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Anticipation of patient-specific component sizes prior to total knee arthroplasty (TKA) is essential to avoid excessive cost associated with additional surgical trays and morbidity associated with imperfect sizing. Current methods of size prediction, including templating, are inconsistent and time-consuming. Machine learning (ML) algorithms may allow for accurate TKA component size prediction with the ability to make predictions in real-time. Consecutive patients receiving primary TKA between 2012 and 2020 from two large tertiary academic and six community hospitals were identified. The primary outcomes were the final femoral and tibial component sizes extracted from automated inventory systems. Five ML algorithms were trained with routinely corrected demographic variables (age, height, weight, body mass index, and sex) using 80% of the study population and internally validated on an independent set of the remaining 20% of patients. Algorithm performance was evaluated through accuracy, mean absolute error (MAE), and root mean-squared error (RMSE). A total of 17,283 patients that received one of 9 TKA implants from independent manufacturers were included. The SGB model accuracy for predicting ± 4-mm of the true femoral anteroposterior diameter was 83.6% and for ± 1 size of the true femoral component size was 95.0%. The SGB model accuracy for predicting ± 4-mm of the true tibial medial/lateral diameter was 83.0% and for ± 1 size of the true tibial component size was 97.8%. Patient sex was the most influential feature in terms of informing the SGB model predictions for both femoral and tibial component sizing. A TKA implant sizing application was subsequently created. Novel machine learning algorithms demonstrated good to excellent performance for predicting TKA component size. Patient sex appears to contribute an important role in predicting TKA size. A web-based real-time prediction application was created capable of integrating patient specific data to predict TKA size, which will require external validation prior to clinical use.

Anterior cruciate ligament (ACL) tears are routinely treated with an ACL reconstruction. This is based on historical literature reporting high failure rates after ACL repairs in addition to the limited healing potential of the ACL. Recently, improved understanding of pathophysiology of ligamentous healing has led to increasing interest in treating proximal avulsions with excellent tissue quality in the acute setting, as this technique allows for ACL healing. Potential advantages of ACL repair include preservation of native proprioceptive and kinematics of the knee, avoidance of graft harvesting morbidity and the possibility to perform a primary ACL reconstruction in case of failure. As a consequence, several techniques for ACL repair have been proposed that can be performed in isolation or with suture augmentation. The primary aim of this technical note is to describe step-by-step the ACL repair technique with and without suture augmentation. The secondary aim of the current study is to review the indications, patient selection and advantages of the technique.

Background : Previous research has investigated the percentage of maximal outcome improvement (MOI) for the American Shoulder and Elbow Surgeons (ASES) and Simple Shoulder Test (SST) scores after reverse total shoulder arthroplasty (rTSA); however, few other outcome scores have been validated. The purpose of this study was to establish thresholds of MOI percentage for the Single Assessment Numeric Evaluation (SANE) and subjective Constant-Murley (Constant) scores associated with patient satisfaction at two-years following rTSA. Methods : A retrospective review of institutional registry data for all patients who underwent primary rTSA between 09/2016 and 02/2018 was performed. All patients completed the ASES, SANE, and Constant outcome measures preoperatively and at a minimum of two-years postoperatively. Changes were assessed with Wilcoxon signed-rank tests. MOI percentage was defined as the score improvement from baseline divided by the highest possible improvement from baseline based on the maximum value of the outcome score used. Receiver operating characteristic (ROC) analyses were used to determine optimal MOI percentage thresholds associated with postoperative satisfaction. Stepwise multivariate logistic regression was performed to identify variables associated with achieving the MOI. Results : A total of 105 patients were included in the final analysis, with a mean (±standard deviation) age of 70.0±7.5 years and BMI of 28.9±5.6 kg/m2. The majority of patients were satisfied postoperatively (81.0%). Statistically significant increases were observed from baseline to two-years postoperatively for the outcome measures assessed (P Conclusion : Achieving 66.9%, 71.0%, and 37.5% of the MOI for the ASES, SANE, and Constant scores is associated with postoperative satisfaction following rTSA. Comorbid diabetes and diagnosis of rotator cuff arthropathy were significantly associated with a decreased likelihood of MOI achievement. Level of Evidence : Level III; Retrospective Case Series (Prognostic)

Background: Temporal changes in revision total knee arthroplasty (rTKA) may have implications in determining the etiology for implant failure. The purpose of this study was to 1) perform an epidemiologic analysis of etiologies that required rTKA and 2) determine whether temporal changes existed for revision over the study period. Methods: All rTKA procedures performed at a single institution from 2009 to 2019 were analyzed. Revision procedures were stratified into 2 time periods, 2009-2013 and 2014-2019, to assess for changes over time. Patients’ electronic medical record, operative report, and radiographs were reviewed to ensure diagnosis information was accurately documented in relation to the predominate etiology necessitating the revision procedure. Results: Three thousand and nine patients undergoing rTKA between 2009 and 2019 were identified with a mean age of 64.6 years. A total of 1,666 (55.4%) patients were female, and the majority of patients were Caucasian (2,306, 76.6%). The 3 most frequent rTKA etiologies were aseptic loosening (35.1%), periprosthetic infection (33.2%), and instability (16.0%). A higher proportion of patients underwent rTKA for arthrofibrosis (5.1% vs 3.4%, P = .023) and periprosthetic joint infection (38.9% vs 28.6%, P < .001) between 2009 and 2013, while a significantly higher proportion of patients underwent rTKA for instability (12.6% vs 18.8%, P < .001) between 2014 and 2019. Conclusion: Aseptic loosening was the most common cause for rTKA over the last decade. rTKA for arthrofibrosis and periprosthetic joint infection was more frequent between 2009 and 2013, while a significantly higher proportion of patients underwent rTKA for instability in 2014-2019. Future studies will need to focus on identifying and reducing risk factors for the trending causes of rTKA.

Background Femoral stem subsidence is a known cause of early implant failure, increasing the risk for aseptic loosening and periprosthetic fracture. Overall survivorship and subsidence in a novel porous tantalum-coated femoral prosthesis have not been well-studied. Methods Consecutive patients undergoing primary total hip arthroplasty with a porous tantalum-coated femoral prosthesis between January 2008 and January 2015 with minimum 5-year follow-up were included. Clinical and radiographic data were obtained from hospital and office records. Multivariate logistic regression analyses were used to determine predictors of subsidence and clinical outcomes. Kaplan-Meier survivorship curves were performed to illustrate primary failure endpoints of (1) all-cause revision and (2) femoral prosthesis revision. Results A total of 398 patients with a mean (±standard deviation) age of 61.0 ± 11.5 years, body mass index (BMI) 32.8 ± 8.0 kg/m2, and follow-up of 6.9 (range 5.0-11.2 years) were included. Survivorship at 5 years was 94.9% for all-cause revision and 98.0% for femoral component revision. Average subsidence was 1.8 ± 1.3 mm (range 0-15.5), with 8.1% patients experiencing subsidence >5 mm. Statistically significant mean improvements were observed at latest follow-up in the Hip Disability and Osteoarthritis Outcome Score Joint Replacement (40.6 ± 11.5 vs 85.2 ± 10.1, P 3 mm. BMI was a statistically significant and independent predictor of subsidence >5 mm (OR 1.25, P 7 mm (OR 1.25, P Conclusion The trabecular metal taper femoral prosthesis conferred excellent clinical outcome improvement and survivorship. Increasing BMI was independently associated with an increased risk of subsidence in these patients and caution is recommended in utilizing this implant in obese, morbidly obese, and super morbidly obese populations.

Purpose To systematically review the literature to better understand the current indications for ligamentum teres reconstruction (LTR), current graft and acetabular fixation options used, patient-reported outcomes after LTR, and incidence of complications and reoperations after LTR. Methods A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. All literature related to LTR published prior to July 2020 was identified. The inclusion criteria consisted of investigations reporting on human patients with pathology of the ligamentum teres who underwent LTR, including mentions of the indications, graft type, acetabular fixation method, postoperative patient-reported outcome scores, and incidence of complications and reoperations. Results Seven studies comprising 26 patients (28 hips) were included. The most commonly reported indication for LTR was persistent pain and instability after failed prior hip arthroscopy (68%, 19 of 28 hips). The mean postoperative modified Harris Hip Score, Non-arthritic Hip Score, and visual analog scale score all showed improvement when compared with preoperative values. A total of 2 complications occurred. Complication rates ranged from 0% to 100% in included case reports and 0% to 11% in included case series. A total of 9 reoperations were performed. Reoperation rates ranged from 0% to 100% for case reports and 18% to 100% for case series. Reoperation rates ranged from 33% to 100% in studies with patients receiving acetabular fixation using anchors versus 0% to 22% in studies performing LTR with buttons. Reoperation rates in athletic patients and patients with Ehlers-Danlos syndrome ranged from 0% to 100% and 0% to 50%, respectively. Conclusions The main indication for LTR was persistent hip or groin pain and instability after a prior hip arthroscopy. The short-term postoperative modified Harris Hip Score, Non-arthritic Hip Score, and visual analog scale score after LTR showed favorable outcomes. However, reoperations after LTR were not uncommon. Level of Evidence Level V, systematic review of Level IV and V studies.

To (1) compare the Altmetric Attention Score (AAS) and citation rates between orthopaedic and nonorthopaedic randomized controlled trials (RCTs) from 5 high-impact medical journals and (2) identify general characteristics of these articles associated with greater exposure on social media platforms.Articles published in The New England Journal of Medicine (NEJM), Lancet, The Journal of the American Medical Association (JAMA), Annals of Internal Medicine, and Archives of Internal Medicine between January 2011 and December 2016 were analyzed. These journals were selected based on retaining high impact factors with rigorous publication standards and availability of the AAS for their publications. The queried time frame was chosen to balance the inception of the AAS with an optimal period for citation accrual. A total of 14 article characteristics, in addition to number of Tweets, Facebook shares, news mentions, and the AAS, were extracted. Inclusion criteria were orthopaedic RCTs reporting on outcomes after surgical intervention. Linear regression was used to assess the relationship between publication characteristics and the AAS and social media attention.A total of 9 orthopaedic and 59 nonorthopaedic RCTs were included. The mean AASs were significantly different (574 ± 565.7 versus 256.9 ± 222.3, P = .003), whereas citation rate was not (192.2 ± 117.1 versus 382.3 ± 560.3, P = .317). Orthopaedic RCTs had a significantly greater number of mentions on Twitter and Facebook (P.001). A higher AAS significantly associated with a greater number of citations (β = 0.75, P = .019) for orthopaedic RCTs. The mean AAS of orthopaedic RCTs favoring nonoperative management (809.6 ± 676.3) was greater than those favoring operative treatment (292.0 ± 248.9) but was not statistically significant (P = .361).Orthopaedic RCTs published in 5 high-impact general medical journals had a significantly greater mean AAS relative to nonorthopaedic RCTs, with no differences in citation rates. Additionally, there was a strong association between the AAS and citation rate of orthopaedic RCTs. Orthopaedic RCTs had greater social media exposure on both Twitter and Facebook.Orthopaedic surgeons, researchers, and providers who publish RCTs in high-impact medical journals can anticipate extensive social media attention for their articles relative to other nonorthopaedic RCTs in the same journals. Social media attention may be related to operative versus nonoperative management topics. This study provides further evidence for the increasing use of the AAS and its association with citation accrual.

To present the results of a mid-term follow-up study on sleep quality at a minimum of 2 years after hip arthroscopy for femoroacetabular impingement syndrome.Original inclusion criteria were consecutive patients undergoing primary hip arthroscopy for cam/pincer correction between March 1, 2017, and July 1, 2017, who did not respond to nonoperative management, whereas exclusion criteria were revision arthroscopy, gluteus medius repair, contralateral procedure during the follow-up period, and known sleep disorders. Patients who had followed up at 6 months were contacted at a minimum of 2 years following their surgery. In total, 37 of 55 (67.3%) were available for follow-up. New Pittsburgh Sleep Quality Index (PSQI) scores were obtained and compared with previously reported scores at preoperative and 6-month time points. The PSQI ranges from 0 to 21, with a score of ≥5 indicating poor sleep quality. Point biserial correlations and χPreoperatively, 94.5% of patients (52/55) had a PSQI of ≥5 with a mean PSQI score of 9.8 ± 4.2. Statistically significant improvements were observed at both 6 (PSQI: 2.2 ± 0.2, P.001) and 24 months (PSQI: 4.3 ± 3.9) postoperatively compared to baseline (P.001, both). The mean PSQIs at 2 years and 6 months postoperatively were not statistically different (P = .06). A total of 21.7% (10/46) of patients continued to experience poor sleep quality at 6 months postoperatively, whereas a total of 29.7% (11/37) did so at 2 years postoperatively (P = .36). No preoperative factors were associated with poor sleep quality (P.05 all).The early improvements in sleep quality observed 6 months postoperatively from an original small cohort were maintained at a mean 2.8-year follow-up in those who responded. However, approximately 30% of hip arthroscopy patients still experience poor sleep quality.IV, therapeutic case series.

Background: Failure to appropriately identify and repair medial meniscal ramp lesions at the time of anterior cruciate ligament (ACL) reconstruction (ACLR) may result in increased anterior tibial translation and internal rotation, increasing the risk for graft failure. Knowledge of the risk factors leading to the development of ramp lesions may enhance clinicians’ vigilance in specific ACL-deficient populations and subsequently repair of these lesions at the time of ACLR. Purpose: To perform a systematic review and meta-analysis of factors tested for associations with ramp lesions and to determine which were significantly associated with the presence of ramp lesions. Study Design: Systematic review and meta-analysis; Level of evidence, 4. Methods: PubMed, OVID/Medline, and Cochrane databases were queried in April 2020. Data pertaining to study characteristics and reported risk factors for ramp lesions were recorded. DerSimonian-Laird binary random-effects models were constructed to quantitatively evaluate the association between risk factors and ramp lesions by generating effect estimates in the form of odds ratios (ORs) with 95% CIs. Qualitative analysis was performed to describe risk factors that were variably reported. Results: The review included 12 studies with 8410 patients. The overall pooled prevalence of ramp lesions was 21.9% (range, 9.0%-41.7%). A total of 45 risk factors were identified, of which 8 were explored quantitatively. There was strong evidence to support that posteromedial tibial edema on magnetic resonance imaging (MRI) (OR, 2.12; 95% CI, 1.27-3.56; P = .004), age Conclusion: Significant associations between male sex, age

Aims Advances in surgical technique and implant design may influence the incidence and mechanism of failure resulting in revision total hip arthroplasty (rTHA). The purpose of the current study was to characterize aetiologies requiring rTHA, and to determine whether temporal changes existed in these aetiologies over a ten-year period. Methods All rTHAs performed at a single institution from 2009 to 2019 were identified. Demographic information and mode of implant failure was obtained for all patients. Data for rTHA were stratified into two time periods to assess for temporal changes: 2009 to 2013, and 2014 to 2019. Operative reports, radiological imaging, and current procedural terminology (CPT) codes were cross-checked to ensure the accurate classification of revision aetiology for each patient. Results In all, 2,924 patients with a mean age of 64.6 years (17 to 96) were identified. There were 1,563 (53.5%) female patients, and the majority of patients were Caucasian (n = 2,362, 80.8%). The three most frequent rTHA aetiologies were infection (27.2%), aseptic loosening (25.2%), and wear (15.2%). The frequency of rTHA for adverse local tissue reaction (ALTR) was significantly greater from 2014 to 2019 (4.7% vs 10.0%; p < 0.001), while the frequency of aseptic loosening was significantly greater from 2009 to 2013 (28.6% vs 21.9%; p < 0.001). Conclusion Periprosthetic joint infection was the most common cause for rTHA in the current cohort of patients. Complications associated with ALTR necessitating rTHA was more frequent between 2014 to 2019, while aseptic loosening necessitating rTHA was significantly more frequent between 2009 to 2013. Optimizing protocols for prevention and management of infection and ALTR after THA may help to avoid additional financial burden to institutions and healthcare systems. Cite this article: Bone Joint Open 2020;2(1):16–21.

Background: Patients with a history of degenerative joint disease secondary to an acute or remote episode of septic arthritis of the native knee or hip present a unique challenge for the orthopaedic surgeon. This study describes our experience with two-stage primary arthroplasty for such patients. Methods: We reviewed 42 patients with a history of septic arthritis treated with two-stage primary arthroplasty between 2008 and 2018. Patients were evaluated using modified Harris Hip Score, Knee Society Score (KSS), and KSS functional component (KSSF). Paired t-tests were used to compare changes for continuous variables within cohorts. Multivariate linear and logistic regression models were constructed to determine predictors of outcomes and complications. Results: At a mean of 3.3-year follow-up, there were 14 (33.3%) complications and the infection cure rate was 95.2%. On average, patients improved in the modified Harris Hip Score (42.9 ± 11.8 vs 83.3 ± 11.1, P < .001), KSS (35.9 ± 16.9 vs 80.1 ± 16.6, P < .001), KSSF (38.0 ± 15.1 vs 71.5 ± 24.0, P < .001), knee flexion (90.9 ± 14.9 vs 100.5 ± 17.1), and hip flexion (73.8 ± 21.2 vs 102.1 ± 11.8, P < .001). Age (β: −0.78, P = .004) was independently associated with lower Harris Hip Score in the hip cohort. There were no independent predictors of the KSS or KSSF. The erythrocyte sedimentation rate (odds ratio: 1.07, P = .043) and C-reactive protein (odds ratio: 1.43, P = .018) at stage 2 were independently associated with a higher likelihood of complications at the final follow-up. Conclusions: Patients with a history of native septic arthritis of the hip and knee, and secondary end-stage degenerative joint disease, showed significant postoperative improvements and a high rate of complications after two-stage primary total joint arthroplasty. Despite improvements, some patients may necessitate a third operation because of the incidence of reinfection and spacer exchange. This information should be used to counsel patients who present with this challenging clinical scenario.

Background Proposed benefits of modularity for femoral revisions in total hip arthroplasty (THA) include more precise biomechanical restoration and improved stability, but this has not been proven with use of a splined, tapered design. This study’s purpose is to compare (1) complication rates, (2) functional outcomes, and (3) radiographic measures of subsidence, offset, and leg length discrepancy with the use of modular vs monoblock splined, tapered titanium stems in revision THA. Methods We retrospectively reviewed 145 femoral revisions with minimum 2-year follow-up (mean, 5.12 years; range, 2-17.3 years). Patients receiving a modular (67) or monoblock (78) splined, tapered titanium stem for femoral revision were included. Results There were no statistically significant differences in rates of reoperation (22.3% vs 17.9%; P = .66), intraoperative fracture (9.0% vs 3.8%; P = .30), postoperative fracture (3.0% vs 1.3%; P = .47), dislocation (11.9% vs 5.1%; P = .23), or aseptic loosening (4.5% vs 6.4%; P = .73) between the modular and monoblock cohorts, respectively. There were similar results regarding subsidence >5 mm (10.4% vs 12.8%; P = .22), LLD >1 cm (35.8% vs 38.5%; P = .74), restoration of hip offset (−5.88 ± 10.1 mm vs −5.07 ± 12.1 mm; P = .67), and Harris Hip Score (70.7 ± 17.9 vs 73.9 ± 19.7; P = .36) between groups. Multivariate regression showed no differences in complications (P = .44) or reoperations (P = .20) between groups. Conclusion Modular and monoblock splined, tapered titanium stems demonstrated comparable complication rates, functional outcomes, and radiographic parameters for femoral revisions. However, a limited number of patients with grade IIIB or IV femoral bone loss received a monoblock stem. Future investigations are required to determine whether modularity is beneficial for more complex femoral defects.

Purpose To compare knotted and knotless transosseous equivalent (TOE) rotator cuff repair (RCR) techniques and evaluate their imaging-diagnosed retear rates. Methods The Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed (2008 to 2019), EMBASE (2008 to 2019), and Medline (2008 to 2019) were used to perform a systematic review and meta-analysis using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria, with the following search terms: rotator cuff repair AND (knotless OR knotted) AND transosseous; rotator cuff repair AND (knotless OR knotted or transosseous); rotator cuff repair AND (“suture bridge” OR “suture bridging”). Data pertaining to demographic characteristics, surgical techniques, retears, and patient-reported outcomes were extracted from each study. Rates and locations of retear were reported using ranges, and risks of bias and heterogeneity for each study were assessed. Results A total of 7 studies (552 shoulders) were included. Patients had a weighted mean (± standard deviation) age of 60.5 ± 2.4 years with 27.8 ± 7.9-month follow-up. The incidence of retears ranged from 5.1% to 33.3% in patients treated with knotless TOE RCR, and the incidence for patients treated with knotted TOE RCR ranged from 7.5% to 25%. The incidence of type I retears ranged from 42.9% to 100% for patients treated with knotless TOE RCR and 20% to 100% for patients treated with knotted TOE RCR. The incidence of type II retears ranged from 0% to 57.1% in patients treated with knotless TOE RCR and 0% to 100% in patients treated with knotted TOE RCR. Conclusions The incidence and location of retears after knotless and knotted TOE RCR appear to be similar.

Purpose To determine the influence of corticosteroid injections (CSIs) before or after primary rotator cuff repair (RCR) on the risk of (1) revision RCR, (2) retears, and (3) infections. Methods The Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, PubMed, Embase, and MEDLINE databases were queried in accordance with the 2009 Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Data pertaining to the use of CSIs before or after primary RCR and adverse events were extracted. A subjective synthesis of these outcomes and bias was performed. Results A total of 10 studies including 240,976 patients were identified; 20.0% received a perioperative CSI. Of the 48,235 patients who received a CSI, 66.2% did so preoperatively whereas 33.8% did so postoperatively. A total of 78 patients received both preoperative and postoperative CSIs. Three studies examined the influence of preoperative CSIs on revision RCR; the incidence ranged from 3.8% to 10.5% with preoperative CSIs and from 3.2% to 3.4% for controls. Two of these studies analyzed outcomes of patients from the same databases over the same period. Five studies examined the influence of postoperative CSI use on retears; the incidence ranged from 5.7% to 19.0% in patients who received postoperative CSIs and from 10.0% to 18.4% for controls. Three studies examined the influence of CSI use on infection; 2 studies examined the risk of infection after postoperative CSI use, which ranged from 0.0% to 6.7% with CSIs and from 0.0% to 0.5% for controls. Conclusions The use of preoperative CSIs could be associated with an increased risk of revision RCR. There were no conclusive data to suggest an increased risk of retear or infection with CSI use based on a subjective synthesis of ranges. There is currently poor-quality literature surrounding this topic. Given that the current literature is limited and heterogeneous, no definitive recommendations can be made on perioperative CSI use for RCR. Level of Evidence Level III, systematic review of Level I and III studies.

Background: Minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) have gained prominence as important variables in the orthopaedic outcomes literature. In hip preservation surgery, much attention has been given to defining early clinically meaningful outcome; however, it is unknown what represents meaningful patient-reported outcome improvement in the medium to long term. Purpose: (1) To define MCID, PASS, and SCB at a minimum 5 years after hip arthroscopy for femoroacetabular impingement syndrome (FAIS) and (2) to evaluate the time-dependent nature of MCID, PASS, and SCB. Study Design: Case series; Level of evidence, 4. Methods: Patients undergoing primary hip arthroscopy for FAIS between January 2012 and March 2014 were included. Clinical and demographic data were collected in an institutional hip preservation registry. MCID, PASS, and SCB were calculated for each outcome score including the Hip Outcome Score–Activities of Daily Living subscale (HOS-ADL), Hip Outcome Score–Sport-Specific subscale (HOS-SS), modified Harris Hip Score (mHHS), and International Hip Outcome Tool (iHOT-12) at 1, 2, and 5 years. MCID was calculated by use of a distribution-based method, whereas PASS and SCB were calculated by use of an anchor method. Results: The study included 283 patients with a mean ± SD age of 34.2 ± 11.9 years. The mean changes in 1-year, 2-year, and 5-year scores, respectively, required to achieve MCID were as follows: HOS-ADL (8.8, 9.7, 10.2); HOS-SS (13.9, 14.3, 15.2); mHHS (6.9, 9.2, 11.4); and iHOT-12 (15.1, 13.9, 15.1). The threshold scores for achieving PASS were as follows: HOS-ADL (89.7, 88.2, 99.2); HOS-SS (72.2, 76.4, 80.9); mHHS (84.8, 83.3, 83.6); and iHOT-12 (69.1, 72.2, 74.3). Last, the threshold scores for achieving SCB scores were as follows: HOS-ADL (89.7, 91.9, 94.6); HOS-SS (78.1, 77.9, 85.8); mHHS (86.9, 85.8, 94.4); and iHOT-12 (72.6, 76.8, 87.5). More patients achieved MCID, SCB, and PASS at 2-year compared with 1-year follow-up; however, by 5 years, fewer patients had achieved clinically meaningful outcome (minimum 1-, 2-, and 5-year follow-up, respectively: MCID, 82.6%, 87.3%, 79.3%; PASS, 67.6%, 74.9%, 67.5%; SCB, 62.3%, 67.2%, 56.6%). Conclusion: The greatest proportion of patients achieved MCID, PASS, and SCB at 2-year follow-up after arthroscopic treatment of FAIS compared with 1- and 5-year time points. Improvements were maintained out to 5-year follow-up, although the proportion of patients achieving clinical significance was slightly decreased.

Background: Several studies have investigated failure rates and magnitude of improvement in patient-reported outcome measures after microfracture surgery for focal chondral defects of the knee; however; what constitutes clinically significant improvement in this patient population is poorly understood. Purpose: To (1) establish the minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) thresholds for microfracture surgery including the time-dependent nature of these thresholds and (2) identify predictors of achieving the MCID and PASS in patients specifically undergoing microfracture of the knee. Study Design: Case series; Level of evidence, 4. Methods: A secure institutional cartilage preservation repository was queried for all patients who underwent microfracture between 2004 and 2017. The distribution method was used to calculate MCID thresholds for the International Knee Documentation Committee (IKDC) score and the Knee injury and Osteoarthritis Outcome Score (KOOS), whereas an anchor-based method was used for the PASS. Multivariate logistic regressions were constructed to determine predictors of achieving the MCID and PASS. Results: A total of 206 patients with a mean ± SD age of 33.7 ± 13.2 years and body mass index of 26.9 ± 5.3 kg/m2 were included. All thresholds for the MCID and PASS increased over time except for the MCID thresholds for the KOOS Sports and Symptoms subscales. The proportion of patients who achieved the MCID (6 months, 78.4%; 12 months, 83.9%; 24 months, 88.6%) and PASS (6 months, 67.7%; 12 months, 79.2%; 24 months, 76.1%) generally increased over time. Older age and larger lesion size were negative independent predictors of MCID achievement. Older age was also a negative predictor of the PASS, whereas male sex and higher preoperative KOOS Symptoms and Pain scores were positive independent predictors of the PASS. Conclusion: The MCID and PASS thresholds for the IKDC and KOOS in patients undergoing microfracture of the knee are dynamic, with an increasing number of patients achieving the MCID over time. The percentage achieving the PASS increased between 6 and 12 months and then declined slightly at 24 months. Independent predictors of achieving the MCID were lesion size and age at surgery, whereas predictors of achieving the PASS included lesion size, male sex, and greater preoperative KOOS Symptoms and Pain scores.

To evaluate the reliability and educational content of YouTube videos concerning the menisci.YouTube was queried using the keyword "meniscus." The first 50 videos were evaluated. Eleven video characteristics were extracted, and videos were categorized by source and content. Video reliability was assessed using the Journal of the American Medical Association (JAMA) benchmark criteria (score range, 0-5). Video educational content was assessed using the Global Quality Score (GQS; score range, 0-4) and a meniscus-specific score (MSS; score range, 0-20).The mean video duration was 551.44 ± 1,046.04 seconds (range, 75-7,282 seconds). The mean number of views was 288,597.7 ± 735,275.9. Collectively, the 50 videos accrued 14,141,285 views. The mean JAMA score, GQS, and MSS were 1.55, 2.12, and 3.67, respectively. The video source was predominately non-physician based (24.49% of source uploaders), whereas video content was predominately concerned with disease information (37.50% of content). Significant between-group effects were observed for the JAMA score and video content (P = .0155), with videos concerning disease information, exercise training, and nonsurgical intervention having the highest mean JAMA scores. Significant between-group effects were also observed for the JAMA score based on video upload source (P.001), with videos uploaded by physicians receiving the highest mean JAMA scores. The mean GQS and MSS were significantly greater for videos categorized as having disease-specific content (P = .0377 and P = .0404, respectively) and for physician video uploaders (P = .0133 and P = .0100, respectively). The number of video dislikes was a negative independent predictor of the JAMA score (β = -0.007, P = .003). Disease-specific content was a positive independent predictor of the GQS (β = 1.13, P = .042). There were no independent predictors of the MSS.Information on the meniscus found in YouTube videos is of low quality and reliability.Orthopaedic health practitioners should caution patients about the inaccuracy of YouTube videos regarding the meniscus given the low quality of content. These health care providers should make efforts to provide patients with higher-quality alternatives.

To determine clinical outcomes of patients undergoing revision hip arthroscopy for failure to improve with magnetic resonance imaging (MRI) and intraoperative evidence of a capsular incompetency as compared with (1) patients undergoing revision hip arthroscopy without evidence of a capsular incompetency and (2) patients undergoing primary surgery for femoroacetabular impingement syndrome (FAIS) at a minimum follow up of 2 years.Data from consecutive patients undergoing revision hip arthroscopy with MRI/arthrogram-confirmed capsular incompetency between January 2012 and June 2016 were analyzed. All revision patients with capsular incompetency was matched 1:1 by age and body mass index to FAIS revision patients without capsular incompetency and primary FAIS patients. Outcomes included the Hip Outcome Score (HOS)-Activities of Daily Living (ADL), HOS-Sports Subscale (SS), Modified Harris Hip Score (mHHS), pain, and satisfaction. The minimal clinically important difference was calculated for HOS-ADL, HOS-SS, and mHHS.In total, 49 patients (54.4%) of 90 undergoing revision hip arthroscopy had MRI evidence of a capsular incompetency. Most patients were female (79.6%), with a mean age of 30 ± 10.5 years and body mass index of 25.7 ± 5.5. The difference among pre- and postoperative HOS-ADL, HOS-SS, mHHS, and visual analog scale score for pain were all statistically significant (P.05). Analysis of reported outcomes among matched groups demonstrated statistically significant differences, with the group undergoing primary surgery having the greatest 2-year outcomes. Only 66.7% of patients undergoing revision surgery with capsular incompetency achieved a minimal clinically important difference; however, there was no significant difference when compared with revision patients without capsular incompetency. When compared with patients undergoing primary surgery, the difference in frequency was statistically significant (66.7% vs 91.3%; P.001).More than one half of patients undergoing revision hip arthroscopy had MRI and intraoperative evidence of capsular incompetency. Revision arthroscopy for capsular incompetency results in significantly improved 2-year outcomes. However, patients undergoing revision for capsular incompetency and intact capsule revision patients reported significantly lower outcomes compared with primary patients.Level III, Retrospective Comparative Study.

Focal chondral defects (FCD) of the knee are common sources of pain and dysfunction in young patients with high activity demands. Both the understanding of the cause of FCDs and the surgical management of these defects has exponentially grown. This is reflected in the number of surgical procedures performed for FCD, which now approximates 200,000 annually. This fact is also apparent in the wide variety of surgical approaches to FCD that now exist, from simple arthroscopic debridement to complex restorative procedures such as osteochondral allograft transplantation. Given the prevalence of FCD and increased attention on treating these lesions, a comprehensive understanding of management from diagnosis to rehabilitation is imperative for the treating surgeon. This chapter presents current concepts in the treatment of FCD, provides an algorithmic approach to selecting interventions to address FCD, and subsequently describes each commonly used surgical technique in the management of these chondral defects, with corresponding clinical outcomes.

Osteochondromas of the femoral neck are a rare but challenging problem because of their distal location, which is difficult to access arthroscopically. Traditional methods of osteochondroma resection used invasive open approaches to manage these lesions. More recently, advances in hip arthroscopy have allowed expanded treatment of extra-articular hip conditions with a minimally invasive approach. Reports have described the use of hip arthroscopy for osteochondroma removal; however, surgical techniques for the procedure have yet to be described. We describe a technique for arthroscopic resection of a femoral neck osteochondroma using an extended capsulotomy and osteochondroplasty with subsequent capsular plication. This technique uses contemporary hip arthroscopic techniques and constitutes a safe and effective approach to addressing this rare intra-articular pathology of the hip.

Background The purpose of this systematic review was to compare functional outcomes, complications, and revision rates between cemented and uncemented reverse shoulder arthroplasty (RSA) for proximal humeral fractures (PHF). Methods A systematic search was performed in April 2021 within PubMed, Scopus Web of Science, and Cochrane Library databases for clinical studies reporting outcomes of RSA performed for PHF. Included studies were published in English, had a minimum one-year follow-up, specified whether the humeral stem was cemented (cRSA) or uncemented (ucRSA), and were evidence level I-IV. Data including range of motion (ROM), functional status, American Shoulder and Elbow Surgeons (ASES) score, Constant score, visual analog scale (VAS) score, tuberosity healing, complications, and reoperations were extracted. DerSimonian-Laird random-effects models with subgroup stratification analyses were applied to investigate differences in outcomes between patients with cRSA and ucRSA. Results A total of 45 studies comprising 1,623 patients were included. The overall pooled age was 75.9±3.4 years. Mean follow-up of 34.6 (range, 12–108) months. There were no significant differences in ROM, VAS score, Constant score, rate of tuberosity healing, or reoperation rates between cRSA and ucRSA cohorts. The mean postoperative ASES score in the cRSA cohort (73.9, 95% CI 71.4 – 76.5) was significantly lower than the ucRSA cohort (82.9, 95% CI 75.9 – 90.0, p=0.013). The incidence of postoperative all-cause complications was significantly lower in the cRSA cohort (5.5%, 95% CI 4.0% – 6.9%) compared with the ucRSA cohort (9.7%, 95% CI 4.5% – 14.9%, p=0.044). Conclusion The use of uncemented humeral stems in RSA for PHF confers similar functional results to the use of cemented stems in terms of pain, range of motion, functional scores, and tuberosity healing. Although the rate of complications was significantly higher in the uncemented cohort compared to the cemented cohort (9.7% vs 5.5% respectively), the rate of reoperations was similar between the groups (1.6% vs 1.9% respectively). The uncemented reverse prosthesis seems to be a valid alternative for the management of patients with complex proximal humerus fractures.

Background: Understanding the relationship between the temporal phases of the baseball pitch and subsequent joint loading may improve our understanding of optimal pitching mechanics and contribute to injury prevention in baseball pitchers. Purpose: To investigate the temporal phases of the pitching motion and their associations with ball velocity and throwing arm kinetics in high school (HS) and professional (PRO) baseball pitchers. Study Design: Descriptive laboratory study. Methods: PRO (n = 317) and HS (n = 54) baseball pitchers were evaluated throwing 8 to 12 fastball pitches using 3-dimensional motion capture (480 Hz). Four distinct phases of the pitching motion were evaluated based on timing of angular velocities: (1) Foot-Pelvis, (2) Pelvis-Torso, (3) Torso-Elbow, and (4) Elbow-Ball. Peak elbow varus torque, shoulder internal rotation torque, and shoulder distraction force were also calculated and compared between playing levels using 2-sample t tests. Linear mixed-effect models with compound symmetry covariance structures were used to correlate pitch velocity and throwing arm kinetics with the distinct temporal phases of the pitching motion. Results: PRO pitchers had greater weight and height, and faster ball velocities than HS pitchers ( P < .001). There was no difference in total pitch time between groups ( P = .670). PRO pitchers spent less time in the Foot-Pelvis ( P = .010) and more time in the Pelvis-Torso ( P < .001) phase comparatively. Shorter time spent in the earlier phases of the pitching motion was significantly associated with greater ball velocity for both PRO and HS pitchers (Foot-Pelvis: B = −6.4 and B = −11.06, respectively; Pelvis-Torso: B = −6.4 and B = −11.4, respectively), while also associated with increased shoulder proximal force (Pelvis-Torso: B = −76.4 and B = −77.5, respectively). Decreased time in the Elbow-Ball phase correlated with greater shoulder proximal force for both cohorts (B = −1150 and B = −645, respectively) with no significant correlation found for ball velocity. Conclusion: Significant differences in temporal phases exist between PRO and HS pitchers. For all pitchers, increased time spent in the final phase of the pitching motion has the potential to decrease shoulder distraction force with no significant loss in ball velocity. Clinical Relevance: Identifying risk factors for increased shoulder and elbow kinetics, acting as a surrogate for loading at the respective joints, has potential implications in injury prevention.

Injuries to the menisci of the knee are common in orthopedic sports medicine. Bibliometric studies can identify the core literature on a topic and help further our collective knowledge for both clinical and educational purposes. The purpose of the current study was to (1) identify and describe the 50 most cited articles in meniscus research over an 80-year time period to capture a wide range of influential articles and (2) identify the “citation classics” and milestone articles related to the meniscus of the knee. The Science Citation Index Expanded subsection of the Web of Science Core Collection was systematically searched for the 50 most cited meniscus articles. Data pertaining to bibliometric and publication characteristics were extracted and reported using descriptive statistics. The top 50 articles were published between the years 1941 and 2014 and collectively cited 13,152 times. The median (interquartile [IQR]) number of total citations per article was 203.5 (167.0–261.8), while the median citation rate was 9.6 (7.4–13.9) citations per year. The most cited article was “Knee joint changes after meniscectomy,” published in 1948. The article with the highest citation rate of 78.4 citations per year was “The long-term consequence of anterior cruciate ligaments and meniscus injuries – osteoarthritis,” published in 2007. The majority of articles were clinical outcome studies (n = 28, 56%). The top 50 most cited meniscus articles represent a compilation of highly influential articles which may augment reading curriculums and provide a strong knowledge base for orthopaedic surgery residents and fellows. The decade with the most articles was the 2000s, representing a recent acceleration in meniscus-based research. This is a level IV, cross-sectional study.

» As smoking increases the risk of adverse events and leads to increased hospital costs following total joint arthroplasty (TJA), many institutions have introduced perioperative smoking cessation initiatives. Although such programs have been demonstrated to improve outcomes for smokers undergoing TJA, the optimal approach, duration, and timing of smoking cessation models have not been well-defined. » Overall, initiating a smoking cessation program 4 weeks preoperatively is likely adequate to provide clinically meaningful reductions in postoperative complications for smokers following TJA, although longer periods of cessation should be encouraged if feasible. » Patients brought in for emergency surgical treatment who cannot participate in a preoperative intervention may still benefit from an intervention instituted in the immediate postoperative period. » Cotinine testing may provide some benefit for encouraging successful smoking cessation and validating self-reported smoking status, although its utility is limited by its short half-life. Further study is needed to determine the value of other measures of cessation such as carbon monoxide breath testing. » Smoking cessation programs instituted prior to TJA have been demonstrated to be cost-effective over both the short and long term.

Background: Previous meta-analyses have demonstrated superior outcomes in patients undergoing arthroscopic repair of medial meniscus posterior root tears (MMPRTs) compared with meniscectomy. However, these analyses have considered only short- or midterm outcomes and low-quality evidence. Purpose: To compare the mid- to long-term rates of radiographic osteoarthritis (OA) between repair and meniscectomy for MMPRT. Study Design: Systematic review and meta-analysis; Level of evidence, 4. Methods: PubMed, EMBASE, Ovid/MEDLINE, and Cochrane Central Register of Controlled Trials databases were queried for articles evaluating repair and meniscectomy for MMPRT. Articles were eligible if they had a minimum mean 4-year follow-up for radiographic OA or conversion to total knee arthroplasty (TKA) and were at least level 3 evidence. Radiographic OA was assessed using Kellgren-Lawrence (KL) progression. Rates of conversion to TKA and International Knee Documentation Committee (IKDC) scores were also extracted. DerSimonian-Laird binary random-effects models were created to evaluate differences in radiographic OA and TKA conversion rates, with odds ratios (ORs) representing pooled estimates. Continuous random-effects models with standardized mean differences (SMDs) were used to compare postoperative IKDC scores. Results: Repair and meniscectomy cohorts were followed for a mean of 64.8 months and 62.5 months, respectively, for KL progression; and 82.8 months and 73.8 months, respectively, for TKA rates and IKDC scores. Overall, 59 of 144 (41%) patients undergoing surgical intervention for MMPRT demonstrated OA progression; 18 of 82 (22%) who underwent repair for MMPRT exhibited OA progression compared with 41 of 62 (66%) who underwent meniscectomy (OR, 0.17; 95% CI, 0.03-0.83; P = .029). Overall, 30 of 143 (21%) patients converted to TKA; 9.8% (8/82) of patients who underwent repair converted to TKA (range, 47-131 months), while 36% (22/61) who underwent meniscectomy converted to TKA (range, 17.8-101 months) (OR, 0.15; 95% CI, 0.05-0.44; P < .001). No significant differences between postoperative IKDC scores were observed (SMD, 0.51; 95% CI, -0.02 to 1.05; P = .06). Conclusion: Medial meniscus posterior root repair results in significantly lower rates of radiographic OA progression and conversion to TKA at >60-month follow-up. On the basis of these findings, we recommend consideration of repair of MMPRTs when degenerative changes are not severe, as it can yield improved outcomes.

Hip arthroscopy is a reproducible and efficacious procedure for the treatment of femoroacetabular impingement syndrome (FAIS). Despite this efficacy, clinical failures are observed, clinical entities are challenging to treat, and revision hip arthroscopy may be required. The most common cause of symptom recurrence after a hip arthroscopy that leads to a revision arthroscopy is residual cam morphology as a result of inadequate femoral osteochondroplasty and restoration of head–neck offset, though several other revision etiologies including progressive chondral and labral pathologies also exist. In these cases, it is imperative to perform a comprehensive examination to identify the cause of a failed primary arthroscopy as to assess whether or not a revision hip arthroscopy procedure is indicated. When a secondary procedure is indicated, approaches may consist of revision labral repair, complete labral reconstruction, or labral augmentation depending on labral integrity. Gross instability or imaging-based evidence of microinstability may necessitate capsular augmentation or plication. If residual cam or pincer morphology is present, additional resection of the osseous abnormalities may be warranted. This review article discusses indications, the evaluation of patients with residual symptoms after primary hip arthroscopy, and the evaluation of outcomes following revision hip arthroscopy through an evidence-based discussion. We also present a case example of a revision hip arthroscopy procedure to highlight necessary intraoperative techniques during a revision hip arthroscopy.

Background: Femoral torsion imaging measurements and classifications are heterogeneous throughout the literature, and the influence of femoral torsion on clinically meaningful outcome improvement after hip arthroscopy for femoroacetabular impingement syndrome (FAIS) has not been well studied. Purpose: To (1) perform a computed tomography (CT)–based analysis to quantify femoral torsion in patients with FAIS and (2) explore the relationship between the orientation and magnitude of femoral torsion and the propensity for clinically meaningful outcome improvement after hip arthroscopy. Study Design: Cohort study; Level of evidence, 3. Methods: Consecutive patients who underwent hip arthroscopy for FAIS between January 2012 and April 2018 were identified. Inclusion criteria were the presence of preoperative CT imaging with transcondylar slices of the knee and minimum 2-year outcome measures. Exclusion criteria were revision hip arthroscopy, Tönnis grade >1, congenital hip condition, hip dysplasia (lateral center-edge angle 25°). Treatment did not differ based on femoral torsion. Patient characteristics and clinical outcomes were analyzed, including the Hip Outcome Score–Activities of Daily Living (HOS-ADL), Hip Outcome Score–Sports Subscale (HOS-SS), modified Harris Hip Score (mHHS), international Hip Outcome Tool (iHOT-12), visual analog scale (VAS) for pain, and VAS for satisfaction. Achievement of the minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) by torsion stratification was analyzed using the chi-square test. Inter- and intrarater reliabilities for CT measurements were 0.980 ( P < .001) and 0.974 ( P < .001), respectively. Results: The study included 573 patients with a mean ± SD age and body mass index of 32.6 ± 11.8 years and 25.6 ± 10.6, respectively. The mean ± SD femoral torsion for the study population was 12.3°± 9.3°. After stratification, the number of patients within each group and the mean ± SD torsion for each group were as follows: SR (n = 36; –6.5°± 7.1°), MR (n = 80; 2.8°± 1.4°), N (n = 346; 12.3°± 4.1°), MA (n = 64; 22.2°± 1.4°), and SA (n = 47; 30.3°± 3.7°). No significant differences in age, body mass index, sex, tobacco use, workers’ compensation status, or participation in physical activity were observed at baseline. No significant differences were seen in pre- and postoperative VAS pain, mHHS, HOS-ADL, HOS-SS, iHOT-12, or postoperative VAS satisfaction among the cohorts. Furthermore, no statistically significant differences were found in the proportion of patients who achieved the MCID or the PASS for any outcome among the groups. Conclusion: The orientation and severity of femoral torsion at the time of hip arthroscopy for FAIS did not influence the propensity for clinically significant outcome improvement.

Purpose To compare kinematic and kinetic parameters between a cohort of fully recovered professional pitchers with prior shoulder injury treated conservatively compared to a cohort with no prior shoulder injury. Methods Twenty-six fully recovered professional baseball pitchers with a history of shoulder injury treated conservatively pitched 8-10 fastball pitches using 3D-motion capture (480 Hz). All shoulder injuries occurred within a 1-4 year timespan from biomechanical evaluation and were severe enough to prevent pitchers from playing between 1-12 months. These pitchers were 4:1 propensity-scored matched by age, height, weight, handedness, and ball velocity to pitchers with no prior injury history (control). Twenty-two kinematic and eleven kinetic parameters were compared between groups using appropriate parametric testing. Sub-analysis comparisons of pitchers with prior superior labrum anterior-posterior (SLAP) injury as well as rotator cuff tendinitis were also performed. Results SLAP tears (n=11, 42.3%) were the most frequently reported injury, followed by rotator cuff tendinitis/shoulder impingement (n=7, 26.9%). Compared to the control group, the twenty-six prior injured pitchers showed no significant differences across kinematic and kinetic factors. However, the SLAP tear subgroup did demonstrate significantly less trunk rotation at foot contact compared to control (34.1±4.9 vs. 39.2±10.2°, p=0.0075). Conclusion Fully recovered professional baseball pitchers with shoulder injuries treated conservatively showed no significant differences in kinetics or kinematics compared to their propensity-matched counterparts, suggesting shoulder injury alone may not greatly alter pitching mechanics. However, while prior groups have demonstrated a decrease in trunk rotation at foot contact after surgical repair for SLAP tear, our study suggests that this kinematic change may alternatively originate with the injury itself. Clinical Relevance Understanding the etiology of biomechanical adaptations by pitchers after injury can better aid clinicians and coaching staff in providing individualized and specific care to the throwing athlete.

Introduction The purpose was to compare robotic assisted (RA), computer navigated (CN), and conventional UKA techniques. Methods Databases were queried for data on study characteristics, UKA systems, complications, and tibiofemoral alignment. Results Four RA and six CN RCTs were identified. No significant differences were found in operative time, tibiofemoral alignment, and reoperation rates when comparing RA or CN to conventional UKA. RA UKA resulted in a significantly lower risk of complications compared to conventional UKA. Conclusions RA UKA results in fewer complications than conventional UKA with a clinically significant increase in operative time. All groups were similar in remaining evaluated parameters.

PURPOSE OF REVIEW: The importance of the hip capsule and its effect on hip biomechanics, functional outcomes, and hip arthroscopy success rates has been demonstrated in recent studies. These results have led to a shift in management of the hip capsule, where an increasing number of surgeons routinely perform complete capsular closure. The purpose of this review is to highlight recent studies evaluating the hip capsule and describe contemporary capsular management and repair. RECENT FINDINGS: Biomechanical studies using cadaveric models have demonstrated that complete capsular closure restores hip distraction, rotation, and extension forces back to the native, intact state. Additionally, capsular closure by plication results in quantifiable intraarticular volume reduction, which increases hip stability, particularly in cases of patulous capsule and hypermobility. Clinical studies have demonstrated superior patient-reported functional outcomes and decreased failure rates when undergoing hip arthroscopy with comprehensive capsular management for femoroacetabular impingement surgery. SUMMARY: Complete capsular management, including appropriate capsulotomy and subsequent closure, is critical for restoring biomechanical properties of the hip, ensuring high survivorship and improving functional outcomes. This review provides an update on the effects of contemporary capsular management as well as a detailed description of efficient T-capsulotomy and comprehensive capsule closure via plication.

Background: There is literature on the association between chronic preoperative pain and worse outcomes among patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS). However, there are few data on whether there is an optimum window that provides the best midterm surgical outcomes. Purpose: To assess the outcomes of hip arthroscopy for FAIS according to timing of surgical intervention. Study Design: Cohort study; Level of evidence, 3. Methods: Patients undergoing arthroscopic intervention for FAIS with a minimum 2-year follow-up were included. All patients completed the Hip Outcome Score–Activities of Daily Living (HOS-ADL), Hip Outcome Score–Sport Specific (HOS-SS), modified Harris Hip Score (mHHS), International Hip Outcome Tool–12 (iHOT-12), and visual analog scales for pain and satisfaction. Patients were stratified by preoperative symptom duration. We compared 3 to 6 months of symptoms with other subsequent time frames (>6-12, >12-24, and >24 months). Clinically significant outcome was determined with the minimal clinically important difference and patient acceptable symptomatic state. Results: A total of 1049 patients were included (mean ± SD: age, 32.3 ± 12.4 years; follow-up, 30.8 ± 6.7 months). Patients undergoing surgery at 3 to 6 months of symptoms had no significant differences in outcome when compared with those in the >6- to 12-month group except for the iHOT-12 ( P = .028). Patients with symptom duration of >12 to 24 months and >24 months had worse outcomes across all measures ( P < .001). Surgery within 3 to 6 months of symptoms was predictive for achieving the minimal clinically important difference on the HOS-ADL (odds ratio [OR], 1.81; 95% CI, 1.20-2.73) and HOS-SS (OR, 1.90; 95% CI, 1.11-3.17), as well as the patient acceptable symptomatic state on the HOS-ADL (OR, 1.85; 95% CI, 1.34-2.56) and HOS-SS (OR, 1.58; 95% CI, 1.14-2.18), when compared with the other groups. In multivariate regression analysis, symptom duration was predictive of visual analog scale for pain (β = 3.10; 95% CI, 1.56-4.63; P < .001) and satisfaction (β = −4.16; 95% CI, −6.14 to −2.18; P < .001). Conclusion: Among patients with FAIS, surgical intervention early after the onset of symptoms (3-6 months) was associated with superior postoperative outcomes when compared with patients who underwent surgical intervention beyond this time frame. This information may help guide preoperative decision making regarding delay of surgery. These findings should be confirmed in a prospective study.

Background As the number of total knee arthroplasty (TKA) procedures continues to rise in the context of bundled payment models, patients dissatisfied postoperatively that require additional care will impose additional cost to the healthcare system. The purpose of this study is to internally validate a predictive model for postoperative patient satisfaction after TKA. Methods In total, 484 consecutive primary TKA patients between January 2014 and January 2016 were included. Patients were stratified into 4 risk tiers based on scores of a retrospectively applied, 11-component novel knee survey for postoperative satisfaction: low risk (>96.5), mild risk (75-96.4), moderate risk (60-74.9), and high risk ( Results The mean (±standard deviation) age was 66.3 ± 9.2 years (range 31.7-100.1) and mean body mass index was 34.2 ± 8.2 kg/m2 (range 16.2-68.4). A knee survey score of 96.5 conferred a 97.5% sensitivity and 95.7% negative predictive value for satisfaction. Patients with higher knee survey scores had greater odds (odds ratio 1.03, 95% confidence interval 1.01-1.06, P = .003) of postoperative satisfaction. Increasing risk tier was significantly associated with decreased satisfaction (low risk 95.7%, mild risk 93.8%, moderate risk 86.4%, and high risk 80.4%; P = .007). The knee survey was not significantly correlated with complications (r = −0.43, P = .32). Conclusion This novel knee survey conferred a 97.5% sensitivity and 95.7% negative predictive value in identifying at-risk patients for postoperative dissatisfaction after primary TKA.

Purpose To describe the prevalence of abnormal sleep quality in patients with femoroacetabular impingement syndrome and to determine whether arthroscopic hip preservation surgery with cam/pincer correction, labral preservation, and capsular plication can improve sleep quality postoperatively. Methods All patients undergoing primary hip arthroscopy for cam/pincer correction who failed nonoperative management between March 1, 2017, and July 1, 2017, were administered a validated sleep quality questionnaire—the Pittsburgh Sleep Quality Index (PSQI)—preoperatively and at 3, 6, 12, and 24 weeks postoperatively. Exclusion criteria included patients undergoing revision arthroscopy, gluteus medius repair, or a contralateral procedure during the follow-up period and those with known sleep disorders. A global (total) PSQI score >5 indicates poor sleep quality. The Hip Outcome Score–Activities of Daily Living, Hip Outcome Score–Sports Specific Subscale, modified Harris Hip Score, and International Hip Outcome Tool-12 were used to assess functional outcomes. A repeated measures analysis of variance with post hoc Greenhouse-Geisser and Bonferroni corrections was conducted to determine statistically significant changes in sleep patterns. Results A total of 52 patients (94.6%) were included in the final analysis. The mean (± standard error) patient age was 37.8 ± 1.9 years, and body mass index was 27.6 ± 0.7. Preoperatively, 49 (94.2%) of patients experienced poor sleep quality, defined as a global PSQI score >5, with a mean PSQI score of 9.8 ± 0.6. At 24 weeks postoperatively, 10 (21.7%) of patients experienced poor sleep quality with a mean PSQI score of 2.2 ± 0.2. All patients had significant improvements in all hip outcome instruments at 24 weeks postoperatively (P Conclusions Preoperatively, patients with femoroacetabular impingement syndrome have a high prevalence of sleep disturbance. These patients experience subsequent improvement in sleep disturbance after arthroscopic hip surgery early in the postoperative period. Level of Evidence Level IV, case series.

In order to determine the associations between age, sex, cortical bone thickness (CBT), and outcomes following hip arthroscopy for FAIS, a retrospective study of patients undergoing hip arthroscopy for FAIS from a single institution from 2012 to 2014 was performed. Based on preoperative radiographs, femoral cortical index (FCI) and femoral canal-to-calcar ratio (FCC) were used as measures of CBT and used to classify patients using the Dorr classification. Linear and logistic regression was used to determine whether CBT was predictive of 2-year patient reported outoutcomes. Patients were stratified by sex and age (

Background: The citation rate of a research published article is an indicator of its quality and impact and contributes to the journal’s impact factor. Within the orthopaedic sports medicine literature, predictors of citation rates have not been previously described. Purpose: To identify characteristics of published articles that predict 5-year citation rates of studies in the orthopaedic sports medicine literature. Study Design: Cross-sectional study. Methods: Research articles published in The American Journal of Sports Medicine (AJSM), Arthroscopy: The Journal of Arthroscopic and Related Surgery, and Knee Surgery, Sports Traumatology, Arthroscopy (KSSTA) from 2012 were analyzed. Extracted characteristics of published articles included journal, author number, origin of study, first author degree, subject of study, study type, sample size, number of references and institutions, conflicts of interest, level of evidence, and 5-year citation rates. Multivariate logistic regression was used to determine predictors of greater than the mean number of citations at 5 years. Results: A total of 825 published articles ( AJSM, n = 313; Arthroscopy, n = 173; KSSTA, n = 339) were included in the final analysis. The mean number of 5-year citations was 23.2 (95% CI, 21.6-24.9; range, 1.0-260.0). AJSM had a significantly greater citation rate (32.4) than Arthroscopy (21.7) and KSSTA (15.2) ( P < .001 for both). Arthroscopy had a greater citation rate than KSSTA ( P = .008). Independent predictors of greater than the mean number of citations at 5 years were published articles in AJSM (odds ratio [OR], 5.17; 95% CI, 2.81-9.52; P < .0001), published articles of North American origin (OR, 1.79; 95% CI, 1.25-2.58; P = .002), and published articles regarding the hip (OR, 2.68; 95% CI, 1.08-6.67; P = .035). Conclusion: Published articles in AJSM, those from North America, and those examining the hip were independent predictors of greater citation rates at 5 years.

Introduction: The Altmetric Attention Score (AAS) has been associated with citation rates across medical and surgical disciplines. However, factors that drive high AAS remain poorly understood and there remains multiple pitfalls to correlating these metrics alone with the quality of a study. The purpose of the current study was to determine the relationship between methodologic and study biases and the AAS in randomized controlled trials (RCTs) published in total joint arthroplasty journals. Methods: All RCTs from 2016 published in The Journal of Arthroplasty, The Bone and Joint Journal, The Journal of Bone and Joint Surgery, Clinical Orthopedics and Related Research, The Journal of Knee Surgery, Hip International, and Acta Orthopaedica were extracted. Methodologic bias was graded with the JADAD scale, whereas study bias was graded with the Cochrane risk of bias tool for RCTs. Publication characteristics, social media attention (Facebook, Twitter, and Mendeley), AAS, citation rates, and bias were analyzed. Results: A total of 42 articles were identified. The mean (±SD) citations and AAS per RCT was 17.8 ± 16.5 (range, 0 to 78) and 8.0 ± 15.4 (range, 0 to 64), respectively. The mean JADAD score was 2.6 ± 0.94. No statistically significant differences were observed in the JADAD score or total number of study biases when compared across the seven journals (P = 0.57 and P = 0.27). Higher JADAD scores were significantly associated with higher AAS scores (β = 6.7, P = 0.006) but not citation rate (P = 0.16). The mean number of study biases was 2.0 ± 0.93 (range, 0 to 4). A greater total number of study biases was significantly with higher AAS scores (β = −8.0, P < 0.001) but not citation rate (P = 0.10). The AAS was a significant and positive predictor of citation rate (β = 0.43, P = 0.019). Conclusion: High methodologic quality and limited study bias markedly contribute to the AAS of RCTs in the total joint arthroplasty literature. The AAS may be used as a proxy measure of scientific quality for RCTs, although readers should still critically appraise these articles before making changes to clinical practice.

Objective To compare clinical outcomes for patients who underwent osteochondral allograft transplantation (OCA) based on the presence or absence of one or more self-reported drug allergies. Design Prospective data were collected from 245 consecutive patients after OCA of the knee from one large academic institution. Patient-reported allergies were obtained via chart review. Patient-reported outcome measures, including activities of daily living of the Knee Outcome Survey (KOS-ADL), Marx Activity Scale, International Knee Documentation Committee (IKDC), and visual analogue scale (VAS) pain were all collected. The minimal clinically important difference (MCID) for each outcome was quantified using a distribution-based method. Independent t tests were used to compare patient-reported outcome measures between those with and without self-reported allergies, while chi-square analysis of association was used to compare rates of MCID achievement. Results Of 245 patients included, 83 (33.9%) reported having at least one drug allergy at the time of OCA. There were no statistically significant differences with regard to patient demographics, including age, body mass index, gender, or sports participation between those with and without a reported allergy. Similarly, there were no significant differences found between baseline preoperative patient-reported outcomes. Overall, both cohorts demonstrated a significant improvement from baseline scores at 2 years postoperatively. There were no differences found between any patient-reported outcome at 2 years postoperatively. The presence of at least one self-reported drug allergy was not a significant risk factor for failing to achieve the MCID in any specific outcome measure. Conclusions The presence of one or more drug allergy was not associated with worse patient-reported outcomes or lower rates of clinically significant outcome improvement after OCA.

The decision to manage first-time shoulder dislocations conservatively or operatively has become increasingly complex because of conflicting literature. Although shoulder dislocations have traditionally been managed with reduction and immobilization, recent evidence has suggested high rates of subsequent recurrence. Surgical intervention is thought to better restore stability and decrease recurrence rates; however, it also has the potential for additional morbidity and financial cost. As such, recent literature has sought to better define patient risk profiles to identify optimal candidates for both conservative and operative management. The purpose of the current review is to provide a comprehensive and evidence-based assessment of the most recent literature to better delineate an appropriate treatment algorithm for this challenging clinical scenario.

Introduction Frequency of citation provides one quantitative metric of the impact that an article has on a given field. The purpose of this study was to evaluate characteristics of the 50 most cited publications on shoulder arthroplasty. Methods The Web of Science database was used to determine the 50 most frequently cited shoulder arthroplasty articles. Articles were evaluated for several factors including type of arthroplasty, citation frequency and rate, source journal, country of origin, study type, and level of evidence. Results The most common countries of origin were the United States (60%) followed by France (24%) and Switzerland (6%). A total of 27 (54%) articles included anatomic total shoulder arthroplasty (TSA), 18 (36%) included reverse total shoulder arthroplasty (RTSA), and 15 (30%) included hemiarthroplasty. Articles including RTSA had the greatest number of citations compared to those on TSA ( p = 0.037) and hemiarthroplasty ( p = 0.035). Citations per year were also greatest with RTSA compared to TSA and hemiarthroplasty ( p ≤ 0.001). Discussion This citation analysis includes many of the landmark studies that shaped, and continue to impact, the field of shoulder arthroplasty. This list provides a group of influential articles that provide a foundation for future research in shoulder arthroplasty.

To perform a systematic review and meta-analysis of the literature on anterolateral ligament (ALL) reconstruction as it relates to techniques, biomechanical properties, and clinical outcomes.PubMed, OVID/Medline, and Embase were queried in July 2020. Data pertaining to (1) techniques, (2) biomechanical properties, and (3) clinical outcomes of ALL reconstruction were recorded. DerSimonian-Laird random-effects meta-analyses were performed for included randomized controlled trials comparing combined ALL/anterior cruciate ligament (ACL) reconstruction and isolated ACL reconstruction. Data from lower levels of evidence were described qualitatively, and when possible, outcomes were reported as ranges to avoid inappropriate pooling of data.A total of 46 articles were identified. Sixteen were biomechanical studies, 16 were clinical outcome studies, and 14 were technique studies. Of the 16 biomechanical studies, the majority demonstrated that anterior translation, internal rotation, and pivot shift was restored with combined ACL/ALL reconstruction and superior to ACL reconstruction alone. Ten biomechanical studies reported on constraint: 4 noted overconstraint when the femoral attachment site was proximal and posterior to the lateral femoral condyle, whereas 1 reported laxity. ACL failure rates after combined ACL/ALL reconstruction ranged between 2.7% and 11.1%. The mean postoperative Lysholm score ranged between 58.7 and 98.0; mean postoperative International Knee Documentation Committee score between 57.8 and 96.3; and mean postoperative Tegner score between 4 and 8. Six outcomes were explored through meta-analysis, of which the mean difference in Lysholm scores (2.26, P.001) and restoration of pivot shift (relative risk 1.1, P = .046) was found to favor combined ACL/ALL reconstruction.Although indications for ALL reconstruction remain heterogeneous, contemporary evidence suggests that ALL reconstruction improves pivot shift and confers comparable clinical and functional outcomes with isolated ACLR.IV, systematic review and meta-analysis.

As the COVID-19 pandemic continues to affect countless lives globally, the current paradigm of medical and surgical treatment continues to rapidly evolve. This is especially true for the sports medicine surgeon, as treatment prior to the pandemic was considered predominantly elective. The purpose of the current perspective is to provide both subjective and objective data on the changes implicated by the COVID-19 pandemic with regards to the interactions and practices of the sports medicine surgeon. This perspective also considers the potential impact on the patients and athletes treated by sports medicine surgeons. It is our hope that this article provides a unique viewpoint on the impact of the COVID-19 pandemic on the field of sports medicine and provides thoughts on how the landscape of the field may continue to change.

Background: Information regarding the treatment of high-grade spondylolisthesis (HGS) in adults has been previously described; however, previous descriptions of the evaluation and surgical management of HGS do not represent more recent and now established approaches. The purpose of the current review is to discuss current concepts in the evaluation and management of patients with HGS. Methods: Literature review. Results: HGS is diagnosed in up to 11.3% of adults with spondylolisthesis and typically presents as nonspecific lower back pain. Regarding evaluation, a thorough history and physical examination should be performed, which may help predict the presence of HGS. Diagnostic imaging, and specifically the use of spino-pelvic parameters, are now commonly implicated in guiding treatment course and prognosis. When surgical intervention is indicated, surgical approaches include in situ fusion variations, reduction and partial reduction with fusion, and vertebrectomy. Although the majority of studies suggest improvements with these approaches, the literature is limited by a low level of evidence with regards to the superiority of one technique when compared with others. Conclusions: HGS is a unique cause of low back pain in adults that carries considerable morbidity, but rarely presents with neurologic symptoms. Although the definitions, classifications, and methods of diagnosis of this spinal deformity have been established and accepted, the ideal surgical management of this deformity remains highly debated. Fusion in situ techniques are often technically easier to perform and provide lower risk of neurologic complications, whereas reduction and fusion techniques offer greater restoration of global spino-pelvic balance. Preoperative spino-pelvic parameters may have utility in assisting in procedural selection; however, future, higher-quality and longer-term studies are warranted to determine the optimal surgical intervention among the widely available techniques currently used, and to better define the indications for these interventions.

Objectives: Minimal clinically important difference (MCID), substantial clinical benefit (SCB) and patient acceptable symptomatic state (PASS) have gained prominence as important variables in the orthopedic outcomes literature. In hip preservation surgery, much attention has been given to defining early clinically significant outcome, however, it is unknown what represents meaningful patient reported outcome improvement in the medium to long-term. The purpose of the present study was to define MCID, PASS and SCB at a minimum five years after hip arthroscopy for femoroacetabular impingement syndrome (FAIS). Secondarily, we sought to evaluate the time dependent nature of MCID, PASS and SCB. Methods: Patients undergoing hip arthroscopy for FAIS between January 2012 and March 2014 were included. Clinical and demographic data were collected in an institutional hip preservation registry. MCID, PASS, and SCB were calculated for each outcome score at 1-, 2-, and 5- years. MCID was calculated using a distribution-based method while PASS and SCB were calculated using an anchor method. Results: Two hundred and eighty-three patients were included with an average age of 34.2+11.9 years. The one year, two year and five-year MCID scores were as follows respectively: HOS-ADL (8.8, 9.7, 10.2); HOS-SS (13.9, 14.3, 15.2); mHHS (6.9, 9.2, 11.4) and iHOT-12 (15.1, 13.9, 15.1). PASS scores were as follows: HOS-ADL (89.7, 88.2, 99.2); HOS-SS (72.2, 76.4, 80.9); mHHS (84.8, 83.3, 83.6) and iHOT-12 (69.1, 72.2, 74.3). SCB scores were as follows: HOS-ADL (89.7, 91.9, 94.6); HOS-SS (78.1, 77.9, 85.8); mHHS (86.9, 85.8, 94.4) and iHOT-12 (72.6, 76.8, 87.5). More patients achieved MCID, SCB and PASS at two-year follow-up than at one-year follow-up. However, 79.3% of the patients achieved MCID by 5 years. Conclusion: The greatest proportion of patients achieve clinically significant outcome improvement at two-year follow-up after arthroscopic treatment of FAIS. Improvements are maintained out to five-year follow-up although there is a slight decrease in the proportion of patients achieving clinical significance. Table 1. Frequency of patients achieving any MCID, PASS, or SCB threshold at 1,2, and 5-years 1-year 2-year 5-year p-value Any MCID 233 (82.6%) 247 (87.3%) 224 (79.3%) 0.035 Any PASS 191 (67.6%) 211 (74.9%) 191 (67.5%) 0.114 Any SCB 176 (62.3%) 190 (67.2%) 160 (56.6%) 0.034

Purpose To perform a systematic review of reporting trends and quantification methods for the minimal clinically important difference (MCID) within the hip arthroscopy literature. Methods Cochrane, PubMed, and OVID/MEDLINE databases were queried for hip arthroscopy articles that reported the MCID. Studies were classified as (1) calculating new MCID values for their specific study-population or (2) referencing previously established MCID values. Data pertaining to patient demographics, study characteristics, outcome measures, method of MCID quantification, MCID value, anchor questions, measurement error, and study from which referenced MCID values were obtained were extracted. Results A total of 59 articles with 18,830 patients (19,867 hips) was included. A total of 19 unique outcome measures was reported. A total of 33 (n = 55.9%) studies (follow-up range 6-60 months) used previously established MCID values to assess their study population (MCID values established at a follow-up range 6-31 months). The remaining 26 studies (44.1%) performed new MCID calculations. The MCID values were inconsistent and varied widely (Hip Outcome Score–Activities of Daily Living: 5.0-15.4; Hip Outcome Score–Sports Subscale: 6-25; modified Harris hip score: 2.4-20.9). Among the 33 studies that used previously established MCID values, 10 different studies were cited as the reference. Among the remaining 26 studies that calculated a new MCID value, the most common method was 0.5 standard deviation method (n = 21, 80.8%). Only 3 of 26 (11.5%) studies reported a measurement of error in conjunction with their MCID values. Conclusions Inconsistencies in MCID reporting and quantification methods led to a wide range of MCID values for commonly administered outcome measures within the hip arthroscopy literature—even for the same outcome measures. The majority of studies referenced previously established MCID values with variable ranges of follow-up and applied those values to assess their specific study population at varying follow-ups. Level of Evidence IV, systematic review.

INTRODUCTION The purpose of this study was to perform a systematic review and meta-analysis of the effects of training simulators on surgical skill measures across randomized controlled trials. The authors hypothesized that simulated training would (1) result in objective improvements in skill acquisition and (2) be heterogeneous regarding the outcomes and types of validity assessed. METHODS The Cochrane Database of Systematic Reviews, the Central Register of Controlled Trials, PubMed, EMBASE, and MEDLINE databases were queried for Level I studies on training simulators between 2007 and 2019 in accordance with the 2009 Preferred Reporting Items for Systematic Review and Meta-Analysis statement. Exclusion criteria were studies without discrete assessment of skills acquisition after surgical simulator training and level of evidence II to V. The Jadad scale was used to assess the methodological quality of all included articles. Data pertaining to patient demographics, validity measures, simulator types, and study-specific outcome measures were extracted. Meta-analyses adjusted for random effects and heterogeneity analyses (I) were used to compare pooled time-to-completion and performance outcomes among included studies. RESULTS A total of 24 studies with 494 participants were identified. The most common simulator type involved knee arthroscopy (11 studies, 45.8%). Eight studies reporting time-to-task completion and performance scores were included in the meta-analysis. Virtual reality training was favored in time-to-task completion (mean difference = -82.25 seconds, P = 0.002) and improvement in objective performance scores (mean difference = 1.24, P = 0.02) relative to traditional training. Sensitivity analysis of time-to-task completion based on the length of training interval revealed a mean difference of -45.24 (P = 0.07) and -137.74 (P < 0.001) seconds for the short-term and immediate posttesting subgroups, respectively. CONCLUSION Overall, improved task efficiency and performance were observed with the use of orthopaedic simulators. However, simulator type, training protocols, and outcome measures were heterogeneous. Future studies are warranted to evaluate financial cost and longitudinal training programs and to standardize outcomes regarding the use of simulators in orthopaedic education. LEVEL OF EVIDENCE Level I.

Background Single Assessment Numerical Evaluation (SANE) is a simple, time-efficient patient reported outcome measure (PROM) used to assess postoperative shoulder function. Clinically significant outcome values and ability to correlate with longer legacy PROM scores at 2 years following shoulder arthroplasty are unknown. Methods A retrospective analysis was performed using SANE, American Shoulder and Elbow Surgeons (ASES), and Constant scores that were collected at minimum two-year follow-up. A total of 153 patients that underwent anatomic total shoulder arthroplasty (TSA) or reverse total shoulder arthroplasty (RTSA) were included. A distribution-based method was used to determine the minimal clinically important difference (MCID). An anchor-based method was used to determine substantial clinical benefit (SCB). The following anchor question was collected alongside the PROMs and graded on a 15-point Likert scale to establish the SCB: “Since your surgery, has there been any change in the pain in your shoulder?” Linear regression was used to assess correlations between PROMs. Results SANE showed moderate correlation with ASES (R2 = 0.493) and Constant (R2 = 0.586) scores (p Conclusions This study establishes concurrent construct validity for SANE and suggests that it is a valid metric to assess the MCID and SCB at two years following anatomic TSA and RTSA. SANE demonstrated moderate correlations with ASES and Constant scores. Patients undergoing RTSA demonstrated a lower propensity to achieve SCB at two-years postoperatively compared to anatomic TSA. Level of evidence Basic Science Study; Validation of Outcome Instruments

Nuclear medicine has been widely applied as a diagnostic tool for orthopedic foot and ankle pathology. Although its indications have diminished with improvements in and the availability of magnetic resonance imaging, nuclear medicine still has a significant and valuable role. The present article offers a comprehensive and current review of the most common nuclear imaging modalities for the orthopedic foot and ankle surgeon. Methods discussed include bone scintigraphy, gallium citrate scintigraphy, labeled-leukocyte scintigraphy, and single-photon emission computed tomography (SPECT). We review the indications and utility of these techniques as they pertain to specific foot and ankle conditions, including osteomyelitis, stress fractures, talar osteochondral lesions, complex regional pain syndrome, oncology, plantar fasciitis, and the painful total ankle arthroplasty. We conclude with a discussion of our approach to nuclear medicine with illustrative cases.Level of Evidence: Level V, expert opinion.

The treatment of multi-ligament injuries of the knee in basketball players is a complex issue that carries a significant risk of inability to return to play. Given the high rate of morbidity and technical challenges associated with these injuries, close attention must be paid to make an accurate diagnosis, a timely treatment, and a comprehensive rehabilitation. Concurrent vascular insult can occur in addition to concomitant ligament and meniscal injuries that may be easily missed in the acute setting. Single-staged ligament reconstruction followed by immediate rehabilitation to prevent arthrofibrosis and restore proper knee mechanics is the preferred management of an athlete with multi-ligament knee injury, independent of the injury type. Postoperative rehabilitation protocols based on the periodization concept should be implemented to protect the surgical reconstruction and restore range of motion and knee function. In this chapter, we will describe the current understanding of multi-ligament knee injuries, focusing on the classification, prevalence, surgical management, and postoperative rehabilitation protocols.