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To report patient characteristics, fracture types, treatment methods, early clinical outcomes and complications of children and adolescents treated for tibial tubercle fractures. Retrospective case series of patients 18 years old and younger treated for tibial tubercle fractures at a single institution from 1995 to 2015. Clinical and radiographic outcomes were reported at minimum six-month follow-up. In 228 patients, 236 tibial tubercle fractures were identified, of whom, 198 (87%) were males. Mean age and BMI was 14.3 years and 25.0, respectively. Pre-existing Osgood-Schlatter disease was identified in 31% cases and was most commonly associated with type I fractures (P < 0.001). Most fractures occurred while participating in athletics (86%). Initial treatment was surgical for 67% fractures. Type III fractures were most common (41%), followed by type I (29%). Type I fractures were most commonly treated nonoperatively (91%) and types II-V fractures were most commonly treated surgically (89%, P < 0.001). Compartment syndrome was identified in 4 (2%) patients, 3 of which had type IV fractures. Most patients returned to sports (88%). Tibial tubercle fractures are sports-related injuries and occur most commonly in adolescent males. They can be associated with pre-existing Osgood-Schlatter disease, a higher than average BMI, and a small but relevant risk of compartment syndrome. Following treatment, most patients return to sports participation.

Background Current advanced imaging classification systems for osteochondritis dissecans (OCD) of the knee grade severity of disease by identifying certain lesion characteristics. The most widely used are the Hefti and Nelson systems. A novel classification presents a simpler 3-group approach to diagnose knee OCD by magnetic resonance imaging (MRI), compared with the Hefti (5-group) and Nelson (4-group) classifications. The purpose of this study was to compare the reliability of this novel classification with that of the more complex, established systems-an initial step in establishing validity and clinical utility. Methods In total, 120 standardized knee MRIs of patients with established knee OCD were preselected to capture the spectrum of lesion types, with regard to both progression and location of the lesion. Each of the MRIs were independently classified by 2 readers into the novel, Hefti, and Nelson classification systems. A random sample was rereviewed by 1 rater 6 weeks after initial review. The inter-rater and intrarater agreements were evaluated by estimating Krippendorff α. Results In total, 106 knees were classified by the novel, Hefti, and Nelson classification systems, as 14 of the knees lacked the necessary MRI sequences. There were no differences in inter-rater and intrarater agreement across classification systems. Krippendorff α for inter-rater agreement was 0.51 (95% confidence interval, 0.33-0.66) for the Hefti classification, 0.50 (0.34-0.64) for the Nelson classification, and 0.49 (0.32-0.65) for the novel classification. The intrarater agreement was 0.88 (0.75-0.97) for the Hefti classification, 0.94 (0.86-0.99) for the Nelson classification, and 0.98 (0.94-1.00) for the novel classification system. Conclusions The novel classification for knee OCD demonstrated near-perfect intrarater agreement and moderate inter-rater agreement, consistent with the current, well-established classification systems. Pending a subsequent study on validity and clinical utility, this simpler classification system may offer an alternative, noninvasive diagnostic method to guide clinical treatment. Level of evidence Level IV.

Background Previous studies have suggested that hip arthroscopy has been performed with increasing frequency. Few studies have examined this trend in the adolescent population. The purpose of this study was to evaluate the trend in the frequency of hip arthroscopy in adolescents standardized by total orthopaedic surgeries in adolescents at pediatric hospitals in the United States. Methods The Pediatric Health Information System (PHIS) database was queried for patients aged 10 to 19 years who underwent orthopaedic surgery at any of the PHIS-participating hospitals from 2008 to 2018. The subgroup of patients in this age cohort who underwent hip arthroscopy was identified using Current Procedural Terminology procedure codes. The yearly rate was expressed as the number of hip arthroscopies per 1000 orthopaedic surgeries. A linear model was used to fit the data and illustrate the relative trend. Results A total of 432,309 orthopaedic surgeries including 9491 hip arthroscopies were performed for patients 10 to 19 years of age. Hip arthroscopies were performed at a yearly rate of 22 per 1000 orthopaedic surgeries. Over the 10-year period, the number of hip arthroscopies increased 6.2-fold, whereas the number of orthopaedic procedures increased 1.6-fold. There was a 3.9-fold increase in hip arthroscopies relative to total orthopaedic surgeries. Conclusions The number of hip arthroscopic procedures in adolescent patients has increased by 3.9-fold times relative to total orthopaedic surgeries in adolescents over a 10-year span, on the basis of data from PHIS-participating institutions. This finding mirrors the trends in the adult population over similar time periods. This may be because of increasing participation in sports in the adolescent population, and a better understanding of the diagnosis and treatment of femoroacetabular impingement and other sports-related hip pathologies. Level of evidence Level IV.

Aims The COVID-19 pandemic presents an unprecedented burden on global healthcare systems, and existing infrastructures must adapt and evolve to meet the challenge. With health systems reliant on the health of their workforce, the importance of protection against disease transmission in healthcare workers (HCWs) is clear. This study collated responses from several countries, provided by clinicians familiar with practice in each location, to identify areas of best practice and policy so as to build consensus of those measures that might reduce the risk of transmission of COVID-19 to HCWs at work. Methods A cross-sectional descriptive survey was designed with ten open and closed questions and sent to a representative sample. The sample was selected on a convenience basis of 27 senior surgeons, members of an international surgical society, who were all frontline workers in the COVID-19 pandemic. This study was reported according to the Standards for Reporting Qualitative Research (SRQR) checklist. Results Responses were received by all 27 surgeons from 22 countries across six continents. A number of the study respondents reported COVID-19-related infection and mortality in HCWs in their countries. Differing areas of practice and policy were identified and organized into themes including the specification of units receiving COVID-19 patients, availability and usage of personal protective equipment (PPE), other measures to reduce staff exposure, and communicating with and supporting HCWs. Areas more specific to surgery also identified some variation in practice and policy in relation to visitors to the hospital, the outpatient department, and in the operating room for both non-urgent and emergency care. Conclusion COVID-19 presents a disproportionate risk to HCWs, potentially resulting in a diminished health system capacity, and consequently an impairment to population health. Implementation of these recommendations at an international level could provide a framework to reduce this burden.

Background: The arthroscopic “bony Bankart bridge” (BBB) repair technique was recently shown to successfully restore shoulder stability at short-term follow-up, but longer-term outcomes have not yet been described. Purpose: To report the outcomes at minimum 5-year follow-up after BBB repair for anterior shoulder instability with a bony Bankart lesion. Study Design: Case series; Level of evidence, 4. Methods: Patients were included if they sustained a bony Bankart lesion, were treated with a BBB technique, and were at least 5 years postoperative. Patients were excluded if they underwent concomitant rotator cuff repair or an open bone fragment reduction. All patients were assessed with the following measures preoperatively and at final evaluation: QuickDASH (Quick Disabilities of the Arm, Shoulder and Hand), American Shoulder and Elbow Surgeons, Single Assessment Numeric Evaluation, and 12-Item Short Form Health Survey (SF-12) Physical Component Summary. Results: From 2008 to 2012, 13 patients who underwent BBB met the inclusion criteria with a mean age of 39.6 years (range, 19.1-68.8 years) and a mean follow-up of 6.7 years (range, 5.1-9.0 years). Mean time from most recent injury to surgery was 6.3 months (range, 1 day–36 months). The mean glenoid bone loss was 22.5% (range, 9.1%-38.6%). Mean SF-12 scores demonstrated significant improvement from 45.8 (SD, 9.7) preoperatively to 55.1 (SD, 5.9) at a mean follow-up of 6.7 years. At final follow-up, the mean American Shoulder and Elbow Surgeons score was 93.1 (range, 68.3-100); the mean QuickDASH score, 6.2 (range, 0-25); and the mean Single Assessment Numeric Evaluation score, 92.8 (range, 69-99). None of the patients progressed to further shoulder surgery. Three of 13 patients (23%) reported subjective recurrent instability. At final follow-up, 9 of 12 (75%) patients indicated that their sports participation levels were equal to their preinjury levels. Median patient satisfaction at final follow-up was 10 of 10 points (range, 3-10). Conclusion: The arthroscopic BBB technique for patients with anterior bony Bankart lesions can restore shoulder stability, yield durable improvements in clinical outcomes, and provide a high return-to-sport rate at a minimum 5-year follow-up. Three of 13 patients experienced postoperative symptoms of instability but did not undergo further stabilization surgery.

The purpose of this study was to investigate clinical outcomes following Achilles tendon allograft-augmented latissimus dorsi tendon transfer (LDTT) for the treatment of irreparable posterosuperior rotator cuff tears with a minimum of 2 years post-operative follow-up. We hypothesized that patients would show significant improvement in outcomes scores with a low failure rate. Patients who were treated with Achilles tendon allograft-augmented LDTT for irreparable posterosuperior rotator cuff tears with a minimum follow-up of 2 years were included. Patient-reported outcomes scores, including ASES, QuickDASH, SANE, SF-12 PCS, and satisfaction, were collected pre- and post-operatively. Pre- and post-operative scores were compared with a Wilcoxon test. Revision to reverse total shoulder arthroplasty (RTSA) was considered as failure. Between March 2006 and November 2014, a total of 16 patients with a mean age of 49 years (range 34–57 years) were included. Minimum 2-year outcomes data were available for 14 of the 16 patients (87.5%) with a mean follow-up of 5.5 years (range 2.1–10.5 years). Two patients (12.5%) advanced to RTSA at a mean of 1.1 years following LDTT. Postoperative median subjective outcomes scores improved, but did not reach statistical significance (SF-12 PCS: 35.4–46.4, P = 0.182; ASES: 47.5–69.9, P = 0.209; QuickDASH: 57.9–31.8, P = 0.176; SANE: 40.0–39.5, P = 0.273). Median post-operative patient satisfaction was 5 on a 10-point scale (range 1–10). Patients with irreparable rotator cuff tears treated with Achilles tendon allograft-augmented latissimus dorsi tendon transfer did not experience significant post-operative improvement in patient-reported outcomes. Thus, the use of an additional allograft-augmentation remains questionable. Retrospective case series, level IV.

The production of lovastatin by Aspergillus terreus PU-PCSIR-1 was studied using submerged fermentation technique. Effects of pH, incubation temperature, incubation time, and the media components on the production of lovastatin were investigated. Maximum lovastatin yield (198.90 mg/L) was achieved after 14 days of incubation at temperature 28°C and pH 7.4. Peptonized milk, linoleic acid, glucose, yeast extract, and trace elements had a positive impact on the production of lovastatin by A. terreus.

Interest in the therapeutic potential of bone marrow aspirate concentrate (BMAC) has grown exponentially. However, comparisons among studies and their processing methods are challenging because of inconsistent reporting of protocols, as well as poor characterization of the composition of the initial bone marrow aspirate and of the final products delivered. The purpose of this study was to perform a systematic review of the literature to evaluate the level of reporting related to the protocols used for BMAC preparation and the composition of BMAC utilized in the treatment of musculoskeletal diseases in published clinical studies.A systematic review of the literature was performed by searching PubMed, MEDLINE, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials from 1980 to 2016. Inclusion criteria were human clinical trials, English language, and manuscripts that reported on the use of BMAC in musculoskeletal conditions.After a comprehensive review of the 986 identified articles, 46 articles met the inclusion criteria for analysis. No study provided comprehensive reporting that included a clear description of the preparation protocol that could be used by subsequent investigators to repeat the method. Only 14 (30%) of the studies provided quantitative metrics of the composition of the BMAC final product.The reporting of BMAC preparation protocols in clinical studies was highly inconsistent and studies did not provide sufficient information to allow the protocol to be reproduced. Moreover, comparison of the efficacy and yield of BMAC products is precluded by deficiencies in the reporting of preparation methods and composition. Future studies should contain standardized and stepwise descriptions of the BMAC preparation protocol, and the composition of the BMAC delivered, to permit validating and rationally optimizing the role of BMAC in musculoskeletal care.

Paste abstract here and remove the remaining text. *For structured abstracts, begin each section under a separate, bolded subheading. Suggested subheadings are below Introduction: Anterior Cruciate Ligament (ACL) tears are one of the most frequent injuries in young athletes. Given the importance of its biomechanical function in knee stability, ACL tears are treated surgically whenever there is sports activities demand. There are key factors in the ACL reconstruction such as graft choice, tunnel positioning, and graft diameter. Grafts less than 8 mm in diameter are a risk factor for re-rupture and relapse. This is especially important if hamstring grafts are used in female patients younger than 20 years old. Objectives: To describe in detail different hamstring graft preparation techniques to obtain an optimal and individualized graft according to patient´s anatomy and the ideal diameter and length for the reconstruction of the ACL. Methods: In the surgical lab, different hamstring graft preparation techniques with allografts, Endobutton femoral cortical suspension device (Smith and Nephew), FiberWire # 2 and FiberLoop # 2 (Arthrex) braided suture were prepare above the graft preparation station. Results: Different techniques of hamstring graft preparation were described in detail: Two-Strand with one tendon; Three-Strand with one tendon; Four-Strand with one and with two tendons; Five-Strand with two tendons; Six-Strand with two tendons and Eight-Strand with two tendons. Conclusion: It is essential to master the different hamstring graft preparation techniques in order to obtain an individualized graft with the appropriate diameter and length according to the patient´s anatomy, height and physical demand.

Chondral lesions of the knee can occur secondary to limb malalignment. To address these interrelated problems, a high tibial osteotomy with concomitant osteochondral allograft transfer may be performed. It is important to address these chondral lesions as they often affect the young and active population and cause morbidity in an otherwise healthy population. Although numerous approaches for the treatment of chondral lesions have been described, long-term results demonstrating regeneration of hyaline cartilage have yet to be reported. Furthermore, larger, full-thickness cartilage defects, which can be caused by limb malalignment, have proven to be particularly challenging to treat. This Technical Note details our technique for multicompartmental osteochondral allograft transplantation with concomitant high tibial osteotomy in a patient with 2 focal cartilage lesions in the knee.

Focal articular cartilage injuries in the knee are common and can cause severe morbidity and reduced function. The articular cartilage is avascular and has limited ability to heal, and hence, patients with cartilage injuries have increased risk of progressing to osteoarthritis. Most of the cartilage injuries are located on the femoral condyles. Engaging focal cartilage injuries involving the trochlea are challenging because of the morbidity caused by these injuries and the limited treatment options. Osteochondral allograft transplantation is emerging as a promising treatment for full-thickness articular cartilage defects. Recent studies have reported high success rates with the use of osteochondral allografts. This article reports our technique of osteochondral allograft transplantation for the treatment of a focal full-thickness defect of the trochlea.

BackgroundThe distinction between normal and pathological extra-axial cerebrospinal fluid (CSF) spaces is unclear, with the use of the term benign external hydrocephalus (BEH) not being well defined in clinical practice. This study aimed to establish a distribution of metrics of the subarachnoid space in a population of children diagnosed as normal, and investigate the clinical use of the term BEH.MethodsA retrospective case-control study on magnetic resonance image scans was performed on 150 children diagnosed as normal and 10 children diagnosed with BEH. Measurements were taken in the axial plane for CSF width (CSFW), and interhemispheric width (IHW).ResultsNormal controls had a mean age of 11.1 ± 7.6 months (78 male, 72 female) and the BEH sample had a mean age of 10.6 ± 7.8 months (six male, four female). Mean CSFW was 7.96 ± 4.79 mm in the BEH sample compared to 4.58 ± 2.25 mm in the normal sample ( p ConclusionThe absence of diagnostic criteria for BEH means reporting is variable. Patients being diagnosed with BEH who have no other clinical defects may represent the extreme of the normal population rather than a distinct clinical entity.

Os acromiale occur frequently in the population and can be a cause of significant shoulder dysfunction and rotator cuff impingement. When symptomatic os acromiale fail conservative management, surgical intervention may become necessary. The purpose of this article is to describe our preferred surgical technique for osteosynthesis of os acromiale using cannulated screws and tension-band wiring.

Chronic anterior shoulder instability due to structural failure of the subscapularis muscle and the anterior capsule is a rare and challenging diagnosis for surgeons to manage because poor-quality capsular, labral, and rotator cuff tissue often limits effective treatment options. If primary repair is not possible because of retraction and poor tissue quality, reconstruction with an allograft or autograft may be the only joint-preserving option. The purpose of this article is to describe a surgical technique for anterior capsular reconstruction using a human acellular dermal allograft for the treatment of irreparable subscapularis tears.

INTRODUCTION Despite the widespread use of arthroscopic double-row transosseous-equivalent (TOE) rotator cuff repair (RCR) techniques, midterm outcome data are limited. The purpose of this article was to assess midterm clinical outcomes of patients following arthroscopic TOE RCR using either a knotless tape bridge (TB) repair or knotted suture bridge (SB) repair technique. We hypothesized that there would be significant improvements in patient-reported outcomes with TOE RCR that would be durable over time. We also hypothesized that the knotless TB technique would yield equivalent clinical results to the knotted SB technique, but that there would be differences in retear types between the two TOE techniques. METHODS Patients included were a minimum of 5 years from an index arthroscopic double-row TOE repair using either a knotless TB or knotted SB technique for one, two, or three tendon full-thickness rotator cuff tears involving the supraspinatus tendon. Preoperative and postoperative American Shoulder and Elbow Surgeons, Short-Form 12 Physical Component Summary, Quick Disabilities of the Arm, Shoulder, and Hand, Single Assessment Numeric Evaluation, and satisfaction scores were collected. Scores were also stratified and compared based on primary and revision repair, tear location, and tear chronicity. Outcomes between techniques were contrasted, and survivorship analysis was conducted, with failure defined as progression to revision surgery. RESULTS One-hundred ninety-two shoulders were included with a mean follow-up of 6.6 years (range, 5.0 to 11.0 years). Fifteen shoulders (7.8%) underwent revision cuff repair. All scores improved significantly for TB repair (P < 0.001). For SB repair, all scores improved, but only American Shoulder and Elbow Surgeons and Short-Form 12 Physical Component Summary scores (P < 0.05) demonstrated statistical significance. No statistically significant differences were found between the repair techniques when stratified by primary and revision repairs, tear location, or chronicity. Postoperative clinical survivorship was 96.6% and 93.6% for knotted SB repairs and 96.7% and 93.9% for knotless TB repairs at 2 and 5 years, respectively. CONCLUSION TOE RCR results in significant clinical improvement and excellent survivorship at a minimum of 5 years of follow-up, using either knotted SB or knotless TB repair techniques in primary and revision cases and in small and large tears. Equivalent results were obtained with both TOE techniques. Patients undergoing repair with a TOE showed significant improvements in patient-reported outcomes that were durable at a minimum of 5 years postoperatively.

Background: Previous studies have examined factors related to the increased use of opioids after hip arthroscopy in adults. However, few have focused on the adolescent population. Purpose: The purpose of this study was to compare the opioids prescribed to opioids consumed after hip arthroscopic procedures in adolescent and young adult patients, and to determine patient or surgical factors associated with increased postoperative opioid use. Methods: Adolescent and young adult patients who underwent hip arthroscopy and associated arthroscopic interventions between January 2017 and January 2020 were included. Patients with a diagnosed pain syndrome or history of chronic pain, as determined by the patient taking opioid medications prior to surgery, were excluded. Daily postoperative opioid intake was recorded via pain-control logbooks. The outcome of the study was defined as the average total number of opioid tablets consumed postoperatively. Results: Fifty-eight patients returned completed logbooks, 72% of whom were female patients. The average age was 21.30 years (range, 14.9 – 34.2). Most patients (73%) were prescribed 30 oxycodone tablets. The median amount of tablets consumed was 7 (range, 0-41) over a median duration of 7 days (range, 1-22). The median ratio of tablets consumed to prescribed was 20% and the 95th percentile of opioids consumed was 28 tablets. Bivariate analysis showed that patient age at surgery was positively correlated to the total amount of tablets consumed (r=0.28, p=0.04) and to the ratio of tablets consumed to prescribed (r=0.30, p=0.03). Duration of surgery was negatively correlated to the number of days tablets were consumed (r=-0.31, p=0.03). Multivariate analysis showed that patients who were prescribed more than 30 tablets took on average 7.8 more tablets overall compared to those prescribed 30 or fewer tablets (p=0.003), and that for each additional year of age, the ratio of tablets consumed to prescribed increased by 1% (p=0.02). Conclusion: After undergoing hip arthroscopy and associated arthroscopic procedures, adolescents and young adult patients are commonly overprescribed opioids, consuming on average only one-fifth of the tablets prescribed. This finding mirrors trends in the pediatric knee arthroscopy literature and provides an opportunity to reassess current opioid prescribing behaviors in the adolescent and young adult populations. [Table: see text][Table: see text][Table: see text][Table: see text][Table: see text]

Clavicle fractures are among the most common fractures occurring in the general population, and the vast majority are localized in the midshaft portion of the bone. Management of midshaft clavicle fractures remains controversial. Although many can be managed nonoperatively, certain patient populations and fracture patterns, such as completely displaced and shortened fractures, are at risk of less optimal outcomes with nonoperative management; surgical intervention should be considered in such cases. The purpose of this article is to demonstrate our technique of midshaft clavicle fixation using minimally invasive intramedullary fixation.

Background: Patients are staying active longer and expect to return to sports or continue participating in recreational activities after total shoulder arthroplasty (TSA) for primary glenohumeral osteoarthritis. Purpose/Hypothesis: The purpose of this study was to assess the ability of patients to return to recreational sports following TSA. We hypothesized that TSA would allow a high rate of return to recreational sports. Study Design: Case series; Level of evidence, 4. Methods: All patients who underwent primary TSA by a single surgeon and were at least 2 years out from surgery were included and were studied for their ability to return to recreational activity following surgery between December 2005 and January 2015. Patient-reported outcomes were obtained, including the 12-Item Short Form Health Survey–Physical Component Summary (SF-12 PCS); Single Assessment Numeric Evaluation (SANE); Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire; American Shoulder and Elbow Surgeons (ASES) score; and satisfaction scores (10-point scale), preoperatively and at a minimum of 2 years postoperatively. Return-to-sport rates were assessed using a standardized patient-reported outcome questionnaire. Results: A total of 165 patients (186 shoulders) that received TSA met the inclusion criteria for the study. Preoperatively, 139 patients (157 shoulders) were involved in recreational sports; 16 (8.6%) shoulders required additional surgical intervention after the index TSA procedure. A significant postoperative increase was noted in the mean ASES (from 48.3 to 87.0; P < .001), QuickDASH (from 41.0 to 15.8; P < .001), SANE (from 49.1 to 81.2; P < .001), and SF-12 PCS scores (from 38.6 to 48.9; P = .004). Of the 157 shoulders in the recreational sports cohort, responses to the survey examining recreational sporting activities after surgery were available for 112 shoulders. The overall rate of return to sport or recreational activity following TSA was 93.7% (105/112 shoulders). The rate of return to recreational sporting activity equal to or better than the preinjury level was 69.7% (78/112 shoulders), while 6.3% (7/112 shoulders) of our cohort reported that they were unable to compete in recreational sports following TSA. Of the patients who participated in predominantly upper extremity sporting activities after TSA, 49% had to modify their postoperative recreational sporting activity because of lifestyle change, pain, weakness, or decreased range of motion. Conclusion: Patients undergoing TSA showed excellent postoperative improvement in their outcome scores, satisfaction, and return to athletic activities. Despite the expected decrease in activity levels with the slow progression of osteoarthritis over time until TSA was performed, almost 94% of patients successfully returned to various recreational sporting activities postoperatively. This study showed that return to recreational sports can be achieved at participation levels that are comparable with preoperative levels, but athletes in some sports such as tennis or swimming, which require more intense levels of exercise, are less likely to return to the same participation levels.

Biologic-based therapy for cartilage pathology has gained considerable recognition due to being minimally invasive, offering capacity for faster healing, and potential for rapid recovery. These therapies include tissue-specific cell culture, marrow-venting procedures, platelet-rich plasma (PRP), bone marrow aspirate concentrate (BMAC), and cell-based therapies. Reports thus far have yielded promising results with a relatively robust safety profile. Although important advances have been made in the field, further well-designed clinical trials are required. Current limitations include their high cost and limited long-term evidence of efficacy. This chapter aims to review the existing literature for biologic-based treatment options for cartilage and identify potential avenues for development.

Background:The cause of spontaneous osteonecrosis of the knee (SONK) and postarthroscopic osteonecrosis of the knee is unknown, and the mechanisms involved have been poorly characterized.Hypothesis/Purpose:The purpose of this study was to perform a detailed systematic review of the literature to examine proposed etiological mechanisms for SONK in order to establish an improved understanding of the processes involved. We hypothesized that the etiology of SONK would be multifactorial.Study Design:Systematic review.Methods:A systematic review of the literature was performed by searching PubMed, Medline, Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials. Inclusion criteria were all original research articles presented in the English language that reported on the suspected etiology of SONK. Reviews, case reports with fewer than 3 patients, cost-effectiveness studies, technical reports, editorial articles, surveys, special topics, letters to the editor, personal correspondence, and studies that only proposed factors for the progression of SONK were excluded.Results:After a comprehensive review of 255 articles, 26 articles were included for final analysis. Twenty-one (80.7%) of 26 articles implicated the role of the meniscus in the development of SONK, in an association with either meniscal tears or its development after meniscectomy. The medial meniscus and posterior meniscal root tears were implicated more frequently. All 4 studies incorporating histological findings supported the insufficiency fracture hypothesis as a pathological basis of SONK.Conclusion:Physicians should be cognizant of the high prevalence of medial meniscus root tears in patients with SONK. Meniscectomy and meniscal tears, particularly of the medial meniscus posterior root, increase contact pressures and create an environment from which insufficiency fractures can emanate. We believe the term SONK is a misrepresentation of the etiology and pathogenesis of the condition and should be replaced with subchondral insufficiency fractures of the knee. Further elucidation of the etiology is required.

Advanced glenohumeral osteoarthritis can transform glenoid morphology and, in some cases, is found in association with severe glenoid retroversion. The associated glenoid retroversion leads to difficulty in fixation of the glenoid component in reverse total shoulder arthroplasty. In the context of extreme glenoid wear, structural grafts can be used to restore glenoid volume and version in order for the glenoid component of the reverse total shoulder arthroplasty to be more easily implanted. Nevertheless, literature regarding structural grafts remains limited, with optimal graft choice and technique still controversial at best. This article details our technique for humeral head autograft transplantation before reverse total shoulder arthroplasty in the context of extreme glenoid retroversion with advanced osteoarthritis.

Humeral avulsion of the glenohumeral ligament (HAGL) is a lesion associated with anterior shoulder instability. Although uncommon, HAGL lesions are a significant contributor to shoulder pain and dysfunction and, if missed, can even be a cause of failed Bankart repair. HAGL lesions should generally be repaired surgically; however, given their low prevalence, there is no consensus on the optimal surgical approach. The purpose of this Technical Note is to describe our preferred surgical technique for the fixation of an HAGL lesion using an all-arthroscopic approach and a knotless suture anchor construct.

Purpose The purpose of this study was to evaluate outcomes following open subpectoral biceps tenodesis for the treatment of isolated type II SLAP lesions in patients 45 years of age or younger and evaluate the rate of return to sport. Methods All patients included in the study were at least 2 years out from open subpectoral biceps tenodesis for treatment of an isolated type II SLAP lesion and were treated between December 2007 and March 2015. All patients older than 45, those who had prior surgery on the index shoulder, and those who had any concomitant reconstructive shoulder procedures were excluded. American Shoulder and Elbow Surgeons (ASES), Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), Single Assessment Numeric Evaluation (SANE), and Short-Form 12 Physical Component Summary (SF-12 PCS) scores were collected pre- and postoperatively along with postoperative patient satisfaction. Patient return to sport was evaluated by questionnaire. Results Twenty patients with a mean age of 38 years (range 21-45) were included, of which 16 were available for follow-up. There was significant improvement in median pre- to postoperative outcome scores (ASES, 66-94 points, P = .001; QuickDASH, 31-8, P = .003; SANE, 60-92, P = .001, SF-12 PCS, 41-52 points, P = .002), with a median patient satisfaction of 8.5 points (range 1-10) at a mean follow-up of 3.4 years (range, 2.0-6.3 years). At final follow-up, all patients had returned to sport, with 73% of patients indicating a return to their previous or comparable level of sports. Subgroup analysis showed 80% of overhead athletes returned to the same or a comparable level postoperatively. Conclusions This study suggests that young patients around their 30s participating in sport at a recreational level may benefit from open subpectoral biceps tenodesis for a primary isolated SLAP II tear and would experience excellent outcomes, high satisfaction, and a high rate of return to sport. Level of Evidence Level IV, therapeutic case study.

Bicep tendon pathology often arises from chronic overuse injuries, acute trauma, or degenerative changes in the glenohumeral joint. These injuries can cause significant shoulder pain, and can greatly limit range of motion and, in turn, activities of daily living. The diagnosis of biceps pathologies can be challenging, because patients often present with nonspecific symptoms. Some bicep tendon pathologies may be treated nonoperatively; however, biceps tendon subluxation and the presence of rotator cuff or SLAP lesions require surgical management. One of the options for the treatment of bicep tendon pathology includes miniopen subpectoral biceps tenodesis. The purpose of this Technical Note is to describe in detail our preferred operative technique for miniopen subpectoral biceps tenodesis with 2 different fixation methods.

Although uncommon, rotator cuff tears that occur medially at the musculotendinous junction can result from acute trauma, anatomic force imbalance, or medial row cuff failure following a previous rotator cuff repair. The quality of the torn muscle and tendon along with the length of the remnant tendon stump should be considered before deciding on the most appropriate repair technique. When muscle and tendon quality are sufficient, the tear can often be repaired directly to the remnant tendon stump and compressed onto the greater tuberosity. If the remnant tendon stump is degenerative, of insufficient length, or lacks tendon in which to place sutures, an allograft patch can be used to augment the repair. When the quality of the remaining muscle and tendon are poor or when the muscle is retracted too far medially and is nonmobile, a bridging technique such as superior capsule reconstruction is preferable. The purpose of this report is to (1) highlight that medial cuff failure can occur both primarily and after previous repair; (2) define and classify the 3 major tear patterns that are encountered, and (3) describe the authors' preferred techniques for medial cuff repair that specifically address each of the major tear patterns.