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Femoroacetabular impingement syndrome (FAIS) is an increasingly prevalent pathology in young and active patients, that has contributing factors from both abnormal hip morphology as well as abnormal hip motion. Disease progression can be detrimental to patient quality of life in the short term, from limitations on sport and activity, as well as the long term through early onset of hip arthritis. However, several concurrent or contributing pathologies may exist that exacerbate hip pain and are not addressed by arthroscopic intervention of cam and pincer morphologies. Lumbopelvic stiffness, for instance, places increased stress on the hip to achieve necessary flexion. Pathology at the pubic symphysis and sacroiliac joint may exist concurrently to FAIS through aberrant muscle forces. Additionally, both femoral and acetabular retro- or anteversion may contribute to impingement not associated with traditional cam/pincer lesions. Finally, microinstability of the hip from either osseous or capsuloligamentous pathology is increasingly being recognized as a source of hip pain. The present review investigates the pathophysiology and evaluation of alternate causes of hip pain in FAIS that must be evaluated to optimize patient outcomes.

Background: Posterior glenoid labrum lesions occur in only 2% to 10% of all cases of shoulder instability, yet these injuries may cause significant shoulder dysfunction in an athletic population. Moreover, these injuries frequently require surgical intervention and present a unique surgical challenge. Indications: Indications for arthroscopic posterior labral repair include symptomatic posterior labral tears identified on magnetic resonance imaging with or without contrast, that failed nonsurgical management (ie, lifestyle modification, nonsteroidal anti-inflammatory drug, and physical therapy). Patients may present with a positive posterior load and shift or positive posterior apprehension test. Technique Description: With the patient in the lateral decubitus position, use a standard posterior superior portal, an ancillary anterior superior portal, a posterior-inferior, and the portal of Wilmington. After portal placement and diagnostic arthroscopy, the torn labrum is debrided. The torn portion of the posterior labrum is then mobilized from approximately the 6 o’clock to 10 o’clock positions, and a curette and shaver are used to produce a bleeding margin for fixation. Two double-loaded 2.4-mm suture anchors are placed, passed, and tied; one at the 6:30 o’clock position and the other at the 8 o’clock position. A cinch stich configuration using a 2.9-mm pushlock anchor can be used at the 10 o’clock position. A polydioxanone suture is used to assist with capsular plication and to close the posterior portal. Results: The literature suggests that 90% to 94% of patients are able to return to their desired sport with 5% to 10% reporting recurrent instability by 2 years after operation. Two out of 3 patients report no limitations at 2 years. Discussion/Conclusion: Arthroscopic repair of posterior labral tears with suture anchors can be an effective surgical option for patients with reverse Bankart lesions. Using advanced imaging to identify concomitant pathologies, meticulous surgical technique, direct visualization of the anatomy and anchor placement, and a dedicated rehabilitation program, greater than 90% of patients can expect to return to sport.

Purpose: To investigate clinical outcomes after superior capsular reconstruction (SCR) for the treatment of massive and/or irreparable rotator cuff tears treated with either allograft or autograft. Methods: Using the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guidelines, in April 2020 a systematic review was performed using PubMed, MEDLINE, EMBASE, and Cochrane databases. Clinical studies were assessed for patient-reported outcomes and range of motion, comparing dermal allografts to fascia lata autografts, with a minimum follow-up of 12 months. Results: A total of 16 clinical studies involving 598 patients (606 shoulders) were included for data analysis, with a weighted mean follow-up of 36.9 months (range 12 to 60). Visual analogue scale (VAS) pain scores decreased from 4.0 to 6.9 mm preoperatively to 0 to 2.5 mm postoperatively. American Shoulder & Elbow Surgeons score increased from 20.3 to 54.5 preoperatively to 73.7 to 97.0 postoperatively. Forward flexion increased from 27.0° to 142.7° preoperatively to 134.5° to 167.0° postoperatively. External rotation increased from 13.2° to 41.0° preoperatively to 30.0° to 59.0° postoperatively. Acromiohumeral distance increased from 3.4 to 7.1 mm preoperatively to 6.0 to 9.7 mm postoperatively. The total rates of complications, graft failure, and revision surgery were 5.6%, 13.9%, and 6.9%, respectively. Conclusions: Irrespective of tissue source, SCR serves as a reasonable joint-preserving option for massive, irreparable rotator cuff tears, with favorable short- to midterm improvements in patient-reported outcomes and range of motion. Level of Evidence: IV, systematic review of level III and IV studies.

Purpose: To define the time required to achieve the minimally clinically important difference (MCID), substantial clinical benefit (SCB) and patient acceptable symptomatic state (PASS) for isolated arthroscopic partial meniscectomy (APM), and define preoperative and intraoperative factors that predict both early and late achievement of the stated metrics. Methods: Patients who underwent isolated APM between 2014 and 2017 were retrospectively included. Patients without preoperative and 6-month patient-reported outcome measure scores, revision procedures, and significant concomitant procedures were excluded. The MCID, SCB, and PASS were calculated for knee-based patient-reported outcome measure scores using receiver operating curve analysis. Kaplan-Meier survival analysis established the time required to achieve MCID, SCB and PASS. Hazard ratios from multivariate Cox regression allowed for the isolation of demographic and intraoperative factors predictive of the delayed time required to achieve MCID, SCB and PASS. Results: A total of 126 patients (42.86% female, age: 48.9 ± 12.4 years) were included. Overall achievement rates ranged between 73.0% and 89.7% for MCID, 43.7% and 68.2% for SCB, and 50.8% and 68.3% for PASS. Median achievement time for MCID was 5.68-5.78 months, 5.73-6.05 months for SCB and 6.54-7.72 months for PASS. Multivariate Cox regression identified older age, workers’ compensation status, diabetes, and various tear types (i.e., longitudinal, transverse, bucket handle, complex) as predictors of early clinically significant outcome achievement (hazard ratio: 1.02-24.72), whereas subsequent steroid injection, higher preoperative scores and root and flap tears predicted delays in clinically significant outcome achievement (hazard ratio: 0.12-0.99). Conclusions: The majority of patients undergoing APM achieve benefit within 6 months of surgery, with diminishing proportions at later timepoints. Important factors for consideration of the the timeline of achieving clinically significant outcome include age, diabetes, workers’ compensation, preoperative score, and tear type. The timeline for achieving improvement that was established by this study may aid in setting patient expectations and designing future outcome studies involving APM. Study design: Level IV, Therapeutic Case Series.

Purpose: To identify the rates of and risk factors for revision arthroscopy and conversion to total knee arthroplasty (TKA) within 1 year of isolated meniscectomy. Methods: Humana and Medicare national insurance databases were queried for patients who underwent isolated meniscectomy. Patients who underwent revision arthroscopy or TKA within 1 year postoperatively were identified by International Classification of Diseases Procedural Codes, Ninth Revision, and Current Procedural Terminology codes. Multivariate binomial logistic regression analysis was used to identify risk factors, and adjusted odds ratios (ORs) and 95% confidence intervals (Cis) were calculated, with P < .05 considered significant. Results: A total of 13,142 patients and 407,888 patients underwent isolated meniscectomy in the Humana and Medicare databases, respectively. Of the patients, 395 (3.01%) and 3,770 patients (0.92%) underwent revision arthroscopy, and 629 patients (4.79%) and 38,630 patients (9.47%) underwent TKA within 1 year of meniscectomy in the Humana and Medicare databases, respectively. Obesity (Humana: OR = 1.33, P = 0.003; Medicare: OR = 1.10, P < 0.001) and age < 20 years (Humana: OR = 2.64, P = 0.022), 20-29 years (Humana: OR = 3.30, P = 0.002), 40-49 years (Humana: OR = 3.80, P < 0.001), 50-59 years (Humana: OR = 1.99, P = 0.027), and < 64 years (Medicare: OR = 1.74, P < 0.001) were risk factors for revision arthroscopy. Obesity (Humana: OR = 1.64, P < 0.001; Medicare: OR = 1.37, P < 0.001), morbid obesity (Medicare: OR = 1.20, P < 0.001), age 70-74 (Medicare: OR = 1.12, P < 0.001), 75-79 (Medicare: OR = 1.25, P < 0.001), 80-84 (Medicare: OR = 1.20, P < 0.001), and concomitant osteoarthritis (Humana: OR = 1.42, P < 0.001; Medicare: OR = 1.46, P < 0.001) were risk factors for conversion to TKA. Conclusions: Medicare and Humana databases showed that 0.92%-3.01% and 4.79%-9.47% of patients undergo revision arthroscopy or conversion to TKA within a year of isolated meniscectomy. Obesity was a risk factor for early revision arthroscopy and conversion to TKA, whereas concomitant osteoarthritis was a risk factor for conversion to TKA. Level of Evidence: Level III, retrospective comparative trial.

Purpose: To evaluate the effect of acromioplasty using a cutting block technique on bony coverage as measured by the critical shoulder angle (CSA) and acromial index (AI). Methods: This study is a retrospective radiographic review using data from a previous prospective randomized clinical trial that offered enrollment to patients aged 18 years or older with a full-thickness tear of the superior rotator cuff between October 2007 and January 2011. Each patient was allocated to repair with either acromioplasty using a cutting block technique or non-acromioplasty treatment arms in a blinded fashion. Medical and demographic information was recorded for each patient. Between January 2017 and December 2017, patients were contacted for repeat follow-up clinical evaluation and radiographs. Measurements of acromial index and critical shoulder angle were performed on pre- and postoperative radiographs by a single reviewer. Results: Seventy-one (75%) patients were available for follow up. The 2 groups were similar in terms of baseline demographics and acromial type. When compared with preoperative measures, acromioplasty did not result in significant reductions in mean CSA (34.5° vs 35.5°; P = .293) or AI (0.68 vs 0.66; P = .283). Furthermore, postoperative CSA (34.5° vs 36.2°, P = .052) and AI (0.66 vs 0.67, P = .535) demonstrated no statistically significant differences between patients with and without acromioplasty, respectively. Conclusions: There was no statistically significant change in either the CSA or AI following acromioplasty, nor was there a significant postoperative difference in CSA or AI between the group that underwent acromioplasty and the group that did not. Clinical Relevance: Some studies suggest a greater postoperative CSA may result in greater risk of retear after arthroscopic rotator cuff repair. The CSA and AI may not be modifiable with acromioplasty.

Instability of the proximal tibiofibular joint (PTFJ) is a rare injury pattern than can affect high-demand athletes involved in twisting or pivoting movements on a flexed knee. Instability may produce painful subluxations during provocative activity and occasional neuritic symptoms from tethering of the common peroneal nerve at the fibular neck. There are several reports of reconstruction for symptomatic PTFJ instability; however, no optimal treatment has been elucidated in the literature. Use of a cortical button suspensory device for fixation of the PTFJ offers the advantage of stabilizing the joint without need for free graft harvest or rigid screw fixation. The present technical report illustrates the operative technique and the advantages, disadvantages, pearls, and pitfalls associated with this operation.

Purpose: To prospectively evaluate the transferability of skills acquired on a low-cost, at-home, nonanatomic triangulation simulation system to cadaveric models. Methods: We randomized 28 medical students into either a simulator-training group (n = 14) or group with no training (control, n = 14). All subjects were pretested using a standardized checklist of arthroscopic skills on cadaveric knees and shoulders. Training-group subjects practiced on the triangulation simulator for 90 minutes per week for 4 consecutive weeks. Control subjects received no training. All subjects completed a post-test checklist of arthroscopic skills on cadaveric knees and shoulders, as well as 4 training tasks on the simulator. A blinded orthopaedic surgeon evaluated the arthroscopic videos using the Arthroscopic Surgical Skill Evaluation Tool (ASSET) score. Results: Training-group knee and shoulder ASSET scores increased from 12.2 ± 1.85 to 14.6 ± 2.76 (P = .02) and from 14.6 ± 3.5 to 17.9 ± 4.5 (P = .29), respectively. In the control group, knee and shoulder ASSET scores increased from 14.3 ± 3.12 to 14.25 ± 4.67 (P = .99) and from 14.2 ± 2.7 to 17.07 ± 6.7 (P = .58), respectively. There were no significant differences in the mean post-test ASSET scores between the training group and control group for either knee or shoulder arthroscopy. The post-test ASSET safety subscore during knee arthroscopy was significantly higher in the training group (P = .03). The training group was able to complete significantly more simulator tasks compared with controls (P = .003) at post-testing. A significant positive correlation was found between knee arthroscopy performance and the number of tasks completed during simulation post-testing (P = .043). There was no significant correlation between shoulder arthroscopy performance and simulation performance (P = .532). Conclusions: Basic triangulation skills may be acquired by training on a low-cost, at-home, nonanatomic triangulation simulation system, although the degree of transferability and universal joint applicability, as well as the existence of an early ceiling effect in skill development, could not be shown. Level of Evidence: Level II, randomized controlled trial.

Osteochondritis dissecans is a focal lesion of articular cartilage that can result in fragment instability with progression of early osteoarthritis. Regarding the knee joint, salvage of an unstable lesion can be achieved using arthroscopic-assisted reduction and fixation via a 2-stage process. The first involves arthroscopic fixation of the fragment using nonbioabsorbable screws, whereas the second stage performed 12 weeks later involves removal of the screws and confirmation of successful healing of the lesion. Previous studies have demonstrated excellent outcomes in patients undergoing fixation for unstable chondral lesions not amenable to conservative treatment. A critical component of successful treatment is understanding the importance of hardware placement and technique. The purpose of the Technical Note is to describe a method performing this 2-stage arthroscopic repair of an unstable chondral lesion located on the medial femoral condyle of the knee.

Bone marrow lesions (BMLs) in the knee represent focal edema caused by subchondral bone attrition and microfractures to the trabecular bone. These lesions are poor prognostic indicators for several orthopaedic procedures but also have been associated with the progression of osteoarthritis. Current research is aimed at treating BMLs with the intent to improve the overall structural integrity of the subchondral bone and delay the need for arthroplasty. The injection of calcium phosphate bone substitute has been proposed to treat BMLs because animal models have shown its potential to stimulate bone repair. This technical note describes the key steps involved in performing percutaneous fixation of BMLs with a hard-setting bone substitute, as well as associated pearls and pitfalls. Although continued research with prospective comparative cohorts and long-term follow-up is needed to determine the efficacy of this procedure, this intervention holds promise in delaying the need for total knee replacement in the arthritic patient with a focal lesion.

Massive rotator cuff tears pose significant clinical and surgical challenges for orthopaedic surgeons and increased morbidity to the patient. Left untreated, this pathology can lead to inability to perform daily activities, weakness, pain, and eventual cuff tear arthropathy. Several treatment options exist for irreparable cuff tears, such as reverse shoulder arthroplasty and tendon transfers. However, there exists significant concern for high complication rates and unpredictable clinical outcomes following such treatments. Superior capsular reconstruction (SCR) represents a viable alternative in treating irreparable cuff tears, providing biomechanical stability and improving pain related to this pathology by reducing superior humeral instability and subacromial impingement. Over-the-top repair of the native rotator cuff tendons with incorporation of the SCR allograft may provide surgeons the opportunity to perform a robust repair in situations where arthroplasty or other more invasive procedures were once the only options. The authors present a surgical technique with associated pearls and pitfalls for their preferred procedure of SCR with incorporation of the native rotator cuff in transosseous equivalent double-row repair for the treatment of massive, irreparable rotator cuff tears.

The subscapularis is the strongest rotator cuff muscle in the shoulder. Until recently, most surgical repairs were performed through an open approach. Furthermore, the reporting of arthroscopic repair techniques and outcomes is fairly limited. This is likely due to the difficulty involved in all-arthroscopic repairs and the relative rarity of this injury compared with injuries of the other rotator cuff tendons. Arthroscopic subscapularis repair can be challenging, even for an expert surgeon, and attempting a double-row repair adds further complexity. Given these issues, this article provides techniques to allow for successful arthroscopic double-row subscapularis repair and avoid potential complications. The key features of an arthroscopic double-row repair include portal placement, surgical technique, and tips to avoid potential pitfalls, all of which are discussed.

Massive rotator cuff tears, as classified by size or tendon involvement, are challenging to repair due to scarring, retraction of the tendons, and difficult visualization. Left untreated, these injuries can lead to fatty infiltration and reduced acromiohumeral distance that precludes future repair. The high rate of failure in these patients often impedes an anatomical repair. However, advanced mobilization techniques of the supraspinatus help facilitate a reduction of an otherwise irreparable tear. By performing this repair, more costly procedures may be avoided, such as a superior capsular reconstruction and reverse total shoulder arthroplasty. This Technical Note presents our preferred technique of an all-arthroscopic, medialized repair with double interval slides for the treatment of a massive rotator cuff tear.