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This is a case of a 57-year-old healthy woman with traumatic bilateral distal biceps tendon rupture with tendon retraction requiring reconstruction. The functional outcomes were recorded pre-operatively and at 3 months, 6 months, 1 year and 2 years postoperatively.Conclusion: Distal biceps tendon rupture usually occurs in male patients; however, this injury may occur in females. Delay in treatment may result in tendon degeneration precluding repair. Distal biceps tendon reconstruction with Achilles allograft yielded favorable outcome in a middle-aged female patient who sustained bilateral distal biceps tendon rupture.

PCL reconstructive techniques are constantly evolving, and further clinical studies are needed to definitively understand the potential benefits of internal brace augmentation and anatomic double-bundle PCL reconstruction. This Technical Note reports an arthroscopic all-inside anatomic double-bundle PCL reconstruction with internal brace augmentation that is effective and reproducible.

Purpose: To report the outcomes of routine arthroscopic meniscectomy in National Collegiate Athletic Association (NCAA) Division I Football players. Methods: NCAA athletes who underwent arthroscopic meniscectomy over 5 years were included. Players who had incomplete data, previous knee surgery, ligamentous injury, and/or microfractures were excluded. Data collected were player position, timing of surgery, procedures performed, return to play (RTP) rate and time, and postoperative performance. Continuous variables were analyzed with Student t-tests or a one-way analysis of variance. Results: Thirty-six athletes (38 knees) who underwent arthroscopic partial meniscectomy (31 lateral, 7 medial) were included. The mean RTP time was 71 ± 39 days. The mean RTP time in athletes who underwent in-season surgery) was significantly shorter than the RTP in athletes who had off-season surgery (58 ± 41 days vs 85 ± 33 days, P < .05). The mean RTP in 29 athletes (31 knees) with lateral meniscectomy was similar to the 7 athletes (7 knees) who had medial meniscectomy (70 ± 36 vs 77 ± 56, P = .6803). The mean RTP time was similar between football players who underwent isolated lateral meniscectomy and those who had lateral meniscectomy with chondroplasty (61 ± 36 days vs 75±41 days, P = .32). Athletes played an average of 7.7 ± 4.9 games the season they returned; position category and anatomical compartment of the knee lesion had no bearing on number of games played (P = .1864 and P = .425). Conclusions: NCAA Division 1 football players who underwent arthroscopic partial meniscectomy RTP at approximately 2.5 months’ postoperatively. Athletes who underwent off-season surgery had longer RTP time compared with those who underwent in-season surgery. RTP time and performance after surgery did not differ based on player position, anatomical location of the lesions, or chondroplasty at the time of meniscectomy. Level of Evidence: Level IV, therapeutic case series.

Chronic rotator cuff pathology is often complicated by fatty degeneration of the rotator cuff (FDRC) muscles, an insidious process associated with poor prognosis with or without surgical intervention. Currently there is no treatment for FDRC, and many studies have described a natural course for this disease almost always resulting in further degeneration and morbidity. Recapitulating FDRC using animal injury models, and using imaging-based studies of human FDRC, the pathophysiology of this disease continues to be further characterized. Researchers studying mesenchymal stem cell–derived progenitor cells and known fibrogenic and adipogenic signaling pathways implicated in FDRC seek to clarify the underlying processes driving these changes. While new cell- and molecular-based therapies are being developed, currently the strongest available avenue for improved management of FDRC is the use of novel imaging techniques which allow for more accurate and personalized staging of fatty degeneration. This narrative review summarizes the evidence on the molecular and pathophysiologic mechanisms of FDRC and provides a clinical update on the diagnosis and management of this condition based on the existing knowledge. We also sought to examine the role of newer biologic therapies in the management of RC fatty degeneration and to identify areas of future research.

Background: Lateral collateral ligament (LCL) injuries are implicated in varus instability of the knee. Often, these accompany other ligamentous injuries including anterior cruciate ligament (ACL), posterior cruciate ligament (PCL) tears, and injury to the anterolateral capsular complex (ALCC). Use of internal brace augmentation with anatomic repair is an alternative to reconstruction to improve patient outcomes and facilitate early range of motion and weight bearing. Indications: We present a case of an anatomic repair of a LCL and an ALCC injury with internal brace augmentation. Technique Description: A curvilinear incision centered over the lateral epicondyle is used. The avulsed LCL and biceps tendon was exposed and a placed #5 FiberWire was placed into the distal LCL, biceps tendon, and the popliteofibular ligament. A split was made in the iliotibial (IT) band and a second #5 FiberWire was placed proximally in the LCL/biceps tendon for additional fixation. A tunnel was made in the fibular head and tibia using a 2.4-mm beath pin and the two #5 FiberWires were passed to the anteromedial tibia. The FiberWires were fixed to the tibia using a 14-mm attachable button system (ABS) manhole cover for suspensory fixation. Repair and internal bracing of the anterolateral capsular complex was accomplished with 2 interlocked TightRopes and a #2 FiberTape. This fixation method achieved repair by compressing the anterolateral capsular complex onto its tibial origin. The suture devices also served to augment the repair and were fixed proximally to the femur using another 14-mm ABS manhole cover. The FiberTape was fixed to the anterolateral tibia distally with a 4.5 mm SwiveLock. The TightRopes were passed through a tunnel to the anterolateral tibia and secured using an ABS Dog Bone. The construct was tensioned in near full extension and gapping was matched fluoroscopically to the contralateral knee. Results: Patient was cleared for full return to sports 9 months postoperatively. At the final follow up visit, the patient had excellent strength, stability, and 135° range of motion on the operative knee. Patient had returned to exercise at home but was unable to return to sports due to COVID-19 restrictions. Conclusion: Anatomic repair of the LCL and the ALCC with internal brace augmentation can serve as an effective alternative to reconstruction and demonstrates excellent patient outcomes regarding restoring stability, ROM, and return to preoperative sports.

Background: Concomitant cartilage injury is commonly associated with patellofemoral instability. While nonoperative treatment remains the gold standard for first time dislocators, there has been an increased trend toward addressing patellar instability when symptomatic cartilage disease is present. Indications: A healthy active 29-year-old woman >2 years of patellar instability and pain symptoms in the right knee. Imaging revealed tibial tubercle to trochlear groove (TT-TG) distance of 19.8 mm, and a Caton Deschamps Ratio of 1.54. Initial staging arthroscopy demonstrated a near full thickness cartilage defect of the lateral patellar facet measuring 2x2 cm. Technique Description: In the index procedure, a staging diagnostic arthroscopy is performed to evaluate the extent of the cartilage defect. Given the size of the lesion, a matrix-induced autologous chondrocyte implantation (MACI) biopsy is performed for later implantation. At the second stage procedure, a midline approach to the patella and tibial tubercle is performed. A 45° osteotomy is initiated with a cutting jig. The osteotomy is detached distally to allow for both anteromedialization and distalization to offload the cartilage defect and improve patellar articulation. The lateral patellar facet cartilage defect is prepared, and a combination of fibrin sealant and digital pressure is used to implant the pre-shaped MACI transplant. The osteotomy is then secured with 2 bicortical screws. A semitendinosus allograft is secured to the upper half of the medial border of the patellar and secured to its anatomometric point on the femur to reconstruct the medial patellofemoral ligament (MPFL). Results: Patient successfully returned to running and is currently working on return to other sports with no anterior knee pain or instability. Recent studies have demonstrated overall good clinical outcomes following MACI for patellofemoral lesions. Addressing underlying bony deformity and offloading patellofemoral cartilage lesions with tibial tubercle osteotomy in combination with MPFL reconstruction has improved patellar stability and good patient satisfaction. Discussion/Conclusion: Combined tibial tubercle osteotomy, MPFL reconstruction, and MACI in a comprehensive approach can successfully address symptomatic patellofemoral cartilage disease in the setting of patellar instability with underlying bony abnormalities.

This a case report of a 40-year-old male with left knee dislocation Type III and associated peroneal nerve palsy underwent delayed allograft reconstruction of his multiligament knee injury (MKI) with Internal Brace augmentation. The patient returned to work at 6 months postoperatively. He then fell and sustained a displaced supracondylar left femur fracture at the site of the internal brace augmentation of his lateral collateral ligament (LCL) reconstruction for which he underwent placement of a retrograde femoral nail. At 2 years of follow-up the patient had no evidence of knee instability.Level of evidence: V.

Category: Midfoot/Forefoot; Sports; Trauma Introduction/Purpose: Optimal management of metadiaphyseal fifth metatarsal fractures (Jones fractures) in athletes remains controversial. In high-level athletes, surgical treatment with intramedullary screw fixation is commonly recommended to minimize the risk of nonunion and to allow for faster return to sport. The purpose of this study was to report the rate and time to return to sport in collegiate athletes who sustained an isolated fracture to the fifth metatarsal bone. Methods: From 2003 to 2020, we retrospectively reviewed the clinical notes and imaging studies of all athletes participating in NCAA Division I sports at a single college and who sustained a fracture of the fifth metatarsal bone. Athletes with a diagnosis of 5th metatarsal bone fracture were included. Athletes were excluded if they had a fracture in any of the other metatarsal bones (1st-4th). Data collected were: demographic information (age, gender), type of sport, date of injury and/or surgery, diagnosis of Jones fracture, type of treatment received (operative with intramedullary screw fixation versus non operative with the application of boot or cast of the lower extremity and non- weightbearing activity), rate of return to sport, and time to return to sport. The rate and time to return to sport were reported as percentage and mean-standard deviation, respectively. The level of statistical significance was set at

Category: Sports; Ankle Introduction/Purpose: No meta-analysis has been conducted to examine the clinical outcomes following operative and nonoperative management of high ankle sprain injuries in elite athletes. the purpose of this systematic review was (1) To report the rate and time to return to sport (RTS) following high ankle syndesmotic injury in elite athletes (2) To examine the rate and time of RTS as well as the postoperative complications in elite athletes who underwent surgical treatment of high ankle syndesmotic injury with screw versus suture button fixation. Methods: Three electronic databases were searched for eligible articles. Two reviewers independently screened the titles, abstract and full-text articles using pre-specified criteria. Eligible articles were those that reported the rate of return to sport following operative and nonoperative treatment of ankle syndesmotic injuries in elite athletes (collegiate or professional level). Data collected were type of sport, type of treatment received (operative versus nonoperative), surgical technique (screw versus suture button fixation), rate and time to return to the preinjury level of competition, and complications. A random-effects model was used for meta-analysis. Results: The estimated overall rate of RTS was 99% (95% CI 95.5-99.9). The mean time to RTS was 38 +- 18 (range: 14-137) days. Of the 440 athletes, 269 (269/440,61%) were treated nonoperatively (nonoperative group); the rate of RTS was 99.6% and the athletes returned at a mean time of 29+-14 (range: 13-45) days. A total of 171 athletes (171/440,39%) underwent surgical treatment (operative group); All (171/171,100%) athletes returned at a mean time of 50.3+-13 (range:41-137) days. Almost all athletes who underwent surgery had suture button fixation (164/171 athletes,96%) and the mean time to RTS was 7 weeks with 9.1% complication rate. Conclusion: Elite athletes with ankle syndesmosis injury return to sport at an extremely high rates, following operative or nonoperative treatment. Suture button fixation remains the gold standard technique in elite athletes with syndesmotic injury requiring surgical treatment. Return to the preinjury level of competition should be expected at 4 weeks and 7 weeks in high-level athletes who undergo nonoperative and operative management, respectively.

Chronic lateral ankle instability (CLAI) is a condition that is characterized by persistent disability and recurrent ankle sprains while encompassing both functional and mechanical (laxity) instability. Failure of conservative treatment for CLAI often necessitates operative intervention to restore the stability of the ankle joint. The traditional or modified Broström techniques have been the gold standard operative approaches to address CLAI with satisfactory results; however, patients with generalized ligament laxity (GLL), prior unsuccessful repair, high body mass index, or high-demand athletes may experience suboptimal outcomes. Synthetic ligament constructs have been tested as an adjunct to orthopedic procedures to reinforce repaired or reconstructed ligaments or tendons with the hope of early mobilization, faster rehabilitation, and long-term prevention of instability. Suture tape augmentation is useful to address CLAI. Multiple operative techniques have been described. Because of the heterogeneity among the reported techniques and variability in postoperative rehabilitation protocols, it is difficult to evaluate whether the use of suture tape augmentation provides true clinical benefit in patients with CLAI. This review aims to provide a comprehensive outline of all the current techniques using suture tape augmentation for treatment of CLAI as well as present recent research aimed at guiding evidence-based protocols.

Purpose: To systematically review the operative versus nonoperative methods for management of iliotibial band syndrome (ITBS) with comparison of the respective clinical outcomes. Methods: By adhering to the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines, 3 databases (Medline, Scopus, Web of Science) searched from inception to October 2019 for randomized clinical trials (RCTs) and observational studies on humans that reported the outcomes following operative or nonoperative management of ITBS. Excluded were case reports, case series with

Purpose: To use mirror imaging to identify the location and magnitude of difference in acetabular rim morphology between the symptomatic and unaffected acetabula in patients with symptomatic unilateral pincer-type or mixed femoroacetabular impingement syndrome (FAIS) using 1-dimensional models created with computed tomography (CT). Methods: CT scans of bilateral hips in 33 patients diagnosed with unilateral pincer-type or mixed FAIS were obtained. Three-dimensional bilateral hip models were constructed, and the unaffected hemipelvis was superimposed onto the symptomatic side to compare acetabular thickness. Protrusion of the symptomatic side was recorded, and rim morphology was divided into clock face quadrants to analyze the location of greatest magnitude of difference between affected and unaffected acetabula. Analysis of the quadrants was performed using analysis of variance with post hoc Bonferroni correction. Results: The study group consisted of more females (51.6%) than males, with an average age of 35.72 ± 7.8 years and an average body mass index of 24.3 ± 4.1 kg/m2. Of the 33 hips included, 14 were isolated pincer-type FAIS and 19 were mixed. The average preoperative symptomatic side lateral center edge angle was 37.5° ± 7.2° compared with 29° ± 5.1° on the asymptomatic side (P = .001). The symptomatic acetabular rim was on average 0.43 ± 0.18 mm thicker than the corresponding location on the unaffected rim. When the acetabulum was divided into clock face quadrants, the 12 to 3 o'clock position showed the greatest difference between symptomatic and unaffected sides (0.55 ± 0.18 mm) compared with the 3 to 6 o'clock position (0.4 ± 0.28 mm; P = .006), 6 to 9 o'clock (0.34 ± 0.07 mm; P < .001), and 9 to 12 o'clock (0.38 ± 0.03; P = .001). Conclusions: Patients with unilateral, symptomatic pincer-type or mixed FAIS show statistical differences in rim thickness between the affected and unaffected acetabula. Small changes in acetabular rim morphology on the order of ≤0.5 mm may be the difference between symptomatic FAIS and the unaffected hip. Level of Evidence: IV, case series.

Rotator cuff disease is one of the most common causes of shoulder pain, yet controversy still exists regarding treatment of “irreparable” tears. Nonoperative management, including physical therapy and steroid injections, should be reserved for those without significant pain or functional impairment. Debridement may be used for low-demand patients, and should be performed with partial cuff repair, subacromial decompression, and/or acromioplasty to maximize outcomes. Biceps tenotomy and/or tenodesis have been shown to reduce postoperative pain and improve satisfaction when performed in conjunction with rotator cuff repairs, with no difference in functional outcome comparatively. Tendon transfers have been advocated with the potential benefit to improve function and decrease pain. More recently, extracellular matrix and human-derived dermal allografts have been used off-label as patch grafts in irreparable tears. Superior capsular reconstructive techniques and subacromial balloon spacers serve a similar function by acting to depress the humeral head in a cuff-deficient shoulder, however long-term data is needed before widespread adoption of these procedures. Finally, reverse shoulder arthroplasty serves as a salvage option for low demand elderly patients.

Quadriceps tendon rupture is an uncommon injury that usually occurs in middle-aged and elderly men with a history of chronic illnesses. We report the case of a 17-year-old healthy adolescent male baseball player who sustained this injury as a result of sudden deceleration in his left knee. He initially reported to the emergency department and then presented to our practice, where he was diagnosed with a quadriceps tendon tear. Preoperatively, he was unable to perform a single straight-leg raise. During surgical repair, the free edge of the quadriceps tendon was mobilized and anchored into the superior pole of the patella, followed by sutures to ensure reinforcement of the quadriceps footprint. His postoperative course progressed normally, demonstrating full range of motion at 3 months and return to team training at 5 months. Unlike previously reported quadriceps tendon ruptures in adolescents, to our knowledge, this is the first report of a patient who sustained such an injury without previous trauma to his knee or quadriceps mechanism. It is possible that weakened tendon integrity from repeated microtrauma during training combined with the sudden weight change distribution may have resulted in the injury. As urgent surgical intervention is necessary to ensure efficient recovery and return to sport, the sports medicine practitioner must remain educated and vigilant on caring for these patients.

Femoroacetabular impingement (FAI) is a clinical syndrome resulting from abnormal hip joint morphology and is a common cause of hip pain in young adults. FAI has been posited as a precursor to hip osteoarthritis, however, conflicting evidence exists and the true natural history of the disease is unclear. The purpose of this article is to review the current understanding of how FAI damages the hip joint by highlighting its pathomechanics and etiology. We then review the current evidence relating FAI to osteoarthritis. Lastly, we will discuss the potential of hip preservation surgery to alter the natural history of FAI, reduce the risk of developing osteoarthritis and the need for future arthroplasty.

Dysphagia after anterior cervical discectomy and fusion (ACDF) is common, with a prevalence ranging between 28% and 57% of cases. However, nearly all cases resolve spontaneously within 2 years, thus identifying patients who require more detailed or invasive work-up is a challenging task for clinicians. A review of literature reveals a paucity of case reports detailing work-up and successful management options. The authors performed a clinical and radiographic review of a case of a 47-year-old female who presented with persistent dysphagia 3 years following anterior cervical spine surgery and was found to have an erosive pharyngeal defect with exposed spinal hardware. The diagnosis was made with direct laryngoscopy and treatment consisted of plate removal and pharyngeal repair, followed by revision fusion with deformity correction. This case and the accompanying pertinent review of the literature highlight the importance of a thorough evaluation of dysphagia, especially in the mid- and late-term postoperative period following ACDF, when most cases of dysphagia should have been resolved. Correctly identifying the underlying etiology of dysphagia may lead to improved revision of ACDF outcomes. Unresolved dysphagia should be a red flag for surgeons as it may be the presentation of erosive esophageal/pharyngeal damage, a rare but serious complication following ACDF.

Hip arthroscopy has become an increasingly utilized surgical technique for the treatment of the young, active patient with hip pain. The clinical outcomes of hip arthroscopy in this patient population have been largely successful; however, there is increasing interest in the contribution of hip capsule in postoperative clinical and functional outcomes. The structure and function of the normal hip capsule will be reviewed. Capsular contributions to hip stability will be discussed in the setting of hip arthroscopy with an emphasis on diagnosis-based considerations. Lastly, clinical outcomes following hip arthroscopy will be discussed as they relate to capsular management.