%) defects. MRI was similarly specific for patellar (86%) and trochlear (89%) defects. MRI was similarly accurate for patellar (84%) and trochlear (83%) defects. Interobserver agreement was substantial to almost perfect for both patellar and trochlear defects. Conclusions: MRI is a highly sensitive, specific, and accurate noninvasive diagnostic modality for the detection of chondral defects in the patellofemoral compartment of the knee, using arthroscopy as the reference gold standard. Although there was wide variability in the statistical parameters assessed, MRI was more sensitive for detection of patellar versus trochlear defects and similarly specific and accurate for patellar and trochlear defects. Interobserver reliability is substantial to near perfect in the assessment of these lesions, without a significant difference between patellar and trochlear defects. Clinical Relevance: Use of MRI may allow early detection of chondral defects within the patellofemoral compartment, enabling clinicians to adopt strategies to delay or prevent progression to osteoarthritis. Level of Evidence: Level III, systematic review of Level I, II, and III studies. [Copyright &y& Elsevier]

Purpose: To determine how femoral condyle chondral defect size and location influence subchondral bone contact within the defect. Methods: Full-thickness, circular chondral defects (0.2 to 5.07 cm2) were created in 9 healthy bovine knees. Knees were loaded to 1,000 N, and subchondral bone contact area measurements were recorded with a Tekscan sensor and I-Scan software (Tekscan, Boston, MA). A MATLAB program (The MathWorks, Natick, MA) was designed to compute defect area and the area within the defect showing subchondral bone contact. One-sample t tests with Bonferroni correction were performed for medial and lateral defects at each defect size to determine when statistically significant (P < .05) contact occurred; the smallest defect size exhibiting significant contact was considered a threshold area. Results: The threshold at which significant subchondral bone contact occurred was different for medial and lateral defects. Contact within all defects was not observed below a defect area of 0.97 cm2. The threshold at which significant (P < .05) contact occurred was 1.61 cm2 and 1.99 cm2 for lateral and medial condyle defects, respectively. Conclusions: Subchondral bone contact within experimental femoral condyle chondral defects is dependent on defect size and intra-articular location. In our bovine model, lateral condyle defects have significant subchondral bone contact at a smaller defect size than medial defects. Clinical Relevance: Current algorithms use size as a primary factor in management of chondral defects of the knee. Although the consequences of subchondral bone contact on femoral condyle articular cartilage defect progression are unknown, the results of this study supplement current algorithms and suggest consideration of defect location, in addition to size, in the management of chondral defects of the knee. [ABSTRACT FROM AUTHOR]

Purpose: To determine which surgical technique(s) has improved outcomes and enables athletes to return to their preinjury level of sports and which patient and defect factors significantly affect outcomes after cartilage repair or restoration. Methods: We conducted a search of multiple medical databases, evaluating studies of articular cartilage repair in athletes. Results: We identified 11 studies for inclusion (658 subjects). Only 1 randomized clinical trial was identified. All other studies were prospective cohorts, case-control studies, or case series reporting results after either microfracture or autologous chondrocyte implantation (ACI) or osteoarticular transplantation (OATS). Eight different clinical outcomes measures were used. Better clinical outcomes were observed after ACI and OATS versus microfracture. Results after microfracture tended to deteriorate with time. The overall rate of return to preinjury level of sports was 66%. The timing of return to the preinjury level of sports was fastest after OATS and slowest after ACI. Defect size of less than 2 cm2, preoperative duration of symptoms of less than 18 months, no prior surgical treatment, younger patient age, and higher preinjury and postsurgical level of sports all correlated with improved outcomes after cartilage repair, especially ACI. Results after microfracture were worse with larger defects. The rate of return to sports was generally lower after microfracture versus ACI or OATS, and if a patient was able to return to sports, performance was diminished as well. Conclusions: Management of chondral defects in the athlete is complex and multifactorial. There is little high-level evidence to support one procedure over another, although good short-term and midterm outcomes with a fair rate of return to preinjury level of sports can be achieved with cartilage repair and restoration in the athlete. Level of Evidence: Level IV, systematic review. [Copyright &y& Elsevier]

An understanding of expected morbidity of various anterior cruciate ligament graft options is important to inform patient expectations and facilitate successful return to sport following anterior cruciate ligament reconstruction. Hamstring harvest results in decreased hamstring strength. Gracilis preservation may mitigate the degree of strength loss, particularly in deep knee flexion. The extent to which knee flexion strength at high flexion angles is important to return to play and functional outcomes remains unknown and is likely sport-dependent. [ABSTRACT FROM AUTHOR]

Purpose: To determine how much volume reduction can be obtained with varying amounts of arthroscopic capsular plication. Methods: Six fresh-frozen, cadaveric specimens were used. Specimens were rejected if a rotator cuff tear was present. The volume of each shoulder joint was measured under 3 conditions: no capsular shift, 5-mm capsular shift, and 10-mm capsular shift. For each shift, 4 sutures were placed arthroscopically, 2 anteriorly and 2 posteriorly. Repeated measures were used to confirm the validity of the measurements. Data were analyzed with parametric and nonparametric tests. Results: The average percentage of volume reduction at 5 mm of capsular plication from control was 16.2% (range, 9.7% to 21.5%). The percentage of volume reduction from control to 10 mm of capsular plication averaged 33.7% (range, 25.3% to 44.6%). Statistical significance was found with both parametric (P < .0001) and nonparametric tests (P < .0313). Conclusions: The current study found that capsular volume reduction was related to the amount of capsular plication with reproducible results. Capsular plication can produce volume reduction comparable to other techniques. Clinical Relevance: The data could be used to determine the potential number of sutures and amount of tissue plication needed for the amount of laxity found at surgery. [Copyright &y& Elsevier]

Purpose: To systematically review the literature regarding the biomechanical properties of various meniscal root repair techniques.Methods: A systematic review of multiple databases was performed. The inclusion criteria included English language, studies relevant to meniscal root repairs, studies comparing 2 or more different discrete techniques, posterior root repairs, controlled laboratory studies, and human cadaveric or animal studies. Abstracts, case reports, cohort studies, case-control studies, systematic reviews and meta-analyses, and studies of meniscal body repairs were excluded.Results: Seventeen controlled laboratory studies were included for final analysis. There is no consensus on biomechanical superiority between transtibial pullout repair (TPR) and suture anchor repair. For TPR, there is no significant difference between 1 and 2 tibial tunnels. Nonanatomic repairs result in significantly lower joint surface contact areas and higher contact pressures, but suture placement farther from the root results in higher maximum load to failure. Two-suture repair has a greater maximum load to failure than 1-suture repair. Use of more than 2 sutures has diminishing returns. The modified Mason-Allen suture configuration is superior to a simple suture configuration, but there is no consensus regarding the superiority or feasibility of more complex sutures. There is no consensus on the superiority of a single suture material or shape.Conclusions: Anatomic meniscal root repairs with either TPR or suture anchor repair have better joint surface contact pressures and contact surface areas than nonanatomic repairs. The use of 2 sutures results in better fixation than 1 suture. There is evidence that the modified Mason-Allen suture configuration is superior to a simple suture configuration in a TPR, although the benefits of more complicated configurations are unclear.Clinical Relevance: This study suggests that, in general, more complex sutures exhibit higher maximum loads. Increasing the number of sutures to up to 2 of the same configuration also increases the maximum load. [ABSTRACT FROM AUTHOR]

Purpose: To assess the isokinetic, functional, and patient-reported outcomes of femoral nerve block (FNB) compared with traditional multimodal anesthesia for FNB in anterior cruciate ligament (ACL) reconstruction.Methods: A systematic search of PubMed, Scopus, Cumulative Index to Nursing and Allied Health Literature, Cochrane Reviews, and Google Scholar was conducted according to the 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Effects of FNB on quadriceps function were evaluated by isokinetic testing, functional scoring systems, range of motion, and patient self-report questionnaires. Heterogeneous reporting of outcomes precluded a formal meta-analysis. The methodologic merit of all studies included was evaluated by the Coleman Methodology Score.Results: Six studies were identified with outcome measures reported between 7 days and 6 months postoperatively. At 6 months, 2 of 4 studies that reported isokinetic testing found significantly greater deficits among patients who received a nerve block; one of the remaining studies showed a deficit at 6 weeks but not 6 months. Limited data showed no significant differences in functional or patient-reported outcomes at 6 months after reconstruction, and data regarding the impact of FNB on return to sport were inconclusive. The mean Coleman Methodology Score for the included studies was 53, indicating poor overall methodologic quality of the available literature.Conclusions: The limited data available suggest that FNB causes a measurable deficit in quadriceps isokinetic strength during the early postoperative period but has no effect on functional outcomes or return to sport at 6 months after ACL reconstruction. However, current clinical evidence is not sufficient to draw any valid or definitive conclusions regarding the effect of FNB on postoperative outcomes after ACL reconstruction.Level Of Evidence: Level IV, systemic review of Level I through IV studies. [ABSTRACT FROM AUTHOR]

Purpose: To perform a systematic review of cartilage repair in athletes' knees to (1) determine which (if any) of the most commonly implemented surgical techniques help athletes return to competition, (2) identify which patient- or defect-specific characteristics significantly affect return to sport, and (3) evaluate the methodologic quality of available literature.Methods: A systematic review of multiple databases was performed. Return to preinjury level of sport was defined as the ability to play in the same or greater level (i.e., league or division) of competition after surgery. Study methodologic quality for all studies analyzed in this review was evaluated with the Coleman Methodology Score.Results: Systematic review of 1,278 abstracts identified 20 level I-IV studies for inclusion but only 1 randomized controlled trial. Twenty studies (1,117 subjects) were included. Subjects (n = 970) underwent 1 of 4 surgeries (microfracture [n = 529], autologous chondrocyte implantation [ACI, n = 259], osteochondral autograft [n = 139], or osteochondral allograft [n = 43]), and 147 were control patients. The rate of return to sports was greatest after osteochondral autograft transplantation (89%) followed by osteochondral allograft, ACI, and microfracture (88%, 84%, and 75%, respectively). Osteochondral autograft transplantation and ACI had statistically significantly greater rates of return to sports compared with microfracture (P < .001, P < .01; Fisher exact test).Conclusions: Athletes may return to sports participation after microfracture, ACI, osteochondral autograft, or osteochondral allograft, but microfracture patients were least likely to return to sports. The athletes who had a better prognosis after surgery were younger, had a shorter preoperative duration of symptoms, underwent no previous surgical interventions, participated in a more rigorous rehabilitation protocol, and had smaller cartilage defects.Level Of Evidence: Level IV, systematic review of Level I-IV studies. [ABSTRACT FROM AUTHOR]