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Background: Full-thickness chondral defects and early osteoarthritis continue to present major challenges for the patient and the orthopaedic surgeon as a result of the limited healing potential of articular cartilage. The use of bioactive growth factors is under consideration as a potential therapy to enhance healing of chondral injuries and modify the arthritic disease process.Questions/purposes: We reviewed the role of growth factors in articular cartilage repair and identified specific growth factors and combinations of growth factors that have the capacity to improve cartilage regeneration. Additionally, we discuss the potential use of platelet-rich plasma, autologous-conditioned serum, and bone marrow concentrate preparations as methods of combined growth factor delivery.Methods: A PubMed search was performed using key words cartilage or chondrocyte alone and in combination with growth factor. The search was open for original manuscripts and review papers and open for all dates. From these searches we selected manuscripts investigating the effects of growth factors on extracellular matrix synthesis and excluded those investigating molecular mechanisms of action.Results: By modulating the local microenvironment, the anabolic and anticatabolic effects of a variety of growth factors have demonstrated potential in both in vitro and animal studies of cartilage injury and repair. Members of the transforming growth factor-β superfamily, fibroblast growth factor family, insulin-like growth factor-I, and platelet-derived growth factor have all been investigated as possible treatment augments in the management of chondral injuries and early arthritis.Conclusions: The application of growth factors in the treatment of local cartilage defects as well as osteoarthritis appears promising; however, further research is needed at both the basic science and clinical levels before routine application. [ABSTRACT FROM AUTHOR]

BACKGROUND: Strain injury to the adductor longus muscle is a common cause of groin pain in athletes and generally occurs in the proximal portion of the muscle, near its origin from the anterior aspect of the pubis. The composition and cross-sectional anatomy of this muscle's origin has not been previously described. HYPOTHESIS: We hypothesize that the adductor longus muscle origin is composed mainly of muscle fibers and that the tendon composes only a small part of the cross section at the origin of the muscle. STUDY DESIGN: Descriptive laboratory study. METHODS: We harvested 42 adductor longus muscles from 28 cadavers and measured the cross-sectional dimensions of the tendon with microcalipers. Next, we determined the relative contributions of the tendon and muscle fibers to the cross-sectional anatomy of the muscle using optical scanning. These 2 sets of measurements were obtained at 3 locations: at the muscle origin and 1.0 and 2.0 cm distal to the origin. RESULTS: The average length and width of the tendon was 11.6 and 3.7 mm, respectively, at the origin. The average cross-sectional areas of the tendon were 49.3, 27.9, and 25.7 mm(2) at points 0.0, 1.0, and 2.0 cm from its origin, respectively. The origin of the adductor longus muscle was composed of 37.9% tendon and 62.1% muscle tissue. At 1.0 cm from the origin, the percentage of tendon decreased to 34%. At 2.0 cm from the origin, the tendon composed 26.7% of the cross section. CONCLUSION: The cross-sectional area of the tendon of the adductor longus muscle is relatively small. The muscle origin is composed predominantly of direct attachment of muscle fibers. CLINICAL RELEVANCE: Knowledge of the cross-sectional anatomy of the adductor longus muscle at its origin may help clinicians better understand the complex nature of injuries in this area. [ABSTRACT FROM AUTHOR]

Introduction: African American, Hispanic, Asian, and Pacific Islanders are groups who are underrepresented in medicine (URM groups). Similarly, although women comprise more than 50% of medical students in the United States, women comprise a smaller percentage of all orthopaedic surgery trainees. Therefore, underrepresented in orthopaedics (URiO) represents the URM groups and women. The purpose of this study is to examine the impact of specific steps to recruit a qualified, diverse trainee complement within a single academic orthopaedic surgery residency program between 2000 and 2023. We aim to explore changes in the representation of URiO during this period as well as explore the strategies and programs implemented by the department that may have impacted recruitment of a diverse complement of trainees., Methods: Match lists from a large, academic, orthopaedic surgery residency between 2000 and 2023 were collected and reviewed for racial and gender data. Match lists were then divided into 6-year quantiles to identify any trends in the recruitment of URiO students. Self-reported racial and gender data from Electronic Residency Application Service applicant reports and the Accreditation Council for Graduate Medical Education (ACGME) data books between 2018 and 2022 were collected and reviewed. In addition, the department's strategies implemented during the study period with the goal of enhancing URiO exposure to orthopaedic surgery were also explored., Results: The department implemented proactive strategies to increase exposure to orthopaedic surgery for URiO students. An increase in URiO representation was noted between 2000 and 2023 with Hispanic, Black/African American, and Native Hawaiian/Pacific Islander resident representation increasing by 5%, 11%, and 1%, respectively. In addition, women representation increased by 27% between 2000 and 2023. The overall attrition rate among URiO residents was 1% with only one resident not completing the program. Self-reported racial and gender data from ACGME data books demonstrated that Black/African American, Hispanic, and Native Hawaiian/Pacific Islander residents comprised 5%, 4%, and 0.04%, respectively, of orthopaedic surgery residents between 2018 and 2022., Conclusions: These results provide insight for other programs to use similar strategies to potentially improve recruitment, retain, and provide support to URiO residents., Competing Interests: Each author certifies that he or she has no commercial associations (e.g., consultancies, stock ownership, equity interest, and patent/licensing arrangements) that might pose a conflict of interest in connection with the submitted article. Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSOA/A681)., (Copyright © 2024 The Authors. Published by The Journal of Bone and Joint Surgery, Incorporated. All rights reserved.)

Objectives: The purpose of this study was to compare clinical outcomes of medial quadriceps tendon-femoral ligament reconstruction (MQTFLR) and medial patellofemoral ligament reconstruction (MPFLR) among patients with recurrent lateral patellar instability., Methods: A retrospective matched-cohort study was conducted involving patients who underwent MQTFLR or MPFLR with or without tibial tubercle osteotomy (TTO) from 2019 to 2021. Subjects were matched 1:1 on age, concomitant osteochondral allograft (OCA), concomitant TTO, and follow-up time. Measured outcomes included 90-day complications, Visual Analog Scale (VAS) knee pain, return to sport/work, Kujala score, Tegner score, and MPFL-Return to Sport after Injury (MPFL-RSI) score. Outcomes were compared between groups using Mann-Whitney U-test for continuous variables and Fisher's exact test for categorical variables. P-values <0.05 were considered significant., Results: Ten MQTFLR patients (mean age 28.7 years, 80% female, mean follow-up 19.7 months) and ten MPFLR patients (mean age 29.1 years, 90% female, mean follow-up 28.3 months) were included in the study. One MQTFLR patient (10%) and three MPFLR patients (30%) underwent reoperation for postoperative arthrofibrosis. Postoperative VAS resting pain was not significantly different between the groups (MQTFLR mean 1.1, MPFLR mean 0.6, p ​= ​0.31). There were no significant differences in rates of recurrent subluxations (MQTFLR 20%, MPFLR 0%, p ​= ​0.47), return to sport (MQTFLR 50%, MPFLR 75%, p ​= ​0.61), return to work (MQTFLR 100%, MPFLR 88%, p ​= ​1.00), or MPFL-RSI pass rate (MQTFLR 75% vs. MPFLR 38%, p ​= ​0.31)., Conclusion: There were no significant differences in knee pain and function, return to work, and rates of recurrent patellar instability between patients who underwent MQTFLR versus MPFLR, though these results should be interpreted with caution given the small sample size and potential selection bias., Level of Evidence: III., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Eric J. Strauss reports a relationship with American Academy of Orthopaedic Surgeons that includes: board membership. Eric J. Strauss reports a relationship with American Orthopaedic Association that includes: board membership. Eric J. Strauss reports a relationship with Arthrex Inc that includes: speaking and lecture fees. Eric J. Strauss reports a relationship with Arthroscopy Association of North America that includes: board membership. Eric J. Strauss reports a relationship with Better PT that includes: equity or stocks. Eric J. Strauss reports a relationship with Cartiheal that includes: funding grants. Eric J. Strauss reports a relationship with Cartilage (journal) that includes: board membership. Eric J. Strauss reports a relationship with Bulletin of the Hospital for Joint Diseases that includes: board membership. Eric J. Strauss reports a relationship with Fidia that includes: funding grants. Eric J. Strauss reports a relationship with Flexion Therapeutics that includes: consulting or advisory. Eric J. Strauss reports a relationship with Jaypee Publishing that includes: funding grants. Eric J. Strauss reports a relationship with JRF Ortho that includes: consulting or advisory. Eric J. Strauss reports a relationship with Organogenesis Inc that includes: consulting or advisory, funding grants, and speaking and lecture fees. Eric J. Strauss reports a relationship with Smith and Nephew Inc that includes: consulting or advisory and speaking and lecture fees. Eric J. Strauss reports a relationship with Springer that includes: funding grants. Eric J. Strauss reports a relationship with Subchondral Solutions that includes: consulting or advisory. Eric J. Strauss reports a relationship with Vericel Corporation that includes: consulting or advisory and funding grants. Laith M. Jazrawi reports a relationship with Arthrex Inc that includes: funding grants and non-financial support. Laith M. Jazrawi reports a relationship with Bulletin of the Hospital for Joint Diseases that includes: board membership. Laith M. Jazrawi reports a relationship with JBJS Reviews that includes: board membership. Laith M. Jazrawi reports a relationship with Lazurite that includes: equity or stocks. Laith M. Jazrawi reports a relationship with DePuy Mitek Inc that includes: funding grants. Laith M. Jazrawi reports a relationship with Smith and Nephew Inc that includes: funding grants and non-financial support. Laith M. Jazrawi reports a relationship with Wolters Kluwer Lippincott Williams & Wilkins Pty Ltd that includes: funding grants. Michael J. Alaia reports a relationship with American Academy of Orthopaedic Surgeons that includes: board membership. Michael J. Alaia reports a relationship with Arthroscopy (journal) that includes: board membership. Michael J. Alaia reports a relationship with Arthroscopy Association of North America that includes: board membership. Michael J. Alaia reports a relationship with BodyCad that includes: consulting or advisory. Michael J. Alaia reports a relationship with Journal of Cartilage and Joint Preservation that includes: board membership. Michael J. Alaia reports a relationship with JRF Ortho that includes: consulting or advisory. Michael J. Alaia reports a relationship with DePuy Mitek Inc that includes: consulting or advisory. Michael J. Alaia reports a relationship with Orcosa Inc. that includes: funding grants and non-financial support. Michael J. Alaia reports a relationship with Springer that includes: funding grants. Kirk A. Campbell reports a relationship with American Academy of Orthopaedic Surgeons that includes: board membership. Kirk A. Campbell reports a relationship with Arthroscopy Association of North America that includes: board membership. Kirk A. Campbell reports a relationship with Stryker that includes: funding grants and non-financial support., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate the effect of fear of reinjury on return to sport (RTS), return to work (RTW), and clinical outcomes following autologous chondrocyte implantation (ACI)., Design: A retrospective review of patients who underwent ACI with a minimum of 2 years in clinical follow-up was conducted. Patient-reported outcomes collected included the Visual Analog Scale (VAS) and Knee Injury and Osteoarthritis Outcome Score (KOOS). Kinesiophobia and pain catastrophizing was assessed using the Tampa Scale of Kinesiophobia-11 (TSK-11) and Pain Catastrophizing Scale (PCS), respectively. Patients were surveyed on their RTS and RTW status., Results: Fifty-seven patients (50.9% female) were included in our analysis. Twenty-two (38.6%) patients did not RTS. Of the 35 patients (61.4%) who returned, nearly half (48.6%) returned at a lower level of play. TSK-11 ( P = 0.003), PCS ( P = 0.001), and VAS pain scores ( P < 0.001) were significantly greater in patients that did not RTS than in those who returned. All KOOS subscores analyzed were significantly lower ( P < 0.001) in patients that did not RTS than in those who returned at the same level or higher. Of the 44 (77.2%) patients previously employed, 97.7% returned to work. Increasing TSK-11 scores were associated with lower odds of returning to sport ( P = 0.003)., Conclusion: Fear of reinjury decreases the likelihood that patients will return to sport after ACI. Patients that do not return to sport report significantly greater levels of fear of reinjury and pain catastrophizing and lower clinical knee outcomes. Nearly all patients were able to return to work after surgery., Level of Evidence: IV case series., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: JT, NR, MB-L, AL, NDR, and JE report no conflict of interest. MJA is a board or committee member in AAOS, editorial or governing board member in Arthroscopy, board or committee member in Arthroscopy Association of North America, a paid consultant for BodyCad, editorial or governing board member of the Journal of Cartilage and Joint Preservation, paid consultant for JRF Ortho and Mitek, receives research support from Orcosa, Inc, and publishing royalties, financial, or material support from Springer. LMJ receives research support from Arthrex, Inc, is an editorial or governing board member of Bulletin for the Hospital for Joint Diseases, editorial or governing board member of JBJS Reviews, receives research support from Mitek and Smith & Nephew, publishing royalties, financial, or material support from Wolters Kluwer Health—Lippincott Williams & Wilkins. EJS is a board or committee member of AAOS and American Orthopedic Association, paid consultant, paid presenter, or speaker for Arthrex, Inc, board or committee member of Arthroscopy Association of North America, has stock or stock options in Better PT, receives research support from Cartiheal, is in the editorial or governing board of Cartilage and Bulletin of the Hospital For Joint Diseases, receives research support from Fidia, is a paid consultant for Flexion Therapeutics, receives publishing royalties, financial, or material support from Jaypee Publishing, is a paid consultant for Joint Restoration Foundation, is a paid consultant, paid presenter, or speaker and receives research support from Organogenesis, is a paid consultant, paid presenter, or speaker for Smith & Nephew, receives publishing royalties, financial, or material support from Springer, is a paid consultant for Subchondral Solutions, and is a paid consultant, paid presenter, or speaker for Vericel. KAC is a board or committee member for AAOS and Arthroscopy Association of North America and receives research support from Stryker.

Purpose: To compare psychological readiness to return to sport (RTS), RTS rate, level of return, and time to return between patients who underwent bilateral anterior cruciate ligament reconstruction (ACLR) and those who underwent unilateral ACLR., Methods: The electronic medical record at a single academic medical center was queried for patients who underwent ACLR from January 2012 to May 2020. The inclusion criteria were skeletally mature patients who underwent either single or sequential bilateral ACLR and who had undergone either the primary ACLR or second contralateral ACLR at least 2 years earlier. Bilateral ACLRs were matched 1:3 to unilateral reconstructions based on age, sex, and body mass index. Psychological readiness to RTS was assessed using the validated ACL Return to Sport After Injury (ACL-RSI) scale. This, along with time to return and level of RTS, was compared between the 2 cohorts., Results: In total, 170 patients were included, of whom 44 underwent bilateral ACLR and 132 underwent unilateral ACLR. At the time of the first surgical procedure, patients in the unilateral cohort were aged 28.8 ± 9.4 years and those in the bilateral cohort were aged 25.7 ± 9.8 years ( P  = .06). The average time difference between the first and second surgical procedures was 28.4 ± 22.3 months. There was no difference in psychological readiness to RTS (50.5 in bilateral cohort vs 48.1 in unilateral cohort, P  = .66), RTS rate (78.0% in unilateral cohort vs 65.9% in bilateral cohort, P  = .16), percentage of return to preinjury sport level (61.2% in unilateral cohort vs 69.0% in bilateral cohort, P  = .21), or time to return (41.2 ± 29.3 weeks in unilateral cohort vs 35.2 ± 23.7 weeks in bilateral cohort, P  = .31) between the 2 cohorts., Conclusions: Compared with patients who undergo unilateral ACLR, patients who undergo bilateral ACLR are equally as psychologically ready to RTS, showing equal rates of RTS, time to return, and level of return., Level of Evidence: Level III, retrospective cohort study., Competing Interests: The authors report no conflicts of interest in the authorship and publication of this article. Full ICMJE author disclosure forms are available for this article online, as supplementary material., (© 2023 The Authors.)

Purpose of Review: Numerous cartilage restoration techniques have proven to be effective in the treatment of articular cartilage defects. The ultimate goal of these procedures is to improve pain and function, thereby increasing the likelihood of a patient's return to physical activity. Postoperative rehabilitation is a key component for a successful and expedient return to activities. The purpose of this article is to review the current literature regarding common surgical options, rehabilitation protocols, and performance outcomes after operative treatment of articular cartilage defects., Recent Findings: Studies have demonstrated improved short- to long-term outcomes in a majority of techniques. However, the clinical benefits of microfracture are short-lived, which has led to the use of alternative procedures. Rehabilitation protocols are not standardized, but emphasis has been placed on bracing, weightbearing, early continuous passive range of motion, and strengthening to improve function. There is growing evidence to suggest that accelerated rehabilitation after matrix-induced autologous chondrocyte implantation may result in superior outcomes compared to delayed rehabilitation. Overall, most techniques result in satisfactory rates of return to play, though existing comparative studies typically include patients with heterogeneous pathology, complicating effective synthesis of outcomes data. In appropriately selected patients, cartilage restoration procedures after articular cartilage injury result in favorable patient-reported clinical outcomes and high rates of return to play. While studies emphasize the critical role that rehabilitation plays with respect to outcomes after surgery, there are substantial inconsistencies in protocols across techniques., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Chondral and osteochondral lesions of the knee are a commonly occurring pathology that can pose challenges to the treating surgeon. For the appropriate cartilage injury, autologous cell-based articular cartilage repair techniques have shown promising results. However, these treatments traditionally require 2 separate surgical procedures. Recent advances in needle arthroscopy technology have made it possible to conduct the first stage of autologous chondrocyte implantation surgery in the wide-awake office setting, mitigating cost and resource utilization. The purpose of this technical note is to serve as a proof of concept and describe the process of obtaining a cartilage sample in the wide-awake patient using a needle arthroscope., (© 2023 The Authors.)

Background: The purpose of the current study was to investigate whether pain, function, satisfaction, return to play (RTP), or psychological readiness to RTP differ between sexes post-operatively following SLAP repair., Methods: A retrospective review of patients who underwent arthroscopic repair of a SLAP tear was performed. The American Shoulder & Elbow Surgeons (ASES) score, Visual Analogue Scale (VAS), Subjective Shoulder Value (SSV), patient satisfaction, willingness to undergo surgery again, revisions, and return to play (RTP) were evaluated. Clinical outcomes were compared between male and female patients., Results: Our study included 169 patients treated with SLAP repair, 133 of them male (78.7%) and 36 of them female (21.3%), with an average age of 32.3 ± 8.3 and 33.4 ± 6.8 respectively. The mean follow-up duration was 5.8 years. At final follow up, there was no difference between treatment groups in any of the functional outcome measures assessed ( p > 0.05)., Conclusion: There is no difference in clinical outcomes, function, satisfaction, or revision procedures in mid- to long-term follow-up after SLAP repair between male and female patients. This data is useful in the preoperative counselling of patients undergoing arthroscopic management of symptomatic superior labral pathology., Level of Evidence: III., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2022.)

Purpose: To evaluate the effects of socioeconomic factors on the operative treatment of anterior cruciate ligament injuries and outcomes following surgical reconstruction., Methods: A retrospective cohort study of primary anterior cruciate ligament reconstruction surgeries at a single institution performed from 2011 to 2015 with minimum 2-year follow-up was conducted. Patient demographics, insurance type, workers' compensation status, surgical variables, International Knee Documentation Committee score, and failure were recorded from chart review. Education level and income were obtained via phone interview. Differences between functional outcome were compared between Medicaid and non-Medicaid groups., Results: In total, 268 patients were included in the analysis (43 patients in the Medicaid group and 225 patients in the non-Medicaid group, overall mean follow-up of 3.1 ± 0.8 years). The Medicaid group demonstrated lower annual income ( P < .001) and a lower level of completed education compared with the non-Medicaid group ( P  < .001). Patients who received Medicaid had a greater duration between time of initial knee injury and surgery compared with the those in non-Medicaid group (11.8 ± 16.3 months vs 6.1 ± 16.5 months, P < .001). At the time of follow-up, patients in the non-Medicaid group had a significantly greater International Knee Documentation Committee score compared with patients who received Medicaid (82.5 ± 13.8 vs 75.3 ± 20.8, P  = .036)., Conclusions: Patients with Medicaid insurance were seen in the clinic significantly later after initial injury and had worse outcomes compared with patients with other insurance types. Also, patients in higher annual income brackets had significantly better clinical outcomes scores at a minimum of 2 years postoperatively., Level of Evidence: Level III, retrospective cohort study., (© 2023 The Authors.)

Background: The purpose of this study was to identify socioeconomic predictors of time to initial evaluation, time to surgery, and postoperative outcomes among lateral patellar instability patients undergoing medial patellofemoral ligament reconstruction (MPFLR)., Methods: We conducted a retrospective review of patients at our institution who underwent primary MPFLR with allograft from 2011 to 2019 and had minimum 12-month follow-up. Patients were administered an email survey in January 2022 to assess symptom history, socioeconomic status, and postoperative outcomes including VAS satisfaction and Kujala score. Predictors of time to initial evaluation, time to surgery, and postoperative outcomes were identified using multivariable linear and logistic regression with stepwise selection., Results: Seventy patients were included in the cohort (mean age 24.8 years, 72.9% female, mean follow-up time 45.7 months). Mean time to evaluation was 6.4 months (range 0-221) and mean time to surgery was 73.6 months (range 0-444). Having a general health check-up in the year prior to surgery was predictive of shorter time to initial evaluation (β = - 100.5 [- 174.5, - 26.5], p = 0.008). Home ownership was predictive of shorter time to surgery (β = - 56.5 [- 104.7, 8.3], p = 0.02). Full-time employment was predictive of higher VAS satisfaction (β = 14.1 [4.3, 23.9], p = 0.006) and higher Kujala score (β = 8.7 [0.9, 16.5], p = 0.03)., Conclusion: Markers of higher socioeconomic status including having a general check-up in the year prior to surgery, home ownership, and full-time employment were predictive of shorter time to initial evaluation, shorter time to surgery, and superior postoperative outcomes., Level of Evidence:  IV, retrospective case series., (© 2023. The Author(s).)

Purpose: The purpose of this systematic review was to evaluate patient outcomes following arthroscopic surgical management for a humeral avulsion of the glenohumeral ligament (HAGL) lesion., Methods: Based on PRISMA guidelines, two independent reviewers performed a literature search to isolate studies on arthroscopic HAGL repair. The functional outcomes, return to play (RTP), and recurrent instability from each study were extracted and analyzed., Results: Overall, 7 manuscripts were included with 49 patients. The patient population was 61.4% male with a mean age of 24.8 years (15-42 years), and 41.9 months of follow-up on average (12-104 months). The Rowe score was the most frequently reported outcome measure with a weighted mean of 89. In total, 81.2% of patients reported being able to RTP post-operatively, with 70.5% reported being able to play at an equal or higher level. There was 1 recurrent dislocation (2%)., Conclusion: The current study found successful clinical outcomes following the arthroscopic management of HAGL lesions. Recurrent dislocation requiring revision was rare, with high rates of return to play including those who could return to the same level of play. However, the paucity of evidence does not permit a statement of best-practice to be made., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023.)

With an increased appreciation of the importance an intact meniscus has on normal knee kinematics and function, more meniscal tears are being treated with a repair rather than partial meniscectomy. There are several techniques for repairing torn meniscal tissue, including the outside-in, inside-out, and all-inside repairs. Each technique comes with its advantages and drawbacks. The inside-out and outside-in techniques allow for greater control of the repair using knots outside the joint capsule; however, they pose a risk for neurovascular injury and require additional incisions. Arthroscopic all-inside repairs have seen increasing popularity, but with current techniques, fixation is achieved either with intra-articular knots or extra-articular implants, leading to variable outcomes and the potential for postoperative complications. This technical note describes the use of SuperBall, an all-inside meniscus repair device that provides an all-arthroscopic approach, no intraarticular knots or implants, and surgeon-guided tensioning of the meniscus repair., (© 2023 The Authors.)

Purpose: The purposes of this study were to determine why athletes did not return to play (RTP) following operative management of superior-labrum anterior-posterior (SLAP) tears, compare these athletes to those who did RTP, and evaluate the SLAP-Return to Sport after Injury (SLAP-RSI) score to assess the psychological readiness of athletes to RTP after operative management of SLAP tears., Methods: A retrospective review of athletes who underwent operative management of SLAP tears with a minimum of 24-month follow-up was performed. Outcome data, including visual analog scale (VAS) score, Subjective Shoulder Value (SSV), American Shoulder & Elbow Surgeons (ASES) score, patient satisfaction, and whether they would undergo the same surgery again was collected. Additionally, the rate and timing of return to work (RTW), the rate and timing of RTP, SLAP-RSI score, and VAS during sport were evaluated, with subgroup analysis among overhead and contact athletes. The SLAP-RSI is a modification of the Shoulder Instability-Return to Sport after Injury (SI-RSI) score, with a score >56 considered to be a passing score for being psychologically ready to RTP., Results: The study included 209 athletes who underwent operative management of SLAP tears. A significantly higher percentage of patients who were able to return to play passed the SLAP-RSI benchmark of 56 compared to those who were unable to return (82.3% vs 10.1%; P < .001), and the mean overall SLAP-RSI scores were also significantly higher among those capable of returning to play (76.8 vs 50.0; P < .0001). Additionally, there was a significant difference between the two groups in every component of the SLAP-RSI score ( P < .05 for all). Fear of reinjury and the feeling of instability were the most common reasons for not returning to play among contact athletes. Residual pain was the most common complaint among overhead athletes. A binary regression model predicting return to sports was performed, which demonstrated ASES score (odds ratio [OR]: 1.04, 95%; (confidence interval [CI]: 1.01-1.07; P  = .009), RTW within 1 month after surgery (OR: 3.52, 95%; CI: 1.01-12.3; P  = .048), and SLAP-RSI score (OR: 1.03, 95%; CI: 1.01-1.05; P  = .001) were all associated with greater likelihood of return to sports at final follow-up., Conclusions: Following the operative management of SLAP tears, patients who are unable to RTP exhibit poor psychological readiness to return, which may be due to residual pain in overhead athletes or fear of reinjury in contact athletes. Lastly, the SLAP-RSI tool in combination with ASES proved to be useful in identifying patients' psychological and physical readiness to RTP., Level of Evidence: Level IV, prognostic case series., (© 2023 The Authors.)

Purpose: To evaluate functional outcomes and satisfaction in patients who underwent telerehabilitation (telerehab) compared with in-person rehabilitation after arthroscopic meniscectomy., Methods: A randomized-controlled trial was conducted including patients scheduled to undergo arthroscopic meniscectomy for meniscal injury by 1 of 5 fellowship-trained sports medicine surgeons between September 2020 and October 2021. Patients were randomized to receive telerehab, defined as exercises and stretches provided by trained physical therapists over a synchronous face-to-face video visit or in-person rehabilitation for their postoperative course. International Knee Documentation Committee Subjective Knee Form (IKDC) score and satisfaction metrics were collected at baseline and 3 months postoperatively., Results: Analysis was conducted on 60 patients with 3-month follow-up outcomes. There were no significant differences in IKDC scores between groups at baseline ( P  = .211) and 3 months' postoperatively ( P  = .065). Patients were more likely to report being satisfied with their rehabilitation group 73% vs. 100% ( P  = .044) if there were in the in-person group. Satisfaction differed significantly between the 2 groups at the end of their rehabilitation course, and only 64% of those in the telerehab group would elect to undergo telerehab again for future indications. Furthermore, they believed that future rehabilitation would benefit from a hybrid model., Conclusions: Telerehab showed no difference versus traditional in-person rehabilitation in terms of functional outcomes up to 3 months after arthroscopic meniscectomy. However, patients were less satisfied with telerehab., Level of Evidence: I, randomized controlled trial., (© 2023 The Authors.)

Background: Single-stage medial meniscus allograft transplantation (MAT) with concomitant anterior cruciate ligament reconstruction (ACLR) is a technically challenging procedure for management of knee pain and instability in younger patients, but clinical and functional outcomes data are sparse. The purpose of this study was to assess surgical and patient-reported outcomes following concomitant ACLR and medial MAT., Methods: We conducted a retrospective case series of patients who underwent medial MAT with concomitant primary or revision ACLR at our institution from 2010 to 2021 and had minimum 12-month follow-up. Complications, reoperations, visual analog scale (VAS) pain, satisfaction, Lysholm score, return to sport, and return to work outcomes were assessed. Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference, Pain Intensity, and Physical Function Scores were used to measure patients' functional status relative to the US population. P-values < 0.05 were considered significant., Results: The cohort consisted of 17 knees of 16 individual patients. The cohort was majority male (82.4%) with mean age of 31.9 years (range 19-49 years) and mean body mass index (BMI) of 27.9 kg/m 2 (range 22.5-53.3 kg/m 2 ). Mean follow-up time was 56.8 months (range 13-106 months). Most patients underwent revision ACLR (64.7%). The 1-year reoperation rate was high (23.5%), with two patients (11.8%) tearing their meniscus graft. Patient-reported outcomes indicated low VAS pain (mean 2.2), high satisfaction (mean 77.9%), and fair Lysholm score (mean 81.1). Return to work rate was high (92.9%), while return to sport rate was low (42.9%). Postoperative PROMIS scores were comparable or superior to the national average and correlated significantly with patient satisfaction (p < 0.05)., Conclusions: The concomitant ACLR and MAT procedure is associated with excellent knee pain and functional outcomes and high rate of return to work after surgery, though the 1-year reoperation rate is high and rate of return to sport is low., Level of Evidence: IV., (© 2023. The Author(s).)

Background: Recent interest has surged in the anterolateral ligament (ALL) and complex (ALC) of the knee. Its existence and role in rotary stability of the knee, particularly in the setting of anterior cruciate ligament (ACL) reconstruction, remains a contentious and controversial topic., Understanding the Alc: We must review our history and recognize the pioneers who pushed our understanding of the ALL forward before it was popularly recognized as a discrete structure. Additionally, given that many eponyms remain in common use related to the ALC, we must standardize our nomenclature to prevent misuse or misunderstanding of terms in the literature. In this review, modern understanding of the anterolateral ligament complex (ALC) is traced to 1829 by exploring eponymous terms first in anatomy and then in surgical technique. Understanding our history and terminology will allow us to better understand the ALC itself., Conclusion: This review aims to provide historical context, define terminology, and provide insight into the clinical relevance of the ALC., (© 2022. The Author(s).)

Purpose: To compare satisfaction and return to play (RTP) rates between patients undergoing primary biceps tenodesis for a symptomatic SLAP tear and patients undergoing secondary biceps tenodesis following a failed SLAP repair., Methods: A retrospective review of patients who underwent subpectoral mini-open biceps tenodesis following failed SLAP repair between January 2011 and October 2019 was performed. Inclusion criteria included age older than 16 years, skeletal maturity, and a minimum follow-up of 12 months. Both athletes and nonathletes were included across all types of sport. Patients who had anterior or posterior instability or rotator cuff tears were excluded; in addition, those requiring concomitant procedures were excluded. Case-control matching was performed using age, sex, indication, follow-up, and type of sport, to generate a 3:1 control group for the primary biceps tenodesis cohort. Primary outcome measurements were collected via telephone in 2020 and included the American Shoulder and Elbow Surgeons score, visual analog scale score, Subjective Shoulder Value score, patient satisfaction, willingness to undergo surgery again, and revisions. RTP and timing of RTP were evaluated as secondary outcomes. A P value of <.05 was considered to be statistically significant., Results: The current study included 76 patients in total; 57 patients with primary biceps tenodesis, and 19 patients with secondary biceps tenodesis. The mean age was 39 years (19-48 years), 100% were male, and the mean follow-up was 54 months (16-99 months). Patient reported outcomes were obtained postoperatively via telephone survey. Overall, we found that primary biceps tenodesis patients reported greater American Shoulder and Elbow Surgeons scores (89.9 vs 76.4, P  = .0162), lower visual analog scale scores (1.0 vs 3.1, P  = .0034), and greater Subjective Shoulder Value scores (86.7 vs 64.7, P  = .0004). Overall, there was no significant difference in the total rate of RTP (84% vs 75%, P  = .5025), or timing of RTP (8.2 months vs 8.1 months, P  = .9529) between patient groups. Patients reported playing tennis, swimming, golf, rock climbing, and basketball. No patients required a further shoulder surgery after undergoing biceps tenodesis., Conclusions: In this study, patients undergoing primary biceps tenodesis had significantly better functional outcomes compared with secondary biceps tenodesis following a failed SLAP repair., Level of Evidence: III, retrospective comparative study., (© 2022 The Authors.)

Purpose of Review: Given the continued controversy among orthopedic surgeons regarding the indications and benefits of arthroscopic partial meniscectomy (APM), this review summarizes the current literature, indications, and outcomes of partial meniscectomy to treat symptomatic meniscal tears., Recent Findings: In patients with symptomatic meniscal tears, the location and tear pattern play a vital role in clinical management. Tears in the central white-white zone are less amenable to repair due to poor vascularity. Patients may be indicated for APM or non-surgical intervention depending on the tear pattern and symptoms. Non-surgical management for meniscal pathology includes non-steroidal anti-inflammatory drugs (NSAIDs), physical therapy (PT), and intraarticular injections to reduce inflammation and relieve symptoms. There have been several landmark multicenter randomized controlled trials (RCTs) studying the outcomes of APM compared to PT or sham surgery in symptomatic degenerative meniscal tears. These most notably include the 2013 Meniscal Tear in Osteoarthritis Research (MeTeOR) Trial, the 2018 ESCAPE trial, and the sham surgery-controlled Finnish Degenerative Meniscal Lesion Study (FIDELITY), which failed to identify substantial benefits of APM over nonoperative treatment or even placebo surgery. Despite an abundance of literature exploring outcomes of APM for degenerative meniscus tears, there is little consensus among surgeons about the drivers of good outcomes following APM. It is often difficult to determine if the presenting symptoms are secondary to the meniscus pathology or the degenerative disease in patients with concomitant OA. A central tenet of managing meniscal pathology is to preserve tissue whenever possible. Most RCTs show that exercise therapy may be non-inferior to APM in degenerative tears if repair is not possible. Given this evidence, patients who fail nonoperative treatment should be counseled regarding the risks of APM before proceeding to surgical management., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Purpose: The purpose of this study was to assess the rate of hospital admissions, inpatient conversions, reoperations, and complications associated with tibial tubercle osteotomies (TTO), high tibial osteotomies (HTO), and distal femoral osteotomies (DFO) performed at our ambulatory surgery center compared with our inpatient hospital facility., Methods: A retrospective review of patients receiving a TTO, HTO or DFO at our institution between June 2011 and October 2019 was performed. Inclusion criteria consisted of patients undergoing the aforementioned procedures for malalignment, and a minimum of 90-days follow-up. Revision osteotomies, those undergoing an osteotomy for an acute fracture, and those with rule-out criteria for outpatient surgery (ASA > 3, and body mass index >40) were excluded. Complications, including readmission and reoperation, were compared between the two groups using either the Fisher's exact test and independent samples t -test, where applicable, and a P value of <0.05 was considered to be statistically significant., Results: The study included 531 patients undergoing osteotomies (222 ambulatory surgical center [ASC] and 309 hospital) with no patients lost to follow-up in the 90-day postoperative period. No patients operated on at an ASC required transfer to inpatient setting. There were no differences in complication rates, readmission, or reoperation rates among the two groups (4.1% vs 4.9%; P  = .8328; 3.1% vs 4.5%, P  = .5026; 3.1% vs 4.5%; P  = .5026; respectively). Complications, including surgical site infection and arthrofibrosis were not significantly different in the two cohorts, (1.4% vs. 2.6%, P  = .341 and 1.4% vs 1%; P  = .698, respectively)., Conclusions: Osteotomies about the knee performed in an ambulatory setting were safe, with no difference in readmission, reoperation, or postoperative complications compared to those performed at an inpatient hospital. Additionally, no patient required conversion from an outpatient to an inpatient setting., Level of Evidence: Level III, retrospective comparative study., (© 2022 The Authors.)

Purpose: To determine whether an association exists between the presence of cervical spine pathology and postoperative patient-reported outcomes (PROs) in patients undergoing open subpectoral biceps tenodesis (BT)., Methods: A retrospective review of patients undergoing isolated BT from August 2011 to May 2019 was conducted. Cases were defined as patients with concomitant cervical spine disease (disc disease, disc herniations, neuroforaminal/central stenosis). Controls were patients without cervical spine disease. Postoperative PROs were collected from all patients with a minimum of 12-month follow-up. Cases and controls were matched 1:1 using age and body mass index. PROs were compared using the χ 2 text, Fisher exact test, or analysis of variance., Results: A total of 23 cases and 23 controls were identified. Cases and controls had similar distributions of age (42.4 ± 4.4 years, 40.4 ± 4.5, P  = .15), sex (83% male, 87% male, P  = .68), body mass index (28.0 ± 4.0, 27.6 ± 4.3, P  = .78), and percentage of athletes (65% athlete, 61% athlete. P  = .76). All cases had evidence of neuroforaminal stenosis and multilevel degenerative disc disease, whereas 19 of 23 (83%) had evidence of central canal stenosis. Cases had a greater visual analog scale (VAS) score during Sport score (3.6 ± 0.7 vs 1.2 ± 0.6, P  = .013) and lower Subjective Shoulder Value (69.5 ± 5.8 vs 84.1 ± 5.4, P  = .070) and Shoulder Instability-Return to Sport after Injury score (60.4 ± 5.8 vs 77.4 ± 6.0, P  = .046). There were no significant differences between groups' ASES, baseline VAS, overall satisfaction scores, and willingness to undergo the same operation again. No significant differences were found in postoperative rate of return to sport, time to return, and return to preoperative competitiveness., Conclusions: Patients with SLAP tears undergoing isolated BT in the presence of cervical spinal stenosis may have inferior Subjective Shoulder Value, Shoulder Instability-Return to Sport after Injury, and VAS during sport scores as compared with controls, although many PROs were similar at follow-up. Athletes undergoing BT, particularly with concomitant cervical spine pathology, should be counseled appropriately before surgery., Level of Evidence: Level III, case-control study., (© 2022 The Authors.)

Background: Patient-reported allergies (PRAs) are often stigmatized as a potential nonmodifiable risk factor for increased pain and worse functional outcomes following surgery. However, there is a dearth of literature directly assessing the impact of PRAs on outcomes in sport surgeries such as medial patellofemoral ligament reconstruction (MPFLR). The purpose of our study was to determine whether PRAs were associated with worse outcomes following MPFLR., Methods: We conducted a retrospective review of patients who underwent MPFLR at our institution from 2011 to 2019. Patients were included if they had at least 12 months of follow-up. PRAs were obtained from preoperative medical assessments and categorized by drug class. Demographic and perioperative data were obtained from electronic medical records. Postoperative outcomes were measured using a telephone survey and included recurrent instability, Visual analog scale (VAS) for pain, VAS for sports, Kujala score, MPFL-Return to Sport after Injury (MPFL-RSI) score, and overall satisfaction score. Multiple linear regression was used to determine association between PRAs and outcome measures, and p-values less than 0.05 were considered significant., Results: The cohort included 141 MPFLR. Most patients were female (98, 70%) with an average age of 25 years (range 12-56 years). Average follow-up time was 47 months. Forty-seven patients (33%) reported at least one PRA. There were no significant differences in postoperative pain, functional outcomes, satisfaction, or return to sport between patients with or without PRAs (all p > 0.05). Absence of antibiotic PRAs was predictive of higher VAS (p < 0.007), but there were no other differences. There were no significant differences in outcomes between patients without PRAs, PRAs without a concomitant psychiatric disorder, or PRAs with a concomitant psychiatric disorder (all p > 0.05)., Conclusions: In conclusion, PRAs with or without concomitant psychiatric diagnoses are not associated with worse postoperative pain, functional outcomes, or satisfaction following MPFLR with allograft, dispelling common misconceptions that increased number of allergies or psychiatric diagnoses lead to inferior surgical outcomes. Presence of antibiotic allergies was associated with lower VAS postoperative pain score. Future research should investigate the relationship between PRAs and other surgeries in the field of sports medicine., (© 2022. The Author(s).)

Importance: There have been several recent systematic reviews of quadriceps tendon autografts (QT), which have not shown any significant difference in outcomes between QT and hamstring tendon autograft (HS) for ACL reconstruction (ACLR). However, several recent comparative studies have been published comparing QT to HS for ACLR., Aim: The purpose of this study is to perform a systematic review and meta-analysis of the studies comparing QT to HS for ACLR., Evidence Review: Two independent reviewers performed the literature search based on the PRISMA guidelines, with a senior author arbitrating discrepancies. Cohort studies comparing QT with HS were included., Findings: There were 15 studies comparing 611 patients with QT to 543 patients with HS, with a mean of 27.4 months follow-up. QT resulted in a significantly lower rate of graft re-rupture (2.5% vs 8.7%, p = 0.01), and donor site morbidity (17.6% vs 26.2%, p = 0.02). There was a significant difference in favour of QT for the positive pivot shift test (Grade I/II: 15.8% vs 23.0%, p = 0.02), but not in the rate of the positive Lachman test (Grade I/II: 18.3% vs 26.7%, p = 0.16). Additionally, there was no difference in the side to side difference in knee stability (1.8 mm vs 2.0 mm, p = 0.48). Functionally, both grafts had similar functional outcomes in terms of the IKDC score (88.0 vs 87.9, p = 0.69), and Lysholm score (89.3 vs 87.6, p = 0.15)., Conclusions and Relevance: Our study showed that QT has a lower re-rupture rate than HS in ACLR, with lower donor site morbidity. QT appeared to be slightly better for residual pivot shift, but there was no difference in patient-reported outcomes., Level of Evidence: III., Competing Interests: Conflicts of interest There is no conflict of interest., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

Despite multiple advances in techniques for posterior cruciate ligament reconstruction (PCL-R), residual posterior laxity continues to be a commonly reported complication. Multiple studies demonstrated a decreased or flat posterior tibial slope, increases posterior laxity, and forces placed across the native and reconstructed PCL. Anterior opening wedge high tibial osteotomies (aOW-HTO) can be used to increase posterior tibial slope, thereby reducing tibial sag and posterior laxity. Depending on the technique used, anterior opening wedge osteotomies can lead to changes in patellar height, affecting patient pain and satisfaction. The purpose of this article is to describe a technique for an aOW-HTO with a tibial tubercle osteotomy and concomitant PCL-R to increase the posterior tibial slope while minimizing changes to patellar height., (© 2022 The Authors.)

Objectives: An isolated medial patellofemoral ligament (MPFL) reconstruction (MPFLR) has been demonstrated to be an effective treatment option in the prevention of patellar instability, but there is growing support for performing a tibial tubercle osteotomy (TTO) in patients with an elevated tibial tubercle-trochlear groove distance. The purpose of this study was to evaluate the impact of adding a TTO to MPFLR on patient-reported outcomes., Methods: A retrospective review of patients who underwent MPFLR with or without TTO with a minimum of 12-month follow-up was performed. Patients in both groups were matched based on age, gender, and follow-up time. Recurrent instability (including redislocation and subluxation), visual analogue scale (VAS) score, Kujala score, and satisfaction were evaluated., Results: There were 59 patients who underwent MPFLR with concomitant TTO performed at our institution and met our inclusion and exclusion criteria. These patients were then matched to patients undergoing isolated MPFLR based on demographics and follow-up time. The mean age was 25.0 years, 76.3% were female, and the mean follow-up time was 49 months. There was a significant difference in mean tibial tubercle-trochlear groove distance (19.8 ± 3.9 vs. 14.1 ± 2.8) between groups. There was no significant difference in VAS (1.48 ± 2.0 vs. 1.49 ± 2.1, p = 0.972), satisfaction (86.1% ± 24.2% vs. 81.2% ± 27.9, p = 0.311) or revision surgeries (10.2% vs. 10.2%) between groups., Conclusion: Matched patients undergoing MPFLR with TTO compared with isolated MPFLR demonstrate no statistically significant difference in patient-reported outcomes, levels of pain, and satisfaction postoperatively. Furthermore, the addition of a TTO does not increase the risk of further surgery or complications., Level of Evidence: III, retrospective comparative study., Competing Interests: Declaration of competing interest There are no conflicts of interest to report., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: The purpose of this study was to evaluate the efficacy of osteochondral allograft (OCA) in patients older than 45 years of age, particularly with respect to return to sport., Design: A retrospective review was performed to evaluate patients greater than 45 who underwent an OCA for a symptomatic osteochondral defect of the knee between June 2011 and January 2019., Results: Overall, there were 18 patients (76% male) that met our inclusion and exclusion criteria. Follow-up was attained in 14 of these patients (78%). The mean age of patients included was 52.6 years (48-57) with a mean of 37 months of follow-up (18-60). Visual Analogue Scale scores decreased significantly from the preoperative baseline to final follow-up (7.7 ± 1.7 vs. 2.0 ± 2.0, P < 0.01). Furthermore, the mean Visual Analogue Scale while playing sport was 3.4 ± 3.2, and the mean Knee Injury and Osteoarthritis Outcome Score was 77.5 ± 12.7 at final follow-up. Overall, 11 patients (78.6%) were able to return to their desired sport. No clinical failures were identified during the follow-up period., Conclusion: In our series of patients 45 years and older who were treated with OCA for focal osteochondral injuries of the knee, we found a significant improvement in clinical outcome scores at a midterm follow-up of 37 months with no revision OCA procedures or conversion to any form of knee arthroplasty. In addition, a high percentage of patients were able to return to their preferred level of athletic activity.

Objective: The purpose of the current study is to evaluate the clinical and radiographic outcomes at early to midterm follow-up between fresh precut cores versus hemi-condylar osteochondral allograft (OCAs) in the treatment of symptomatic osteochondral lesions., Design: A retrospective review of patients who underwent an OCA was performed. Patient matching between those with OCA harvested from an allograft condyle/patella or a fresh precut allograft core was performed to generate 2 comparable groups. The cartilage at the graft site was assessed with use of a modified Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) scoring system and patient-reported outcomes were collected., Results: Overall, 52 total patients who underwent OCA with either fresh precut OCA cores ( n = 26) and hemi-condylar OCA ( n = 26) were pair matched at a mean follow-up of 34.0 months (range 12 months to 99 months). The mean ages were 31.5 ± 10.7 for fresh precut cores and 30.9 ± 9.8 for hemi-condylar ( P = 0.673). Males accounted for 36.4% of the overall cohort, and the mean lesion size for fresh precut OCA core was 19.6 mm 2 compared to 21.2 mm 2 for whole condyle ( P = 0.178). There was no significant difference in patient-reported outcomes including Visual Analogue Scale, Knee Injury and Osteoarthritis Outcome Score for Joint Replacement, and Tegner ( P > 0.5 for each), or in MOCART score (69.2 vs. 68.3, P = 0.93)., Conclusions: This study found that there was no difference in patient-reported clinical outcomes or MOCART scores following OCA implantation using fresh precut OCA cores or size matched condylar grafts at early to midterm follow-up.

Objective: The purpose of this study is to systematically review the literature and to evaluate the reported rehabilitation protocols, return-to-play guidelines, and subsequent rates of return to play following cartilage restoration procedures in the knee., Design: MEDLINE, EMBASE, and the Cochrane Library were searched according to the PRISMA guidelines to find studies on cartilage restoration procedures in the knee, including (1) microfracture (Mfx), (2) osteochondral autograft transfer (AOT), (3) osteochondral allograft implantation (OCA), and (4) autologous chondrocyte implantation (ACI). Studies were included if they reported return-to-play data or rehabilitation protocols., Results: Overall, 179 studies fit our inclusion criteria, with 48 on Mfx, 34 on AOT, 54 on OCA, and 51 on ACI. The rate of return to play was reported as high as 88.2% with AOT, and as low as 77.2% following OCA, with rates of return to play at the same/higher level as high as 79.3% with AOT, and as low as 57.3% following ACI. The average reported time of return to play was as low as 4.9 months with AOT, and as high as 11.6 months following ACI., Conclusions: The majority of patients are able to return to play following cartilage restoration procedures in the knee, regardless of surgical procedure utilized. However, while the rate of return to play at the same level was similar to the overall rate of return following AOT, there was a large number of patients unable to return to the same level following Mfx, OCA, and ACI. Additionally, there is wide variety in the rehabilitation protocols, and scant literature on return-to-play protocols.

Importance: Cadaveric and MRI findings have demonstrated significantly less labral separation and displacement when the shoulder is placed in external rotation as compared with internal rotation., Objective: The purpose of the current study is to meta-analyse the randomised controlled trials in the literature to compare immobilisation in external versus internal rotation after first-time anterior shoulder dislocation., Evidence Review: A literature search of MEDLINE, EMBASE and the Cochrane Library was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Randomised controlled trials comparing immobilisation in external rotation versus internal rotation for first-time anterior shoulder dislocation were included., Findings: Nine randomised controlled trials with 795 patients were included. The mean age of included patients was 29 years, 82.4% were male and the mean follow-up was 25.5 months. As compared with immobilisation in internal rotation, compliance was significantly higher (74.5% vs 67.4%, p=0.01), and the rate of recurrent dislocations was significantly lower (22.2% vs 33.4%, p=0.02) with immobilisation in external rotation. Additionally, in patients 20-40 years old the rate of recurrent dislocations was significantly lower in those treated with immobilisation in external rotation than internal rotation (12.1% vs 31.4%, p=0.006). Immobilisation in external rotation also resulted in a higher rate of return to preinjury level of play (60.1% vs 42.6%, p=0.0001)., Conclusions and Relevance: Immobilisation of the shoulder in external rotation after a traumatic first-time anterior shoulder dislocation results in a higher compliance rate, a lower recurrent dislocation rate and a higher rate of return to play as compared with immobilisation in internal rotation., Level of Evidence: Level I., Competing Interests: Competing interests: EJS: AAOS: board or committee member; American Orthopaedic Association: board or committee member; Arthrex: paid consultant; paid presenter or speaker; Arthroscopy Association of North America: board or committee member; Better PT: stock or stock options; Cartiheal: research support; Cartilage, Bulletin of the Hospital for Joint Diseases: editorial or governing board; Fidia: paid consultant; research support; Flexion Therapeutics: paid consultant; Jaypee Publishing: publishing royalties, financial or material support; Joint Restoration Foundation: paid consultant; Organogenesis: paid consultant; paid presenter or speaker; research support; Smith & Nephew: paid consultant; paid presenter or speaker; Springer: publishing royalties, financial or material support; Subchondral Solutions: paid consultant; Vericel: paid consultant; paid presenter or speaker. LMJ: Arthrex: research support; Bulletin for the Hospital for Joint Diseases: editorial or governing board; JBJS Reviews: editorial or governing board; Mitek: research support; Smith & Nephew: research support; Wolters Kluwer Health-Lippincott Williams & Wilkins: publishing royalties, financial or material support. MJA: AAOS: board or committee member; Arthrex: paid consultant; research support; Arthroscopy Association of North America: board or committee member; Concours Pharmaceuticals: research support., (© International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: To evaluate the efficacy of oral nonsteroidal anti-inflammatory drugs (NSAIDs) as the primary postoperative pain medication compared with standard oral opioids after arthroscopic shoulder capsulolabral (Bankart) repair for recurrent anterior shoulder instability., Methods: This was a single-center, prospective, randomized controlled study. Patients aged 18 to 65 years indicated for arthroscopic shoulder capsulolabral repair for recurrent anterior shoulder instability were included. Postoperatively, patients were prescribed 1 of 2 analgesic regimens: (1) 30 ibuprofen (600 mg every 6 to 8 hours as needed) and 10 tablets of oxycodone/acetaminophen (5/325 mg every 6 hours as needed for breakthrough pain) or (2) 30 tablets oxycodone/acetaminophen (5/325 mg every 6 hours as needed). Subjects completed questionnaires at 24, 48, and 96 hours and 1 week after surgery, which included questions about analgesic medication usage, visual analog scale (VAS) pain score, incidence of adverse events, and patient satisfaction., Results: Between December 2017 and May 2019, 80 patients (mean age 31.3 ± 10.4 years) were enrolled. Overall there were no significant differences in VAS pain score or patient satisfaction between the 2 groups. Patients in the opioid-only group had a significantly higher mean opioid consumption on postoperative days (PODs) 2 to 4 (5.5 versus 2.9, P  = .05) and after 1 week (11.7 versus 7.9 tablets, P  = .05) compared with patients in the NSAID group. Of patients in the NSAID group, 17.5% experienced adverse effects, compared with 35% in the opioid-only group., Conclusions: Use of oral NSAIDs with limited breakthrough opioids results in significantly less opioid use after arthroscopic Bankart repair in the first postoperative week compared with opioids only. Both groups used limited amounts of opioids to control postoperative pain. There were no differences in pain levels at any time point postoperatively or satisfaction between patient groups., Level of Evidence: II, nonblinded randomized control trial., (© 2020 by the Arthroscopy Association of North America. Published by Elsevier Inc.)

Purpose: To systematically review the literature and assess the reported rehabilitation protocols, return-to-play guidelines, and reported rates of return-to-play after meniscal repair., Methods: MEDLINE, EMBASE, and the Cochrane Library were searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify studies on meniscal repair. Studies were included if return-to-play data and/or rehabilitation protocols were reported. The rate and timing of return-to-play was assessed. The rehabilitation protocols were documented, in addition to when to start range of motion (ROM), full ROM, partial weight-bearing (WB), and full WB., Results: Overall, 88 studies met our inclusion criteria. Thirteen studies, including 507 patients, cited a range of 71.2% to 100% of return-to-play, with 53.9% to 92.6% returning to the same/greater level, ranging between 3.3 and 10 months. There was considerable variability in the reported rehabilitation protocols, but the most frequently reported time to begin ROM exercises was within the first week (78.9%) and full ROM at 6 weeks (33.3%). Partial WB was typically begun during the first week (61.0%), and full WB between the fourth and sixth week (65.6%) postoperatively. Following surgery, time elapsed was the most commonly cited criteria for return-to-play (97.0%), with 6 months being the most common time point applied (46.9%). No study advised against returning to competitive or contact sports after meniscal repair., Conclusions: In conclusion, there was a high rate of return-to-play following meniscal repair, with 60% of patients returning to the same level of play. However, there was considerable diversity in the reported rehabilitation protocols and insufficient reporting on return-to-play criteria in the literature. This demonstrates the need for further research and formulation of an evidence-based consensus statement for this patient population., Level of Evidence: Level IV, systematic review of Level I to IV studies., (© 2020 by the Arthroscopy Association of North America. Published by Elsevier Inc.)

Purpose of Review: The purpose of the current article is to review the available literature related to bone marrow-derived mesenchymal stem cell therapy in the management of musculoskeletal pathologies and demonstrate the critical need for additional well-designed clinical studies., Recent Findings: In recent years, there has been a rapid increase in interest regarding the use of bone marrow-derived mesenchymal stem cells in the treatment of musculoskeletal injury and disease. The clinical use of BM-MSCs and other forms of stem cell therapy has far outpaced the basic and translational science evidence required to elucidate the potential efficacy of this orthobiologic treatment approach. Early studies have demonstrated potential clinical benefit of utilizing bone marrow-derived mesenchymal stem cell therapy in the management of knee osteoarthritis, focal chondral lesions, shoulder pathology including rotator cuff tears and glenohumeral arthritis, and degenerative disk disease in the spine. To date, most published studies are small case series often lacking a control group or a standardized method of treatment. Bone marrow-derived mesenchymal stem cell therapy is becoming an increasingly common treatment for musculoskeletal injuries and disease. Although early clinical studies have shown promising outcomes, methodological flaws and lack of standardization among trials have limited the conclusions that can be drawn from the existing literature. A better understanding of the underlying mechanism of action and more carefully designed clinical trials will help reveal the efficacy and utility of BM-MSCs as a treatment modality for various orthopedic pathologies.

Purpose of Review: The purposes of this review are to (1) discuss the epidemiology and workup of the rare posterior cruciate ligament (PCL) avulsion fracture, (2) review the indications for nonoperative and operative management of patients with PCL avulsion fractures, (3) examine surgical outcomes in this patient population, and (4) discuss the authors' preferred management algorithm and surgical approach., Recent Findings: In accordance with the rarity of these injuries, the literature is sparse regarding surgical outcomes. Many of these injuries are in the setting of a multi-ligamentous injury. Most authors suggest that displaced PCL avulsion fractures should undergo operative fixation and current data suggests excellent outcomes when treating these patients with either open or arthroscopic fixation, with a low complication rate. PCL avulsion fractures, although rare, should undergo fixation when displacement is present. Current studies report successful outcomes and a low complication rate.

The meniscus plays a vital role in knee biomechanics, and its physical absence or functional incompetence (e.g., irreparable root or radial tear) leads to unacceptably high rates of joint degeneration in affected populations. Meniscal allograft transplantation has been used successfully to treat patients with postmeniscectomy syndrome, and there is early laboratory and radiographic evidence hinting at a potential prophylactic role in preventing joint degeneration. We present a technique for lateral meniscal allograft transplantation using the CONMED Meniscal Allograft Transplantation system.

Over recent years, appreciation for the critical role of the meniscus in joint biomechanics has led to an emphasis on meniscal preservation. Meniscal allograft transplant (MAT) is a promising biological solution for the symptomatic young patient with a meniscus-deficient knee that has not developed advanced osteoarthritis. As surgical techniques are refined and outcomes continue to improve, it is vital to consider the utility of such procedures and offer a straightforward approach to MAT. This article and accompanying video provide a step-by-step tutorial on how to perform a MAT using the bridge and slot technique, its key pearls and pitfalls as well as the relevant advantages and disadvantages of MAT.

In an effort to better restore normal joint function and kinematics, recent emphasis has been placed on surgical techniques that provide a more anatomic reconstruction of the anterior cruciate ligament (ACL). With femoral tunnel placement shown to play a vital role in the biomechanics, stability, and clinical outcomes after ACL reconstruction, approaches that better approximate the ACL's native femoral origin have been adopted. The independent anteromedial portal technique is thought to better position the femoral tunnel within the native ACL footprint and leave the graft more posteroinferior on the wall of the lateral femoral condyle than the more traditional transtibial approach. This article outlines the surgical technique for an anteromedial portal ACL reconstruction with a tibialis anterior allograft fixed with the Mitek Femoral and Tibial Intrafix sheath and screw system (DePuy Synthes, Raynham, MA).

Osteochondral lesions of the talus are common injuries that affect a wide variety of active patients. The majority of these lesions are associated with ankle sprains and fractures though several nontraumatic etiologies have also been recognized. Patients normally present with a history of prior ankle injury and/or instability. In addition to standard ankle radiographs, magnetic resonance imaging and computed tomography are used to characterize the extent of the lesion and involvement of the subchondral bone. Symptomatic nondisplaced lesions can often be treated conservatively within the pediatric population though this treatment is less successful in adults. Bone marrow stimulation techniques such as microfracture have yielded favorable results for the treatment of small (<15 mm) lesions. Osteochondral autograft can be harvested most commonly from the ipsilateral knee and carries the benefit of repairing defects with native hyaline cartilage. Osteochondral allograft transplant is reserved for large cystic lesions that lack subchondral bone integrity. Cell-based repair techniques such as autologous chondrocyte implantation and matrix-associated chondrocyte implantation have been increasingly used in an attempt to repair the lesion with hyaline cartilage though these techniques require adequate subchondral bone. Biological agents such as platelet-rich plasma and bone marrow aspirate have been more recently studied as an adjunct to operative treatment but their use remains theoretical. The present article reviews the current concepts in the evaluation and management of osteochondral lesions of the talus, with a focus on the available surgical treatment options., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

In cases of chronic distal biceps ruptures, the combination of muscle atrophy, distal tendon retraction, and fibrosis makes primary anatomic reattachment of the tendon particularly challenging. To regain tendon length and avoid flexion contractures, reconstruction with graft augmentation has been proposed as an alternative for cases not amenable to primary repair. We describe our technique using an Achilles allograft through a modified Henry approach to reconstruct the distal biceps tendon to regain length as well as restore flexion and supination strength. With proper and detailed exposure, chronic distal biceps injuries can be reconstructed safely and efficaciously using an Achilles allograft.

Patellofemoral chondral lesions are unique and difficult-to-treat entities often affecting a young and active patient population. Recent advances in our understanding of cartilage injuries, surgical techniques, and surgical technology have provided treatment options for symptomatic patients with lesions of the patellofemoral compartment. A number of surgical treatment options are available, including surgical microfracture, autologous or juvenile chondrocyte implantation, osteochondral autograft transfer, and osteochondral allograft implantation. Management decisions are based on a number of patient- and lesion-related factors in an effort to relieve pain, restore function, and preserve the patellofemoral articulation. The present article reviews the evaluation and management of cartilage injuries affecting the patellofemoral joint.

Indications for the use of osteochondral allografts for orthopaedic surgical applications are increasing with improved surgical techniques and advancing experience. Modern tissue banks have developed harvesting, processing, and storage methods that ensure an adequate, safe supply of grafts. Continued research is necessary to find a technique that maximizes chondrocyte viability and metabolism both during storage and implantation. The majority of published data on the use of osteochondral allografts has focused on the management of osteochondral defects about the knee. Successful outcomes following these procedures have led to increased interest in their application to pathology affecting other joints including the shoulder and ankle. The current paper aims to review the basic science and clinical applications of osteochondral allografts.

Background: Scapular notching is a unique complication of Grammont-style reverse total shoulder arthroplasty. While reverse total shoulder arthroplasty has revolutionized the treatment of pseudoparalysis secondary to cuff tear arthropathy, the implications of scapular notching with regard to patient function and implant stability remain unclear., Questions/purposes: We reviewed literature to determine the etiology and incidence, radiographic progression and effect on implant stability, relationship with postoperative function, and risk factors for the development of scapular notching., Methods: We reviewed PubMed, the Cochrane Central Register of Controlled Trials, and EMBASE with the terms "reverse total shoulder arthroplasty" and "scapular notching." Inclusion criteria were a level of evidence of IV (or better). Twenty-four articles were selected after manual review., Results: Scapular notching after reverse total shoulder arthroplasty is due to repetitive contact between the polyethylene of the humeral component and the inferior scapular neck during adduction, leading to erosion of the scapular neck, polyethylene wear, joint inflammation, and potential implant loosening. Scapular notching appears between 6 and 14 months postoperatively, with an incidence of 44% to 96%. Radiographic progression and effect on patient function remain controversial. Predictors of scapular notching include surgical approach, glenoid wear, preoperative diagnosis, infraspinatus muscle quality, cranial-caudal positioning, and tilt of the glenosphere., Conclusions: Improved understanding of the etiology and risk factors for scapular notching will lead to refinement in implant technology and surgical technique that may translate into improved patient function and implant longevity for Grammont-style reverse total shoulder arthroplasty.

The menisci have an essential function in force transmission across the knee. Injuries to the menisci are common. The indications for repair should be expanded, as the results of partial meniscectomy may deteriorate over time. Tears in younger, higher demand patients should be prepared to optimize the healing environment and be meticulously repaired, particularly in the setting of concurrent anterior cruciate ligament reconstruction. For complex, recurrent, or avascular zone tears, particularly when surgery is limited to meniscal work, consideration can be given to augmenting the repair with a fibrin clot or platelet rich plasma. Partial meniscectomy is a suitable option for lower demand or older patients. Meniscal allograft transplantation is a salvage procedure.

Spontaneous osteonecrosis of the knee (SPONK) and osteo necrosis in the postoperative knee (ONPK) are two clinical entities that have the potential to cause significant morbidity in affected patients. In addition to the knowledge of the patient population at risk and the classic presentation and imaging characteristics of SPONK and ONPK, the treating orthopaedic surgeon needs to maintain a high index of suspicion for these disorders since early diagnosis and treatment may allow for an improved clinical outcome. The following review presents the current knowledge regarding these two pathological processes of the knee.

Context: Lateral meniscus tears are a common entity seen in sports medicine. Although lateral-side knee pain is often the result of a meniscus injury, several extra-articular pathologies share signs and symptoms with a meniscus tear. It is critical for the clinician to be able to identify and understand extra-articular pathologies that can present similar to a lateral meniscus tear., Evidence Acquisition: Data were collected through a thorough review of the literature conducted through a MEDLINE search for all relevant articles between 1980 and February 2010., Study Type: Clinical review., Results: Common extra-articular pathologies that can mimic lateral meniscal tears include iliotibial band syndrome, proximal tibiofibular joint instability, snapping biceps femoris or popliteus tendons, and peroneal nerve compression syndrome or neuritis. The patient history, physical examination features, and radiographic findings can be used to separate these entities from the more common intra-articular knee pathologies., Conclusions: In treating patients who present with lateral-sided knee pain, clinicians should be able to recognize and treat extra-articular pathologies that can present in a similar fashion as lateral meniscus tears.

Injuries to the articular cartilage of the knee are common. They alter the normal distribution of weightbearing forces and predispose patients to the development of degenerative joint disease. The management of focal chondral lesions continues to be problematic for the treating orthopaedic surgeon. Although many treatment options are currently available, none fulfill the criteria for an ideal repair solution: a hyaline repair tissue that completely fills the defect and integrates well with the surrounding normal cartilage. Autologous chondrocyte implantation (ACI) is a relatively new cell-based treatment method for full-thickness cartilage injuries that in recent years has increased in popularity, with early studies showing promising results. The current article reviews the nature of cartilage lesions in the knee and the treatment modalities utilized in their management, focusing on the role ACI plays in the surgical treatment of these complex injuries.

The operative management of focal chondral lesions continues to be problematic for the treating orthopedic surgeon secondary to the limited regenerative capacity of articular cartilage. Although many treatment options are currently available, none fulfills the criteria for an ideal repair solution, including a hyaline repair tissue that completely fills the defect and integrates well with the surrounding normal cartilage. The microfracture technique is an often-utilized, first-line treatment modality for chondral lesions within the knee, resulting in the formation of a fibrocartilaginous repair tissue with inferior biochemical and biomechanical properties compared to normal hyaline cartilage. Although symptomatic improvement has been shown in the short term, concerns about the durability and longevity of the fibrocartilaginous repair have been raised. In response, a number of strategies and techniques for augmentation of the first-generation microfracture procedure have been introduced in an effort to improve repair tissue characteristics and reduce long-term deterioration. Recent experimental approaches utilize modern tissue-engineering technologies including local supplementation of chondrogenic growth factors, hyaluronic acid, or cytokine modulation. Other second-generation microfracture-based techniques use different types of scaffold-guided in situ chondroinduction. The current article presents a comprehensive overview of both the experimental and early clinical results of these developing microfracture augmentation techniques.

The diagnostic and therapeutic modalities utilized in the management of pelvic ring fractures depend on patient characteristics, mechanism of injury, and hemodynamic status at the time of presentation. Knowledge of the complex anatomy and biomechanics of pelvic stability may guide appropriate initial management strategies. Even with the development of specific treatment algorithms and advances in both diagnostic and operative techniques, fractures of the pelvis continue to cause significant morbidity and mortality. The current paper reviews the diagnosis and management of pelvic ring fractures, focusing on current concepts with respect to initial assessment and treatment protocols, including the identification of associated injuries and emergency methods of provisional pelvic stabilization.

Background: The Bio-Transfix pin is a biodegradable device used for femoral tunnel anterior cruciate ligament (ACL) graft fixation. Recent clinical studies have suggested the possibility of the pin's postoperative failure., Methods: This investigation evaluates the initial strength of several Bio-Transfix pin ACL fixations in a simulated femoral tunnel model. The forces generated by five surgeons during simulated ACL graft tensioning were also measured., Results: Average strengths of the pins ranged from 1075 to 2160 N for 10 and 8 mm tunnels, respectively, whereas the maximum surgeon-generated forces were 535 N., Conclusions: These results imply that initial fracture of the pin itself is unlikely; however, failure of the supporting bone or a decrease in pin strength due to biodegradation could account for early loss of the fixation.

Rugby football continues to grow in popularity internation- ally and within the United States. In 1995, rugby union, one form of rugby, turned from amateur to professional through- out Europe, increasing the potential for monetary reward, which, in turn, secondary to higher levels of play, increased the risk of injury. With this increased higher interest and the increasing number of inexperienced and professional players in the U.S., there is a need for a comprehensive analysis of professional rugby union injury in the American literature and increased awareness of rugby injuries, in general, for all levels of players. This paper provides an in-depth analysis of professional rugby union injuries that will assist ortho- paedic surgeons treating these injuries in the U.S. The data described highlights the potential impact of rugby injury in the U.S. and provides an overview of the international data to serve as the basis for future American studies. An additional goal of this review is to stimulate discussion regarding the necessity of implementing additional safety precautions for this high-risk sport. Finally, this analysis highlights the in- consistencies and discrepancies of the literature with respect to rugby union injury and the variability and weak interstudy reproducibility of current rugby injury data.