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Introduction Several surgical techniques have been proposed for the treatment of patellar fractures. The aim of this study is to compare the clinical efficacy and complication rates of treatment using suture tape circumferential cerclage (STCC) and metallic wire circumferential cerclage (MWCC) for the surgical treatment of displaced transverse patellar fractures (TPFs). Hypothesis The hypothesis is that the use of the suture tape would be associated with a significantly lower rate of re-peration than metallic cerclage but no differences in other clinical outcomes. Patients and methods A retrospective comparative analysis of the clinical outcomes of consecutive patients undergoing fixation of TPFs with either MWCC or STCC between January 2017 and December 2018 was undertaken. All patients underwent evaluation with standardised radiographs at one, three, and six months after surgery to determine rates of union, non-union, loss of fixation and malunion. All patients underwent a final clinical evaluation at 18 months post-operatively to evaluate clinical scores and complications. Results A total of 26 patients were included in the study. Thirteen patients underwent STCC and 13 underwent MWCC. There were no complications in the STCC group. In the MWCC group, one patient underwent hardware removal at two months post-operatively due to painful prominence. There was no significant difference in reoperation rates between the STCC and MWCC groups (p = 1). There were no cases of non-union, malunion or loss of reduction throughout the series. At the final clinical follow-up of 18 months, there were no significant differences in KSS, KOOS or Bostman scores between the groups. Conclusion No significant differences were identified when comparing the clinical outcomes of fixation of AO/OTA 34C1/2 fractures with suture tape or metallic cerclage fixation concerning re-operation rates, union rates, loss of fixation and functional outcome measures. These results cannot be extrapolated to more complex injury patterns or surgical techniques in which prominence of implanted material is more likely. Level of evidence III.

The presence of preoperative tunnel widening and/or malposition can pose technical challenges for revision anterior cruciate ligament reconstruction. This Technical Note describes the use of outside-in drilling to avoid the need for 2-stage reconstruction in the presence of tunnel widening or semi-anatomic tunnels., Technique Video Video 1 This video presents a reproducible one-stage technique for the revision of anterior cruciate ligament reconstruction. It highlights the use of outside-in drilling to avoid the need for 2-stage reconstruction in the presence of tunnel widening or semi-anatomic tunnels.

Superior capsular reconstruction (SCR) is increasingly considered a "game-changer" for young patients with irreparable rotator cuff tears. Popular graft choices include fascia lata autograft (FLA) and human dermal allograft (HDA), with the latter strongly preferred in North America and Europe. Despite that, there seems to be a general perception that FLAs are associated with better healing rates due to better biology. However, critical analysis of the literature demonstrates abundant limitations that preclude strong conclusions about whether one graft type is optimal. Furthermore, recent studies have demonstrated that HDAs used for SCR have good healing potential and are also associated with generally good short-term clinical outcomes. A clinical pearl is that humeral sided repair failures are not uncommon, and double-row repair techniques should be thoughtfully considered. The main downside of FLAs is the associated donor site morbidity. Given the lack of proven advantage of FLAs, the impetus to move away from the current trend to use HDAs is low.

Most patellar dislocations are associated with disruption of the proximal medial patellar restraints (PMPRs). The PMPRs comprise the medial patellofemoral ligament (MPFL) and medial quadriceps tendon-femoral ligament (MQTFL). Although isolated MPFL reconstruction is the most frequently performed procedure for the surgical management of recurrent dislocation, recent studies have shown that the MQTFL has a synergistic role with the MPFL in resisting lateral patellar displacement close to full extension. It has therefore been suggested that surgical techniques that gain the benefits of both proximal and distal PMPR biomechanical behavior may be best. This article describes an established technique for combined MPFL and MQTFL reconstruction using semitendinosus autograft.

We are united as an orthopaedic community in trying to improve the outcomes of anterior cruciate ligament (ACL) reconstruction. Graft rupture rates of 10% to 28% are reported in high-risk populations, reoperation for non-graft rupture-related indications are reported in 18% to 26%, and only 50% to 65% of recreational athletes return to their preinjury level of sports. Numerous groups across the world have published studies providing evidence demonstrating significant clinical efficacy of lateral extra-articular tenodesis in improving the outcomes of ACL surgery. Finally, the reductions in ACL graft rupture rates augmented with anterolateral ligament or a modified Lemaire reconstruction appear to be broadly comparable. In our hands, anterolateral ligament may result in fewer adverse events.

Needle arthroscopic procedures of the knee offer potential advantages over standard arthroscopic procedures. The small size of the instruments allows for surgery without the use of a scalpel or suture, potentially decreased recovery times, and potentially reduced complication rates compared with traditional arthroscopy. In some patients, the procedure can be performed without the use of either general anesthesia or sedation. The purpose of this article is to provide a standardized technique guide for needle arthroscopic partial medial meniscectomy under local anesthesia.

Meniscal ramp lesions occur much more frequently than was previously considered, and particularly so in ACL-injured knees. The historically high rate of missed diagnoses is a result of unfamiliarity with this injury pattern within the orthopedic community, and also the difficulty in diagnosis. A systematic exploration of the posteromedial compartment of the knee is mandatory to reliably identify ramp lesions. Failure to recognize and repair these injuries is associated with persistent anterior and posteromedial instability. Understanding their nature, biomechanics, and epidemiology is essential in allowing orthopedic surgeons to suspect their presence and adequately treat these lesions.

Background Irreparable rotator cuff tears in active patients provide a significant challenge and a consensus on the gold standard treatment is currently lacking. Superior capsule reconstruction (SCR) has recently been advocated and functions by providing a passive biological constraint to superior humeral head migration. The aim of this study is to systematically review the literature to evaluate the role of SCR in terms of functional outcome scores and failure rates. Patients and methods A review of the online databases Medline and EMBASE was conducted in accordance with the PRISMA guidelines on the 28th January 2019. Clinical studies reporting SCR using any type of graft or surgical technique were included if reporting either functional outcome scores or rate of secondary surgery. The studies were appraised using the Methodological index for non-randomised studies tool. Results The search strategy identified nine studies eligible for inclusion; five reported on fascia lata autografts and four studies reported on dermal allografts. All nine studies reported significant improvement in functional scores after SCR. Rates of secondary surgery were only provided in the dermal allograft studies at short-term follow-up (mean 10.9 to 32.4 months) and ranged from 0 to 18.6%. Radiological assessment revealed graft failure in 5.5 to 55% of dermal allografts and 4.2 to 36.1% of fascia lata autografts. Conclusion This review demonstrates that SCR is a useful treatment modality for patients with irreparable rotator cuff tears. SCR was associated with significantly improved functional outcome scores in all studies. All studies reported a preserved or increased mean AHD. The radiological graft failure rate ranged from 4.2 to 55% and the short duration of follow-up in most studies means that this remains an important concern that requires longer-term evaluation. Level of evidence IV, systematic review.

Objectives: Anterior cruciate ligament (ACL) injuries are often associated with meniscal and chondral lesions. Meniscal lesions are present in up to 50% of ACL injured knees, and chondral lesions occur with an incidence of 20% to 40% in acute ACL-injured knees. The major importance of this lies in the fact that menisectomy and severe chondral damage are important predictors of poor outcomes including the subsequent development of knee osteoarthritis. Furthermore, patient reported outcomes following revision ACL reconstruction remain inferior to primary ACL reconstruction and this may, at least in part, be due to an increased incidence and severity of meniscal and chondral injuries. Although multiple studies have demonstrated that meniscal and chondral lesions are generally present at a higher rate at the time of revision ACL reconstruction when compared to primary ACL reconstruction, large studies following individual patients through primary and revision ACL reconstruction and tracking the change in the occurence of these injuries are scarce. The primary objective of this study was to determine the proportion of patients with meniscal and chondral injuries at the time of primary ACL reconstruction and determine how this rate changed by the time they underwent revision ACL reconstruction. The hypothesis was that the proportion of patients with meniscal and/or chondral lesions would be significantly greater at revision ACL reconstruction when compared to the primary procedures. Methods: Consecutive patients who underwent primary and then revision ACL reconstruction between March 1999 and February 2018 were identified using a single center registry. Patient characteristics, and intraoperative data from each procedure were collected and analyzed. This specifically included the occurrence and type of meniscal and chondral pathology. Descriptive statistics were used to evaluate the study sample using medians, descriptive data analysis was conducted depending on the nature of the criteria. Comparison between variables were assessed with student’s t test for quantitative variables and Mcnemar test for categorical variables. Statistical significance was set a t pResults: 213 consecutive patients underwent both primary ACL reconstruction and then revision surgery during the study period. The average time from primary ACLR to Revision was 46.8 ± 36.6 months (range 5-181).The mean age of patients at primary ACLR was 22.21±7.21 years. The mean age of patients at revision ACLR 26.1 ± 8.3 years. The mean IKDC for the entire population was 85.53 ± 11.59, The mean ACL-RSI score was 71.89 ± 23.95. The mean Lysholm score was 91.77±10.24. The proportion of patients with chondral lesions significantly increased from 7% at primary ACL to 15.5% at revision ACL (p < 0.05). Meniscal lesions also significantly increased from 44.6 % at primary ACLR to 70% at revision ACLR (p < 0.05). There was no significant difference in the rate of lateral meniscal lesions (11.7 vs 13.1, p > 0.05). However, the proportion of patients with a medial meniscus lesion (25.4 vs 36.2, p < 0.05) and bimeniscal lesions (7.5 vs 20.7, p < 0.05) increased significantly at revision ACL reconstruction. Conclusions: The proportion of patients with meniscal and//or chondral injuries at the time of revision ACL reconstruction is significantly higher than at the time of primary ACL reconstruction. Specifically, the rate of medial meniscus and bimeniscal injuries is significantly higher in patients undergoing revision ACL reconstruction

Ramp lesions are increasingly recognized as a hallmark of posteromedial knee instability. Although the precise mechanisms through which these lesions occur is not completely understood, the distal semimembranosus complex has been implicated in their pathogenesis due to its attachment to the posterior horn of the medial meniscus (PHMM). Arthroscopic dissection of the distal semimembranosus tendon, and the application of traction to it, results in posterior translation of the PHMM and stretching of the meniscocapsular region. This demonstrates a mechanism through which ramp lesions can occur. Furthermore, the subsequent open dissection highlights the complex anatomical relationships of the distal semimembranosus tendon complex, particularly its tensioning effect on the posterior oblique ligament. The clinical relevance of this is that when a ramp lesion occurs, it is likely to be part of a spectrum of posteromedial injury and it should be considered a hallmark of posteromedial instability rather than an isolated meniscocapsular injury.

Background Management of displaced midshaft clavicle fractures is controversial. Nonoperative treatment can lead to shortening, a risk factor for nonunion and poor functional outcomes. These inferior results have resulted in authors recommending surgical fixation for fractures with significant shortening. The aim of this systematic review was to analyze the effect of fracture shortening on shoulder function and nonunion rates in nonoperatively managed displaced midshaft clavicle fractures. Methods A review of the online databases MEDLINE and Embase was conducted on February 16, 2018, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The review was registered prospectively in the PROSPERO database. Clinical studies with midshaft clavicle fractures treated nonoperatively reporting an evaluation of the degree of clavicle shortening and either shoulder function or nonunion were included. The studies were appraised using the Methodological Index for Non-Randomized Studies (MINORS) tool. Results The search strategy identified 16 studies eligible for inclusion, comprising 4 randomized controlled trials and 12 nonrandomized retrospective comparative studies. Of the 12 case series, 11 failed to demonstrate any correlation between shortening and shoulder outcome scores. Of the 4 randomized controlled trials, 3 reported no significant association between fracture shortening and shoulder outcome scores. The studies also failed to demonstrate a significant association between nonunion and the presence of clavicle shortening. Conclusion There is no significant association between fracture shortening and nonunion rates or shoulder outcome scores in displaced midshaft clavicle fractures managed nonoperatively.

A renewed interest in arthroscopic knee ligament repair is emerging as a result of diagnostic and technical improvements. In pediatric patients with posterior cruciate ligament (PCL) injury, surgical reconstruction is rarely considered as an option because of the risk of iatrogenic physeal injury. In this Technical Note, we describe an arthroscopic surgical repair technique of PCL proximal avulsions in pediatric patients. The main reasons to consider arthroscopic PCL repair in this population include minimal surgical morbidity, preservation of the complex biomechanical properties of the native ligament, the small diameter of the bone tunnels, the physeal respecting nature of the procedure, the absence of graft harvesting, and the absence of fixation devices. The indications for this technique are limited to patients with an acute proximal PCL avulsion. Investigation performed from at Centre Orthopedique Santy, FIFA Medical Center of Excellence, Lyon, France.

Introduction Variations in the length of lateral extra-articular reconstruction (LER) have been widely investigated during knee flexion but there is no information about length changes during pivot shift. This study sought to assess the changes in LER tension during weightbearing knee flexion in a normal knee and in a computer-simulated pivot-shift scenario. Hypothesis Placing the femoral tunnel posterior and proximal to the lateral femoral epicondyle allows the LER to tighten early in the flexion range during weightbearing (squatting motion) and simulated pivot-shift. Material and methods A computer model was used to simulate weightbearing knee flexion and pivot shift scenarios. Changes in LER tension were calculated in both scenarios by estimating the distance between six femoral attachment sites (posterior and proximal to the lateral femoral epicondyle) and two tibial tunnel locations: Gerdy's tubercle (GT) and the anterolateral ligament (ALL) anatomic attachment site. Results Independent of the location of the femoral and tibial tunnels, the LER tightened by up to 22% of its resting length during the early portion of weightbearing knee flexion and then relaxed from 40° to 60° of knee flexion. The ALL tibial tunnel position allowed complete LER relaxation at 60° flexion whereas LER using the GT tibial tunnel position remained tighter. In the simulated pivot-shift test, and for all femoral tunnel locations, the LER tightened by 20% to 34% of its resting value for the GT tibial tunnel position and by 11% to 26% for the ALL tibial tunnel position. Discussion During weightbearing knee flexion, placing the femoral tunnel proximal and posterior to the femoral epicondyle was associated with LER tightening in the early degrees of flexion and LER relaxation between 40 and 60° flexion. LER tightening occurred during a simulated pivot-shift test supporting the concept that a posterior and proximal femoral LER tunnel position is most effective during weightbearing knee flexion and altered knee kinematics.

Introduction ACL reconstruction is the gold standard of surgical treatment for ACL tears. Recently, there has been a renewed interest in ACL repair, and early results are promising. The purpose of this study was to compare outcomes following ACL repair versus ACL reconstruction at a minimum follow-up of two years. Materiel et methode A retrospective analysis of prospectively collected data was undertaken. Patients who underwent ACL repair were matched 1 :1 to those who underwent ACL reconstruction using a propensity score. All patients underwent a return to sports evaluation (isokinetic test, K-START and ACL-RSI) at 6 months post-operatively. At final face-to-face follow-up, physical examination findings (including side to side laxity difference & pivot shift) were recorded. At final overall follow-up return to sport, complications, re-operations and outcome measures, including Lysholm, Tegner, International Knee Documentation Committee (IKDC), ACL-RSI, Forgotten Joint Score-12 (FJS) were recorded. Resultats Eighty-two patients with ACL repair were matched with 82 patients who underwent isolated ACL reconstruction. 7 matched pairs were lost to follow-up, leaving 75 patients in each group. At 6 months postoperatively, the ACL repair group had a lower mean hamstring muscle deficit (1.7 % ± 12.8) (p Conclusions The outcomes of ACL repair were non-inferior to ACL reconstruction with respect to IKDC subjective scores and anteroposterior laxity. ACL repair was associated with better forgotten joint score and superior hamstring strength, without increase in graft rupture rates. ACL repair can be considered a useful option in carefully selected patients.

Background: Remnant preservation during anterior cruciate ligament (ACL) reconstruction (ACLR) is controversial, and it is unclear whether the stump aids or obscures tibial tunnel positioning. Purpose/Hypothesis: The aim of this study was to determine whether the rate of tibial tunnel malposition is influenced by remnant preservation. The hypothesis was that using a remnant-preserving technique to drill entirely within the tibial stump would result in a significant reduction in tibial tunnel malposition as determined by postoperative 3-dimensional computed tomography (3D-CT). Study Design: Cohort study; Level of evidence, 2. Methods: Patients undergoing ACLR between October 2018 and December 2019 underwent surgery with a remnant-preserving technique (RP group) if they had a large stump present (>50% of the native ACL length) or if there was no remnant or if it was Results: Overall, 52 patients were included in the study (26 in each group). The mean tunnel positions were 36.8% ± 5.5% AP and 46.7% ± 2.9% ML in the RP group and 35.6% ± 4.8% AP and 47.3% ± 2.3% ML in the RA group. There were no significant differences in the mean AP ( P = .134) and ML ( P = .098) tunnel positions between the groups. Inter- and intraobserver reliability varied between fair to excellent and good to excellent, respectively. There was no significant difference in the rate of malposition between groups (RP group, 7.7%; RA group, 11.5%; P ≥ .999). Conclusion: Drilling entirely within the ACL tibial stump using a remnant-preserving reconstruction technique did not significantly change the rate of tunnel malposition when compared with stump ablation and utilization of standard landmarks.

Introduction Recurrent shoulder instability is frequently associated with glenohumeral bone loss. Recently there has been a surge of interest in arthroscopically performed bone block procedures. The aim of this systematic review was to determine the clinical and radiological outcomes of arthroscopic glenoid bone block stabilisation for recurrent anterior dislocation. Methods This systematic review was performed in accordance with PRISMA guidelines. The search strategy was applied to MEDLINE and Embase databases on 20th July 2020. Studies reporting either clinical or radiological outcomes following arthroscopic bone block stabilisation for recurrent anterior dislocation were included. Primary outcomes were function and instability scores. Secondary outcomes included recurrent instability, graft union and resorption rates, return to activity/sports, and complications. Pooled analysis was performed when an outcome was uniformly reported by more than one study. Critical appraisal of studies was conducted using the Methodological Index for Non-Randomized Studies (MINORS) tool. Results Application of the search strategy resulted in the inclusion of 15 eligible studies; 12 used iliac crest bone graft while 3 used distal tibial allograft. The overall population comprised 265 patients (mean age range, 25.5–37.5 years; 79% of participants were men). All post-operative outcome scores were significantly improved, and the overall rate of recurrent instability was low (weighted mean 6.6%, range 0–18.2%) at mean follow up of 30.4 months. The Rowe score was the most frequently reported outcome measure, improving on average by 53.9 points at final follow-up, exceeding the minimal clinically important difference (MCID) threshold. Graft union rates ranged between 92–100% in 8 out of 10 studies at mean follow up range 6–78.7 months but two reported lower rates ranging from 58.3–84% for autografts and 37.5% for allografts. Graft resorption rates averaged between 10–16% for autografts and 32% for allografts. Hardware-related complications occurred in 2% with the most frequent being screw breakage or symptomatic mechanical irritation. Conclusion Arthroscopic bone block stabilisation is associated with high rates of graft union, significant improvements in the WOSI, Rowe, Constant and SSV scores (exceeding MCID thresholds where known), and a low rate of complications, including re-dislocation in the short to mid-term. Graft union rates were high, but the long-term implications of graft resorption (which occurs more frequently with allograft) are unknown. Longer follow-up of these patients and future experimental studies are required to further examine the effects of graft type and fixation methods. Level of Evidence IV; systematic review.

Background:The occurrence of rapid chondrolysis after partial lateral meniscectomy is rare. The pathophysiology, risk factors, and outcomes of treatment have not been established.Purpose:The primary aim of this study was to perform a scoping review of the literature to determine the potential risk factors and pathogenesis of rapid chondrolysis. The secondary objective was to report outcomes of treatment.Study Design:Systematic (scoping) review.Methods:A scoping review of the literature was conducted in accordance with the framework of Arksey and O’Malley. A search strategy based on the terms “chondrolysis” AND “knee,” “chondrolysis” AND “meniscus,” and “chondral damage” AND “lateral meniscus” was applied to the PubMed database on March 31, 2020. All relevant studies were included. Patient demographics and clinical data were extracted from these studies and analyzed in order to investigate the potential risk factors, pathogenesis, and outcomes of treatment for rapid chondrolysis.Results:Five articles (22 cases) featuring rapid chondrolysis in the lateral compartment after partial lateral meniscectomy were identified and included. The condition occurred most frequently in patients who were young (mean age, 25.6 years), male (20/22 cases; 91%), and participating in high-intensity sports (19/22 cases; 86.4%) within 1 year of the index procedure. Half of the included study population underwent surgery for a radial tear. All professional athletes (13/13) returned to the preinjury level of sport. All authors of included studies suggested that the main causal risk factor was mechanical focal cartilage overload in the lateral compartment of the knee.Conclusion:Rapid chondrolysis after partial lateral meniscectomy is a rare condition that typically occurs within 12 months of the index procedure. Younger age, male sex, high-intensity sports participation, and some meniscal tear patterns (eg, radial tear) are potentially important risk factors. Return-to-sport rates at short-term follow up are high, but no long-term studies were identified. The pathogenesis of rapid chondrolysis seems to relate to mechanical focal cartilage overload.

The use of tantalum is well established in orthopaedic surgery. It has a modulus of elasticity that is close to bone and a high yield and ultimate strength allowing it to be used to form large, weight-bearing constructs with a high volumetric porosity conducive to osseointegration. However, its role in soft tissue re-attachment remains undefined due to variable clinical outcomes. Successful re-attachment of tendons to tantalum mega-prostheses, in tumour and revision surgery, has been reported but several authors report almost universal failure of long term soft tissue re-attachment with tantalum patella augments when no residual bone stock is present. It is postulated that these failures are due to a lack of stability of the implants and an inhibitory effect of tantalum on soft tissue integration. Tantalum has previously been considered an excellent biomaterial for soft tissue integration based on animal studies where implants were retrieved and subjected to mechanical testing. However, clinical studies suggest that this soft tissue in-growth does not reliably tolerate the high mechanical loads that are generated in the clinical setting. Furthermore, recent laboratory evidence suggests that tantalum may in fact directly inhibit fibroblasts, limiting the potential for mature collagen fibrillogenesis. This review collates the evidence from laboratory, animal and clinical studies to inform and guide future directions in biomaterial research and to drive improved outcomes for soft tissue re-attachment surgery.

Background: Cyclops syndrome is characterized by a symptomatic extension deficit attributed to impingement of a cyclops lesion within the intercondylar notch. The syndrome is an important cause of reoperation after anterior cruciate ligament reconstruction (ACLR). It has been suggested that remnant-preserving ACLR techniques may predispose to cyclops syndrome, but there is very limited evidence to support this. In general terms, risk factors for cyclops syndrome are not well-understood. Purpose: To determine the frequency of and risk factors for reoperation for cyclops syndrome in a large series of patients after ACLR. Study Design: Case-control study; Level of evidence, 3. Methods: A retrospective analysis of prospectively collected data was performed, including all patients who underwent primary ACLR between January 2011 to December 2017. Patients undergoing major concomitant procedures were excluded. Demographic data, intraoperative findings (including the size of preserved remnants), and postoperative outcomes were recorded. Those patients who underwent reoperation for cyclops syndrome were identified, and potential risk factors were evaluated in multivariate analysis. Results: A total of 3633 patients were included in the study, among whom 65 (1.8%) underwent reoperation for cyclops syndrome. Multivariate analysis demonstrated that preservation of large remnants did not predispose to cyclops lesions (odds ratio [OR], 1.11; 95% CI, 0.63-1.93). The most important risk factor was extension deficit in the early postoperative period. If present at 3 weeks postoperatively, it was associated with a >2-fold increased risk of cyclops syndrome (OR, 2.302; 95% CI, 1.268-4.239; P < .01), which was increased to 8-fold if present 6 weeks after ACLR (OR, 7.959; 95% CI, 4.442-14.405; P < .0001). None of the other potential risk factors evaluated were found to be significantly associated with an increased frequency of cyclops syndrome. Conclusion: Failure to regain full extension in the early postoperative period was the only significant risk factor for cyclops syndrome after ACLR in a large cohort of patients. Other previously hypothesized risk factors, such as preservation of a large anterior cruciate ligament remnant, did not predispose to the development of this debilitating postoperative complication.

Transverse patellar fractures are a relatively common injury and typically require surgical fixation. An adequate restoration of patella integrity is essential for proper functioning of the extensor mechanism of the knee and for the prevention of patellofemoral osteoarthritis. Currently, the treatment of transverse fractures of the patellar bone involves several surgical techniques, most of which involve the use of metallic implants. Despite good clinical results following surgery, numerous complications exist, including primarily symptomatic hardware following surgical treatment. The purpose of this article is to describe the technique for treatment of a transverse patellar fracture using a high-resistance tape (FiberTape; Arthrex) and a tensioner (Arthrex) instead of traditional metallic implants.

Background: Distal humeral fractures represent about 1% to 2% of adult fractures. Open reduction and internal fixation (ORIF) has traditionally been the standard treatment; however, fracture comminution and osteoporotic bone may prevent adequate fixation, and total elbow arthroplasty (TEA) is an alternative. The aim of this meta-analysis was to determine which procedure provided superior clinical outcomes for elderly patients with distal humeral fractures. Methods: A systematic review of the literature was conducted in accordance with the PRISMA guidelines. Cases series and comparative studies reporting functional outcomes or complications after TEA and ORIF in patients over 60 yr of age with an acute distal humeral fracture were included. The studies were appraised using validated quality assessment scales. Results were pooled from different studies using meta-analysis techniques, and the functional outcomes, complications, and frequency of revision surgery were compared. Results: The search strategy identified 27 studies: one randomized controlled trial, four comparative studies, 14 ORIF cases series, and eight TEA case series. TEA was associated with statistically significant and clinically superior Mayo Elbow Performance score (MEPS) and Disability of the Arm, Shoulder and Hand (DASH) scores when compared to ORIF in elderly patients while having a statistically significant lower complication rate. Conclusions: Meta-analysis of comparative studies demonstrated that TEA is associated with statistically significant and clinically superior MEPS and DASH scores when compared to ORIF in elderly patients.

Knee extension deficit is frequently observed after anterior cruciate ligament reconstruction or rupture and other acute knee injuries. Loss of terminal extension often occurs because of hamstring contracture and quadriceps inactivation rather than mechanical intra-articular pathology. Failure to regain full extension in the first few weeks after anterior cruciate ligament reconstruction is a recognized risk factor for adverse long-term outcomes, and therefore, it is important to try to address it. In this Technical Note, a simple, rapid, and effective technique to help regain full knee extension and abolish quadriceps activation failure is described.

Introduction Recurrent shoulder instability is frequently associated with glenohumeral bone loss. Recently there has been a surge of interest in arthroscopically performed bone block procedures. The aim of this systematic review was to determine the clinical and radiological outcomes of arthroscopic glenoid bone block stabilisation for recurrent anterior dislocation. Methods This systematic review was performed in accordance with PRISMA guidelines. The search strategy was applied to MEDLINE and Embase databases on 20th July 2020. Studies reporting either clinical or radiological outcomes following arthroscopic bone block stabilisation for recurrent anterior dislocation were included. Primary outcomes were function and instability scores. Secondary outcomes included recurrent instability, graft union and resorption rates, return to activity/sports, and complications. Pooled analysis was performed when an outcome was uniformly reported by more than one study. Critical appraisal of studies was conducted using the Methodological Index for Non-Randomized Studies (MINORS) tool. Results Application of the search strategy resulted in the inclusion of 15 eligible studies; 12 used iliac crest bone graft while 3 used distal tibial allograft. The overall population comprised 265 patients (mean age range, 25.5–37.5 years; 79% of participants were men). All post-operative outcome scores were significantly improved, and the overall rate of recurrent instability was low (weighted mean 6.6%, range 0–18.2%) at mean follow up of 30.4 months. The Rowe score was the most frequently reported outcome measure, improving on average by 53.9 points at final follow-up, exceeding the minimal clinically important difference (MCID) threshold. Graft union rates ranged between 92–100% in 8 out of 10 studies at mean follow up range 6–78.7 months but two reported lower rates ranging from 58.3–84% for autografts and 37.5% for allografts. Graft resorption rates averaged between 10–16% for autografts and 32% for allografts. Hardware-related complications occurred in 2% with the most frequent being screw breakage or symptomatic mechanical irritation. Conclusion Arthroscopic bone block stabilisation is associated with high rates of graft union, significant improvements in the WOSI, Rowe, Constant and SSV scores (exceeding MCID thresholds where known), and a low rate of complications, including re-dislocation in the short to mid-term. Graft union rates were high, but the long-term implications of graft resorption (which occurs more frequently with allograft) are unknown. Longer follow-up of these patients and future experimental studies are required to further examine the effects of graft type and fixation methods. Level of evidence IV; systematic review.

Objectives: The aim of this study was to report long term comparative clinical outcomes of isolated Anterior Cruciate Ligament (ACL) reconstruction versus combined ACL and Anterolateral Ligament (ALL) reconstruction in a matched pair analysis. Methods: A retrospective analysis of prospectively collected data was undertaken. Patients who underwent combined ACL and ALL reconstruction were matched 1:1 to patients who had undergone isolated ACL reconstruction using a propensity score. Matching was based upon age, BMI, side to side laxity difference, duration of time between injury and surgery, type of sports participation (e.g pivoting, contact), presence of concomitant meniscal injuries and their treatment. At the end of the study period all patients completed Lysholm, Tegner, IKDC and KOOS scores, and underwent telephone interview and medical notes review to determine whether they had experienced any complications or re-operations after the index procedure. Kaplan-Meier analysis was used to determine survivorship with respect to graft rupture rates in each group Results: 90 patients who underwent combined ACL and ALL reconstruction were matched to 90 patients who underwent isolated ACL reconstruction. The mean duration of follow up was 108.09±9.43 months (range 97-182). The combined ACLR and ALLR group had significant lower graft rupture rate (3.5%) than the isolated ACLR group (16%) (OR=5.306 ; CI =1.46-19.19 ; p=0.007) (Fig 1). There was no significant difference between groups with respect to non-graft rupture related reoperation rates (secondary meniscectomy, cyclops excision, arthroscopic lavage for infection or hemarthrosis). Contralateral ACL rupture rates were comparable between combined ACL and ALL reconstruction (16.27%) and isolated ACL reconstruction (19.5%) groups. The KOOS score was significantly higher in the combined group with respect to subdomains of pain (p=0.007) and quality of life (p=0.007). There was no significant difference in other KOOS domains, Tegner, Lysholm, or IKDC Conclusions: This study reports the first long-term results of combined ACL and ALL reconstruction. The results demonstrate a significantly lower graft failure rate when compared to isolated ACL reconstruction in a matched pair series with a minimum follow-up of 9 years.

Background:Early clinical results of anterolateral ligament (ALL) reconstruction are promising, but concerns exist due to high rates of complications after other types of lateral extra-articular tenodesis. The rate of surgery after combined anterior cruciate ligament (ACL) and ALL reconstruction is not known.Purpose:To determine the rate of reoperation after combined ACL and ALL reconstruction.Study Design:Case series; Level of evidence, 4.Methods:A retrospective analysis of prospectively collected data from the Scientific ACL Network International (SANTI) Study Group database was performed to include all patients who had undergone combined ACL and ALL reconstruction between January 2012 and June 2014. At the end of the study period, all patients were contacted by telephone, and the operative notes of those who stated that they had undergone reoperation were reviewed to determine the type and rates of the subsequent procedures performed. Descriptive data were analyzed for the entire patient cohort.Results:The study population comprised 548 quadruple hamstring graft (4HT)+ALL reconstructions. The mean age (±SD) was 24.3 ± 7.9 years (range, 11.9-55.7 years), and 70.3% of subjects were male. The mean duration of follow-up was 35.5 ± 8.0 months (range, 24-54 months). Seventy-two patients (13.1%) underwent ipsilateral reoperation. This comprised a total of 77 procedures. Graft revision occurred in 14 knees (2.6%) at a mean of 18.3 months (±7.4 months) after the index procedure. There were 63 reoperations for ipsilateral, non–graft rupture–related indications (meniscus, n = 30; arthrofibrosis, n = 22; removal of hardware, n = 4; deep infection, n = 3; arthroscopic lavage without infection, n = 4). The only specific complications related to the ALL procedure (n = 3) were all related to femoral hardware that required removal. In both univariate and multivariate analyses, only the presence of a medial meniscal lesion at the index procedure was significantly associated with ipsilateral reoperation (odds ratio, 2.58; 95% CI, 1.43-4.76; P = .002).Conclusion:The reoperation rate after combined ACL and ALL reconstruction in this series is broadly comparable to the reoperation rate after isolated ACL reconstruction as reported in previous studies. In addition, the high rates of knee stiffness and reoperation reported in historical series of nonanatomic, lateral extra-articular tenodesis were not observed in the current series.

Resume Introduction L’objectif de cette etude etait de comparer l’efficacite de l’analgesie postoperatoire apres reconstruction du ligament croise anterieur (LCA), entre une injection intra-articulaire d’un anesthesique local et l’infiltration du site de prelevement des ischio-jambiers. L’hypothese etait que le controle de la douleur postoperatoire n’est pas different. Materiel et methodes Cent cinquante-huit patients operes consecutivement d’une reconstruction du LCA aux ischio-jambiers (semi-tendineux-gracile [STG] ou semi-tendineux 4 brins [ST4]) ont ete inclus dans l’etude. Aucun bloc nerveux peripherique n’a ete realise. Le premier groupe de 79 patients recevait une injection intra-articulaire de 20 mL de 7,5 mg/mL de ropivacaine tandis que le second groupe recevait une infiltration du site de prelevement des ischio-jambiers avec 20 mL de 7,5 mg/mL de ropivacaine. La douleur postoperatoire a ete evaluee subjectivement par les patients a l’aide de l’echelle visuelle analogique (EVA). Les caracteristiques demographiques des patients, les gestes chirurgicaux associes, le score EVA, les analgesiques supplementaires utilises ; la duree du sejour, et la satisfaction des patients ont ete enregistres. Les patients ont ete interroges une nouvelle fois par telephone a j1 afin d’enregistrer le score EVA, les effets secondaires et la satisfaction du patient. Resultats Il n’y avait pas de difference significative dans le score de douleur EVA entre les deux groupes, immediatement apres la chirurgie ou a 24 heures postoperatoire (moyenne EVA postoperatoire : injection intra-articulaire 2,08, infiltration site de prelevement des ischio-jambiers 1,88, p = 0,6 NS). Il n’y avait pas de difference entre les groupes en ce qui concerne l’utilisation d’analgesiques supplementaires, la satisfaction des patients et la contraction postoperatoire du quadriceps. Conclusion L’infiltration du site de prelevement des ischio-jambiers dans la reconstruction du LCA (STG ou DT4) n’est pas significativement differente de l’injection intra-articulaire d’un anesthesique local pour le controle de la douleur postoperatoire.

The recent literature shows that imaging modalities, physical examination tests, and glenohumeral arthroscopy all have low sensitivities and specificities with respect to the diagnosis of the long head of biceps tendon pathology. Biceps tenoscopy is a strategy that aims to reduce the rate of missed diagnoses by improving visualization of the extra-articular part of the tendon. This is an area of predilection of pathology that is not adequately visualized with conventional arthroscopic techniques. This technical note presents the surgical technique for biceps tenoscopy.

Background The widespread historical abandonment of lateral extra-articular procedures in ACL-injured knees occurred due to concerns about high rates of adverse events. Recently there has been a resurgence in popularity of lateral extra-articular procedures and this warrants an urgent evaluation of their safety profile. Hypothesis/Purpose The aim of this study was to perform an interim analysis of the ongoing (blinded for journal review) randomized controlled trial in order to determine whether combined ACL and anterolateral ligament reconstruction (ACL + ALLR) is associated with an increased rate of adverse outcomes when compared to isolated ACL reconstruction (ACLR). The hypothesis was that there would be no significant difference between groups at a minimum follow-up of one year. Study Design Randomized Controlled Trial Methods Recruitment was commenced in November 2016. Patients scheduled for ACL reconstruction were randomized to either isolated ACL reconstruction (bone-patella tendon-bone autograft) or combined ACL + ALLR (hamstring tendon autograft). All patients with a minimum follow-up of one year, in March 2019 were included. Complications and re-operations, knee laxity parameters, range of motion, Tegner, Lysholm, IKDC and KOOS scores were evaluated. Results Deux cent vingt quatre patients (112 in each group) with a mean follow-up 12.3 ± 1.9 (range 12 to 19) months formed the study population. There was a significantly higher rate of re-operation for cyclops syndrome in the isolated ACL group (B-PT-B 8.9 %, ACL + ALLR 0 %, p = 0.0012). There was no significant difference in the frequency of graft rupture (B-PT-B 5.4 %, ACL + ALLR 0.9 %, p = 0.1191), range of motion deficits, pain, or re-operation for meniscectomy between groups. There were no cases of post-operative infection, venous thromboembolism, or arthrofibrosis. Subjective IKDC (81.2 vs. 86.8, p = 0.0048), Lysholm (88 vs. 92, p = 0.0131) and some components of KOOS were significantly better in the ACL + ALL group. Conclusion This study demonstrates no evidence of an increased risk of adverse events after combined ACL + ALL reconstruction when compared to isolated ACL reconstruction with a B-PT-B graft. The trend towards a reduced graft rupture rate and significantly better subjective IKDC, Lysholm and KOOS scores with the combined procedure is consistent with the previous literature and expected to be more pronounced at the end of the overall study period.

Background Pre-operative high-grade pivot shift is associated with higher rates of ACL graft failure; persistent instability and inferior patient reported outcomes. The pathophysiology of high-grade pivot shift is multifactorial and numerous factors have been implicated. Purpose The aim of this study was to determine risk factors for high-grade pivot shift, with a particular emphasis on addressing the limitations of previous studies, by including a comprehensive evaluation of both soft-tissue and osseous parameters. Study design Case series. Methods A prospective evaluation of 200 consecutive patients undergoing acute ACL reconstruction (within 10 days of injury) was undertaken. An open lateral exploration was undertaken at the time of the index procedure. Details regarding patient and injury characteristics were recorded. Osseous parameters (tibial slope and condylar ratios) were determined using established MRI protocols. A multivariate logistic regression with Penalized Maximum Likelihood was used to identify risk factors associated with grade 3 pivot shift. A stepwise descending strategy was applied from the initial full model to determine the most parsimonious one, removing step-by-step all the non-statistically significant parameters and keeping only the clinically relevant parameters and confounding factors (if any). Results The mean age of the population was 28.3 ± 9.8 years. 67.5% of patients were male. Thirty-five (17.5%) of patients had a high grade (grade 3) pivot shift and 165 (82.5%) had a low-grade pivot shift (grades 1 and 2). Both uni- and multivariate analyses demonstrated that injury to the Anterolateral structures of the knee was the only significant risk factor for high-grade pivot shift. When this was subcategorized further, it was identified that both complete and incomplete tears of the ALL, and Segond fractures were all significant risk factors for high-grade pivot shift. Conclusions A comprehensive evaluation of soft-tissue and osseous factors has identified that injury to the Anterolateral Structures of the knee is the most important risk factor for explosive pivot shift in acute ACL-injured knees.

In-office needle arthroscopy offers the potential advantage of reduced injury to intervention time, without the need for advanced imaging. It is particularly appropriate for those with contraindications to advanced imaging and also may reduce the risk of incorrect diagnoses in those situations in which imaging is associated with low sensitivity/specificity. The purpose of this article is to provide a standardized diagnostic approach to needle arthroscopy of the shoulder.

Despite technical advances in anterior cruciate ligament (ACL) reconstruction surgery, there remains a need to improve postoperative outcomes with respect to graft failure rates. Recently, it has been shown that combined ACL-anterolateral ligament (ALL) reconstruction (using a graft composed of a tripled semitendinosus and single-strand gracilis tendon) is associated with a significant reduction in graft rupture rates compared with isolated ACL reconstruction. It is recognized that the hamstring tendons are not always available (revision scenario) or are not always the primary ACL graft choice. Some surgeons prefer to use quadriceps tendon ACL grafts because of the suggestion that these grafts may be associated with equal or better functional scores. However, if surgeons wish to try to reduce the risk of graft failure by performing an ALL reconstruction, either a combined reconstruction or the use of an independent ALL graft, with a separate femoral socket, could be considered. The disadvantage of an independently performed extra-articular procedure is the risk of femoral socket collision with the femoral ACL tunnel. This Technical Note therefore describes the use of a combined ACL-ALL reconstruction using quadriceps tendon autograft (ACL graft), gracilis allograft (ALL graft), and a single femoral tunnel.

Resume Introduction Le comportement d’une reconstruction laterale extra-articulaire (LER) a ete largement etudie lors de la flexion du genou, alors qu’aucune information n’est donnee lors d’un pivot-shift. Ainsi, l’objectif de cette etude etait d’evaluer les variations de tension d’une LER lors d’une tâche de flexion de genou en charge et lors de scenarios de pivot-shift simules. Hypothese Un tunnel femoral posterieur et proximal a l’epicondyle femoral lateral permettait a la LER de se tendre dans les premiers degres de flexion du genou, lors de la flexion en charge et lors de pivot-shift simules. Materiel et methode Un modele informatique a ete implemente pour simuler des flexions en charge et des scenarios de pivot-shift. La mise en tension de la LER a ete calculee dans les deux conditions en estimant la distance entre six localisations de tunnels femoraux (tous posterieurs et proximal a l’epicondyle femoral) et deux postions de tunnels tibiaux : le tubercule de Gerdy (GT) et l’insertion anatomique du ligament anterolateral natif (ALL). Resultats Independamment de la position des tunnels femoraux ou tibiaux, la LER se tendait jusqu’a 22 % de la valeur de repos lors des premiers degres de flexion de genou en charge, puis se relâchait de 40 a 60° de flexion de genou. Cependant, un tunnel tibial localise a l’insertion du ligament anterolateral (ALL) permettait un relâchement complet de la LER a 60° de flexion de genou alors que lorsque le tunnel etait place en GT la LER restait plus tendue. Pour les mouvements de pivot-shift simules et quelle que soit la position du tunnel femoral, la LER se tendait entre 20 et 34 % de la valeur de repos pour un tunnel tibial en GT et entre 11 et 26 % pour un tunnel tibial en ALL. Discussion Lors d’une flexion de genou en charge, un tunnel femoral posterieur et proximal a l’epicondyle femoral permet a la LER de se tendre lors des premiers degres de flexion et de se relâcher entre 40 et 60° de flexion. Lors de pivot-shifts simules la LER se tend, supportant ainsi la notion qu’un positionnement postero-proximal du tunnel femoral de la LER serait efficace a la fois lors d’une flexion de genou en charge et lors d’une cinematique alteree de genou.

Introduction Arthroscopic shoulder surgery is increasingly performed as a day case procedure. Nausea, vomiting and inadequate pain control are the most frequent reasons for reattendance or failed discharge. Gabapentin is advocated as an adjunct to mitigate these symptoms and its use in shoulder arthroscopy may provide improved post-operative symptom control. The aim of this study was to perform a meta-analysis of studies evaluating the role of gabapentin in the peri-operative management of shoulder arthroscopy. Hypothesis Gabapentin is associated with significant improvements in post-operative nausea, vomiting and pain control after shoulder arthroscopy. Material and methods A systematic review using Medline was conducted in accordance with the PRISMA guidelines. Randomised controlled trials studies reporting on patients >15 years old receiving either preoperative gabapentin or placebo before any shoulder arthroscopic surgery were considered for eligibility. Studies were appraised against the Consolidated Standards of Reporting Trials (CONSORT) checklist. A meta-analysis was performed using Review Manager 5.3. Results Four randomized controlled trials were identified for inclusion (n = 227). Meta-analysis demonstrated a beneficial effect of gabapentin in preventing nausea and vomiting in the postoperative period (Odds Ratio 0.30, p = 0.04). However, pooled data analysis did not show significant advantage in using gabapentin for postoperative pain control (p = 0.11), although one study demonstrated a significant reduction in opioid consumption after gabapentin. No significant difference was reported in post-operative dizziness or sedation between the groups. Discussion Gabapentin did not show any significant benefit in postoperative pain control but is associated with significant reductions in post-operative nausea and vomiting after shoulder arthroscopy. Level of evidence I, meta-analysis.

PURPOSE To evaluate clinical outcomes in professional athletes after combined anterior cruciate ligament (ACL) and anterolateral ligament (ALL) reconstruction at a minimum follow-up of 2 years. METHODS A retrospective analysis of prospectively collected data from the Scientific Anterior Cruciate Ligament Network International (SANTI) Study Group database was performed. All professional athletes who underwent primary combined ACL and ALL reconstruction between January 2011 and March 2016 were included. Patient assessment included physical examination, pre- and postoperative subjective and objective International Knee Documentation Committee (IKDC), Tegner activity scale, and Lysholm scores. RESULTS Seventy-two professional athletes underwent primary ACL and ALL reconstruction; 70 (97%) were available, with a mean follow-up of 3.9 years (range, 2-7). The preoperative side-to-side anteroposterior laxity difference was 7.1 ± 1.4 mm, and this decreased significantly after surgery to 0.4 ± 0.9 mm (P < .0001). Pivot-shift grade evolved from 16 grade I (22.8%) and 54 grade II or III (77.2%) preoperatively, to 66 absent pivot shift (94.3%) and 4 grade I (5.7; P < .001). By 1-year postoperatively, 60 athletes (85.7%) returned to professional sport, with a mean time interval of 7.9 months (range, 5-12). Preoperatively, the mean subjective IKDC was 56.1 ± 12.3, the Lysholm score was 48.4 ± 12.5, and the Tegner score was 9.3 ± 1. At final follow-up, the mean subjective IKDC was 90.5 ± 7.6 (P < .0001), the Lysholm score was 94.4 ± 7.5 (P < .0001), and the Tegner score was 8.8 ± 1.5 (P < .004). The objective IKDC evolved from 39 grade C (55.7%) and 31 grade D (44.3%) preoperatively to 65 grade A (92.9%) and 5 grade B (7.1%) (P < .0001). Eleven Patients (15,7%) underwent a subsequent ipsilateral reoperation including 4 (5.7%) revision ACL reconstructions. The risk of graft rupture was significantly higher in female patients (13.6% vs 2.1% in male patients; P = .048). CONCLUSIONS Combined ACL and ALL reconstruction is associated with excellent outcomes in professional athletes with respect to graft rupture rates, return to sport, knee stability, and reoperation rates after injury. LEVEL OF EVIDENCE Level IV, case series.

The purpose of this study was to evaluate the correlation between tibial acceleration parameters measured by the KiRA device and the clinical grade of pivot shift. The secondary objective was to report the risk factors for pre-operative high-grade pivot shift.Two-hundred and ninety-five ACL deficient patients were examined under anesthesia. The pivot shift tests were performed twice by an expert surgeon. Clinical grading was performed using the International Knee Documentation Committee (IKDC) scale and tibial acceleration data was recorded using a triaxial accelerometer system (KiRA). The difference in the tibial acceleration range between injured and contralateral limbs was used in the analysis. Correlation coefficients were calculated using linear regression. Multivariate logistic regression was used to identify risk factors for high grade pivot shift.The clinical grade of pivot shift and the side-to-side difference in delta tibial acceleration determined by KiRA were significantly correlated (r = 0.57; 95% CI 0.513-0.658, p 0.0001). The only risk factor identified to have a significant association with high grade pivot shift was an antero-posterior side to side laxity difference 6 mm (OR = 2.070; 95% CI (1.259-3.405), p = 0.0042).Side-to-side difference in tibial acceleration range, as measured by KiRA, is correlated with the IKDC pivot shift grade in anaesthetized patients. Side-to-side A-P laxity difference greater than 6 mm is reported as a newly defined risk factor for high grade pivot shift in the ACL injured knee.Level II.

Background: Combined partial lateral collateral and complete anterolateral ligament (PLCCALL) injuries are a specific injury pattern seen in Brazilian Jiu-jitsu due to the knee varus/flexion mechanism that frequently occurs during grappling.\ud \ud Purpose: The aim of this article was to evaluate the incidence of this injury pattern in a series of Brazilian Jiu-jitsu athletes with an acute knee injury, and also to evaluate clinical and functional outcomes after non-operative management, at a minimum follow up of one year.\ud \ud Hypothesis: Our hypotheses were that partial lateral collateral and complete anterolateral ligament (PLCCALL) injuries are common in BJJ and that non-operative treatment is associated with excellent clinical outcomes and return to the pre-injury level of sport\ud \ud Study Design: Case series – cohort\ud \ud Methods: All Brazilian Jiu-jitsu athletes presenting with an acute knee injury between July 2013 and June 2017 who underwent MRI of the knee were included. A specific emphasis was placed on identifying those whose imaging demonstrated PLCCALL injury. Clinical evaluation included physical examination, Lysholm and International Knee Documentation Committee (IKDC) score.\ud \ud Results: Of the 27 patients analyzed, seven (25.9%) were identified to have MRI proven PLCCALL injuries. The mean follow-up was 41.3 months. The mean IKDC/Lysholm score pre-injury was 94.3/92, at initial assessment after injury was 26/35.6 and this improved to 82.8/78.2 at 12 months post-injury (p

Background:The widespread historical abandonment of lateral extra-articular procedures in anterior cruciate ligament (ACL) injuries occurred as a result of concerns about high rates of adverse events. Recently, the popularity of lateral extra-articular procedures has resurged, warranting an urgent evaluation of their safety profile.Purpose/Hypothesis:The aim of this study was to perform an interim analysis of the ongoing SANTI randomized controlled trial to determine whether combined ACL and anterolateral ligament reconstruction (ACL + ALLR) is associated with an increased rate of adverse outcomes when compared with isolated ACL reconstruction (ACLR). The hypothesis was that there would be no significant difference between groups at a minimum follow-up of 1 year.Study Design:Randomized controlled trial; Level of evidence, 1.Methods:Recruitment commenced in November 2016. Patients scheduled for ACLR were randomized to either isolated ACLR (with bone–patellar tendon–bone [BPTB] autograft) or combined ACL + ALLR (with hamstring tendon autograft). All patients with a minimum follow-up of 1 year by March 2019 were included. The evaluated parameters included complications and reoperations, knee laxity parameters, range of motion, and scores on the Tegner, Lysholm, International Knee Documentation Committee (IKDC), and Knee injury and Osteoarthritis Outcome Score (KOOS) instruments.Results:A total of 224 patients (112 in each group) with a mean ± SD follow-up of 12.3 ± 1.9 months (range, 12-19 months) formed the study population. A significantly higher rate of reoperation for cyclops syndrome was noted in the isolated ACLR group compared with the combined ACL + ALLR group (8.9% vs 0%, respectively; P = .0012). No significant differences were found in frequency of graft rupture (ACLR, 5.4%; ACL + ALLR, 0.9%; P = .1191), range of motion deficits, pain, or reoperation for meniscectomy between groups. No cases of postoperative infection, venous thromboembolism, or arthrofibrosis were seen. Subjective IKDC (81.2 vs 86.8; P = .0048), Lysholm (88 vs 92; P = .0131), and some components of the KOOS were significantly better in the combined ACL + ALLR group.Conclusion:This study demonstrates no evidence of an increased risk of short-term adverse events after combined ACL + ALLR compared with isolated ACLR with BPTB graft.Registration:NCT03740022 ( ClinicalTrials.gov Identifier)

Background: Ramp lesions are characterized by disruption of the peripheral meniscocapsular attachments of the posterior horn of the medial meniscus. Ramp repair performed at the time of anterior cruciate ligament reconstruction (ACLR) has been shown to improve knee biomechanics. Purpose: The primary objectives of this study were to evaluate the incidence of and risk factors for ramp lesions among a large series of patients undergoing ACLR. Secondary objectives were to determine the reoperation rate for failure of ramp repair, defined by subsequent reoperations for partial medial meniscectomy. Study Design: Case-control study; Level of evidence, 3. Case series; Level of evidence, 4. Methods: All patients underwent transnotch posteromedial compartment evaluation of the knee during ACLR. Ramp repair was performed if a lesion was detected. Potentially important risk factors were analyzed for their association with ramp lesions. A secondary analysis of all patients who underwent ramp repair and had a minimum follow-up of 2 years was undertaken to determine the secondary partial meniscectomy rate for failed ramp repair. Results: The overall incidence of ramp lesions in the study population was 23.9% (769 ramp lesions among 3214 patients). Multivariate analysis demonstrated that the presence of ramp lesions was significantly associated with the following risk factors: male sex, patients aged 6 mm, and concomitant lateral meniscal tears. The secondary meniscectomy rate was 10.8% at a mean follow-up of 45.6 months (range, 24.2-66.2 months). Patients who underwent ACLR + anterolateral ligament reconstruction had a >2-fold reduction in the risk of reoperation for failure of ramp repair as compared with patients who underwent isolated ACLR (hazard ratio, 0.457; 95% CI, 0.226-0.864; P = .021). Conclusion: There is a high incidence of ramp lesions among patients undergoing ACLR. The identification of important risk factors for ramp lesions should help raise an appropriate index of suspicion and prompt posteromedial compartment evaluation. The overall secondary partial meniscectomy rate after ramp repair is 10.8%. Anterolateral ligament reconstruction appears to confer a protective effect on the ramp repair performed at the time of ACLR and results in a significant reduction in secondary meniscectomy rates.

Introduction: Transtendon repair (TTR) and tear completion and repair (TCR) are common repair techniques for partial thickness rotator cuff tears (PTRCTs). Previous systematic reviews have not demonstrated any advantage of either but have not specifically addressed early recovery.\ud \ud Aim: To compare the outcomes of these two techniques in treating PTRCTs with respect to post-operative stiffness, delay in functional recovery and re-tear rates.\ud \ud Material and methods: A systematic review of the Medline and EMBASE database was performed in accordance with the PRISMA guidelines. Both cases series and comparative studies reporting functional outcomes, post-operative stiffness or re-tear rate after either TTR or TCR for PTRCTs were included.\ud \ud Results: The search strategy identified 21 studies (n = 797); 4 comparative studies (n = 214), 15 TTR (n = 511) and 2 TCR case series (n = 72). All four comparative studies included were randomised controlled trials. One RCT reported early outcomes and demonstrated significantly slower recovery in the TTR group at 3 months (ASES p = 0.037, Constant score p = 0.019 and pain p = 0.001). Similarly, data from the case series suggested that the rate of post-operative stiffness was higher in the TTR group. All comparative studies demonstrated no significant difference at final follow up in terms of pain, range of motion or functional score.\ud \ud Discussion: The results of this systematic review suggest that transtendinous repairs are associated with more pain and worse function during the first 3 months. This suggests that tear completion and repair should be the preferred option, as comparative studies do not demonstrate any long-term advantage of transtendinous repair.\ud \ud Type of study: Systematic review\ud \ud Level of proof: Level II evidence.

Introduction Arthroscopic capsular release for adhesive capsulitis of the shoulder is a treatment option. The present study aimed to investigate the clinical outcomes following arthroscopic capsular release among idiopathic, diabetic and secondary adhesive capsulitis. Hypothesis Different aetiological groups yield variable outcomes following arthroscopic capsular release. Materials and Methods A literature search was performed using MEDLINE, EMBASE, CINAHL and the Cochrane Database in April 2017. Comparative studies that reported range of motion or functional outcomes following arthroscopic capsular release in patients with adhesive capsulitis were included. A systematic review of the studies was conducted following the PRISMA guidelines. Results Six studies met the eligibility criteria. The overall population included 463 patients; 203 idiopathic, 61 diabetic and 199 secondary cases. Of four studies comparing idiopathic and diabetic patients, three reported significantly worse range of movement and function in the diabetic group at various follow up points. No significant difference in function and motion was reported between the idiopathic and secondary groups. Recurrent pain was highest in diabetic patients (26%) compared to idiopathic groups (0%) and the secondary group had a higher rate of revision surgery when compared to the idiopathic group (8.1% vs. 2.4%) Discussion Arthroscopic capsular release has a high success rate regardless of the underlying aetiology. However, diabetic patients are reported to have more residual pain, reduced motion and inferior function compared to idiopathic cases. The rate of revision capsular release is higher among patients with post-surgical adhesive capsulitis when compared to idiopathic cases. Level of evidence IV, systematic review.

Objective To determine the key factors that influence return to sports (RTS) test scores (when using K-STARTS) in a large cohort of patients following ACL reconstruction. Design A retrospective analysis of prospectively collected data was undertaken. All patients who underwent ACL reconstruction surgery during the study period, and also had a K-STARTS assessment at 6 months post-operatively were included. In order to identify factors influencing the K-STARTS score, an analysis of variances was performed. Results A total of 676 patients were included in the study. The K-STARTS score was significantly higher in males than females (13.9 vs. 12.4, p > 0.001), in younger patients (those aged less than 30 vs older patients, 14.2 vs. 12, p > 0.001), ACL reconstructions performed with hamstring tendon autografts compared to bone-patellar tendon-bone (13.5 vs. 13.1, p = 0.03) and in those who completed a specific RTS program in addition to standard rehabilitation, compared to those who did not participate (17.1 vs. 13.1, p > 0.001). However, the only factor that significantly influenced the K-STARTS score beyond the minimal detectable change threshold was the completion of the additional RTS program. The pre-injury frequency of sports participation, whether the dominant limb was injured, time from injury to surgery, the presence of associated meniscal injuries and whether a lateral tenodesis was performed, did not significantly influence the K-STARTS score. Conclusion Completion of a specific return to sports program, in addition to standard rehabilitation, was the most important factor influencing the K-STARTS composite functional and psychological return to sports test score at 6 months after ACL reconstruction.