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To perform a systematic review of return to play (RTP) and return to previous level of performance (RPP) in competitive overhead athletes after SLAP repair to identify factors associated with failure to RTP.Systematic review was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Review was registered with PROSPERO International prospective register of systematic reviews (CRD42020215488). Inclusion criteria were literature reporting RTP or RPP following SLAP repair in overhead athletes were run in the following databases: PubMed/MEDLINE, Scopus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Google Scholar. Categories for data collection for each full article included (1) article information; (2) patient demographics; (3) surgical techniques; (4) level of competition; (5) rotator cuff treatment; (6) player position; (7) patient-reported outcome measures; and (8) RTP and RPP rates. The Methodological Index for Non-randomized Studies checklist was used to evaluate quality of all included studies.Eight studies with 333 subjects were identified. Overall RTP and RPP rates were 50% to 83.6% and 35.3% to 64%, respectively. Patients with surgically treated rotator cuff pathology had lower RTP (12.5%-64.7%) rates compared with those without (80.0%-83.6%). Professional athletes had similar RTP rates (62.5%-81.5%) compared with high-school (75.0%-90.0%) and college athletes (12.5%-83.3%). However, professional athletes demonstrated the lowest relative range of reported RPP rates (27.7%-55.6%). Pitchers had lower RTP (62.5%-80.0%) and RPP (52.0%-58.9%) compared with position players (91.3% RTP, 76.3%-78.2% RPP).Studies reviewed reported moderate RTP and RPP rates following SLAP repairs in competitive overhead athletes. Those with associated rotator cuff tear requiring treatment, and baseball pitchers were less likely to RTP and RPP. Professional athletes had similar RTP to an amateur; however, they were less likely to RPP.Level IV, systematic review of Level III-IV studies.

Background: Given the increasing interest and potential use of social media for the promotion of orthopedic literature, there is a need to better understand Altmetrics. Purposes: We sought to determine the relationship between the Altmetric Attention Score (AAS) and the number of citations for articles on total joint arthroplasty (TJA) published in orthopedics journals. We also sought to determine the predictors of greater social media attention for these articles. Methods: Articles on TJA published in Bone and Joint Journal (BJJ), Journal of Bone and Joint Surgery (JBJS), Clinical Orthopedics and Related Research (CORR), Journal of Arthroplasty, Journal of Knee Surgery, Hip International, and Acta Orthopaedica in 2016 were extracted ( n = 498). One-way analysis of variance with Bonferroni corrections was used to compare AAS and citations across journals. Multivariate regressions were used to determine predictors of social media attention and number of citations. Results: The mean AAS and number of citations were 7.5 (range: 0–289) and 16.7 (range: 0–156), respectively. Significant between-group effects were observed according to journal for AAS and number of citations. Publishing an article in JBJS was the strongest predictor of higher number of citations. Publishing an article in BJJ was the only independent predictor of higher AAS, while publishing an article in JBJS or CORR trended toward statistical significance. A higher AAS was a significant predictor of a higher number of citations. Number of citations and number of study references were positive predictors of greater social media attention on Twitter and Facebook. Conclusions: In articles on TJA published in 7 journals in 2016, a higher AAS was a associated with a higher number of citations. Various bibliometric characteristics were found to be significantly associated with greater social media attention; the most common influences were number of citations and number of references. Researchers in orthopedics can use this information when considering how to assess the impact of their work.

To determine if patients with preoperative symptom durations greater than two-years' experience inferior patient-reported and clinical outcomes at a minimum of two years after high tibial osteotomy.An institutional registry was retrospectively queried for patients treated with high tibial osteotomy for symptomatic medial knee overload/arthritis and varus malalignment between February 2006 and March 2018. Demographic characteristics, clinical outcomes, patient-reported outcomes (PROs), including the International Knee Documentation Committee ​score, Knee Injury and Osteoarthritis Outcome Score for Joint Replacement ​and Patient-Reported Outcome Measurement Information System Pain Interference ​and Physical Function ​scores, were assessed at a minimum of two-years postoperatively. Patients were compared based on preoperative symptom duration greater than or less than two years. Correlation coefficients were used to analyse the association between patient demographics and postoperative outcomes for the overall patient sample.A total of 41 patients were included in the analysis with a mean age (± standard deviation) of 37.0 ​± ​8.2 years and body mass index of 27.6 ​± ​4.2 ​kg/mPatients with a preoperative duration of symptomatic medial knee overload/arthritis of two years or greater do not experience inferior PRO or clinical outcomes than patients with a symptom duration of less than 2 years at mid-term follow-up. Greater age and BMI were weakly correlated with conversion to TKA. Greater age was negatively correlated with undergoing at least one reoperation.IV; Retrospective case series.

Background: Although the risk of tibial tunnel convergence in the setting of multiligamentous reconstruction has been reported in the literature, the risk of tunnel convergence in the setting of posterior cruciate ligament (PCL), anterior cruciate ligament (ACL) reconstruction and medial and lateral meniscus root repair has not been defined. Purpose: To examine the risk of tunnel convergence and to determine optimal tunnel placement for ACL and PCL reconstruction performed in conjunction with posterior medial and lateral meniscus root repairs on the anteromedial proximal tibia. Study Design: Descriptive laboratory study. Methods: Three-dimensional (3D) tibial models were created using computed tomography scans of 20 cadaveric specimens. After determining optimal tunnel entry and exit points for ACL and PCL reconstructions, and medial and lateral meniscus root reattachment to the anatomic footprints, we used image processing software to create root tunnels over the anteromedial tibia on the tibial models. ACL and PCL tunnels were kept constant. The meniscus root repair tunnels were then reoriented to match the angle of the ACL tunnel, making both tunnels parallel in the sagittal plane. Tunnel convergence risk was analyzed by identifying the shortest 3D distance between tunnel axes and subtracting the radius of each tunnel from this distance for single- and double-tunnel repair techniques in both case scenarios. Results: All specimens demonstrated convergence between the ACL and lateral meniscus root tunnels when the root tunnel’s entry was created proximal to the ACL tunnel’s entry for single- and double-tunnel techniques, but no convergence was seen between these tunnels using the parallel orientation in the sagittal plane. There were no cases of convergence between the ACL and medial meniscus root tunnels in any of the configurations. The greatest distance between the ACL and medial meniscus root tunnels was achieved using the single-tunnel technique in parallel orientation (12.1 ± 2.8 mm). There were no cases of convergence between the PCL and medial meniscus root tunnels in the original orientation; however, 2 of 20 specimens demonstrated convergence using the parallel orientation with the double-tunnel technique, and there were no cases of convergence using the single-tunnel technique. The PCL and lateral meniscus root tunnels did not demonstrate convergence in any configuration. Conclusion: There was a high risk of convergence between ACL and posterior meniscus root tunnels when all the tunnels were created on the anteromedial tibia. Reorienting meniscus root tunnels parallel to ACL tunnels may help reduce this risk. There is increased risk of tunnel convergence with root repairs in cases of bicruciate reconstructions, and therefore a double-tunnel root repair technique should be used with caution. Clinical Relevance: To avoid tibial tunnel convergence when performing ACL and PCL reconstruction with medial and lateral meniscus root repair, surgeons should reorient the meniscus root repair tunnels to be parallel on the sagittal plane to the ACL tunnel to decrease the risk of convergence. In cases of bicruciate ligament reconstruction, use of the double-tunnel technique requires caution to avoid convergence risk with the PCL tunnel.

Persistent pain after hip arthroscopy may be due to residual impingement, hip dysplasia, osteoarthritis progression, labral injury, or insufficient capsular closure. A patient's history, physical examination findings, and imaging studies should be used to determine whether revision hip arthroscopy is indicated. If surgical management is chosen, careful preoperative planning is essential. During revision hip arthroscopy, the presence and location of adhesions should be considered during interportal capsulotomy and T-capsulotomy creation and while applying traction sutures. The presence of a residual cam or pincer lesion and the adequacy of the labrum or labral graft should be assessed and properly addressed. If capsular redundancy is recognized, capsular plication may be performed. The purpose of this Technical Note is to describe an approach to revision hip arthroscopy for labral repair and residual cam lesion resection.

PURPOSE OF REVIEW: Anterior closing wedge osteotomies (ACWO) are utilized to better restore knee stability and in situ forces on anterior cruciate ligament (ACL) grafts during ACL revision reconstruction while reducing the risk of retearing and subsequent revision procedures. However, clinical outcomes following ACWO for patients undergoing ACL reconstruction remains largely limited. The purpose of this review was to provide a concise overview of the current literature on indication, techniques, and outcomes following ACWO in ACL-deficient patients undergoing primary or revision ACL reconstruction while discussing the authors’ preferred technique to ACWO during a staged ACL revision reconstruction. RECENT FINDINGS: Currently available clinical studies and case reports have demonstrated ACWO to improve knee stability and outcomes for patients with an increased posterior tibial slope undergoing primary or revision ACL reconstruction with low complication rates. SUMMARY: The ACWO provides an adjunct surgical option to decrease graft failure while improving knee stability and post-surgical outcomes for patients with an increased posterior tibial slope undergoing primary or revision ACL reconstruction. Further investigations are warranted to validate currently reported outcomes following ACWO in higher-level clinical studies with longer-term follow-up.

Purpose To establish an infection rate following primary arthroscopic rotator cuff repair (ARCR) from a single institutional database and to ascertain whether there is a relationship between the use of preoperative corticosteroid injection (CSI) and the risk of postoperative infection. Methods All medical records at a single institution were retrospectively reviewed to identify patients who had undergone arthroscopic repair from January 2016 to December 2018. Patient charts were reviewed for CSI treatment within 6 months of surgery, superficial or deep infection within 2 months postoperatively, and specific treatment of the infection. Patient characteristics were summarized by descriptive statistics using means with standard deviations for continuous variables and frequencies with percentages for categorical variables. A χ2 correlation analysis was performed to determine the association between receiving an injection and having an infection. Results A total of 1773 patients were included for analysis with an average age of 59.24 ± 9.4 years. The overall infection rate was 0.11% (2/1773 patients). Both patients were treated with oral antibiotics. Of the included patients, 616 had a preoperative CSI within 6 months of their surgery, and 102 injections were administered within 1 month of surgery. None of these patients had a postoperative infection. A χ2 correlation analysis showed a negligible relationship between preoperative injections and postoperative infection (φ = 0.02, χ2 = 0.84). Conclusions Through this single-institution, large cohort retrospective review, we found an overall 0.11% rate of postoperative infection following primary arthroscopic RCR. In addition, we found no correlation between the use of preoperative CSI ahead of elective ARCR at any time point and risk of developing a postoperative infection. Infection is uncommon following ARCR, and preoperative steroid injection did not increase infection risk in our study population. Level of Evidence Level IV, therapeutic case series.

Anterior cruciate ligament (ACL) reconstruction is one of the most commonly performed orthopaedic sports procedures. Two main techniques are used for accomplishing an ACL reconstruction: transtibial and anteromedial portal techniques. The transtibial technique has been criticized for its inability to create an anatomic femoral tunnel given the intrinsic constraint of the tibial tunnel during drilling. However, technical modifications of the transtibial technique can result in anatomic tunnel entrance positioning and a properly oriented graft. This Technical Note presents our technique for anatomic transtibial ACL reconstruction., Technique Video Video 1 This video describes our tips for a successful anatomic trans-tibial anterior cruciate ligament reconstruction (ACL). The steps highlight the technical modifications that can be implemented in the technique to help replicate the native anatomy by ensuring anatomical positioning of the tunnel entrance and proper orientation of the ACL graft.

Meniscal root repair is becoming more common with increasing knowledge regarding the function of the meniscal root and its role in long-term joint preservation, as well as improved surgical techniques and instrumentation. Despite this, adequate visualization of the posterior horn of the medial meniscus may be challenging, particularly in those with tight medial compartments. Instrument handling and attempt to visualize and repair the meniscal tear may lead to iatrogenic chondral injuries in these instances. We describe our preferred technique for improved visualization via mini-open release of the distal medial collateral ligament that allows for increased joint distension, increased access to the posterior horn of the medial meniscus, and the ability to repair the released medial collateral ligament., Technique Video Video 1 This video demonstrates our mini-open MCL release technique to increase access to the posterior horn of the medial meniscus for arthroscopic root repair. After an incision medial to the tibial tubercle and dissection through the sartorial fascia, the distal MCL is able to be visualized and released. The meniscal root is repaired through a transtibial pullout repair. An all-suture anchor is then used to reduce the MCL to its native footprint. (MCL, medial collateral ligament.)

To synthesize the epidemiology, cause, management, and return to sport (RTS) outcomes of ilium avulsion fractures sustained during sporting activities in young athletes. Studies reporting on athletes18 years old sustaining an avulsion fracture along the ilium [injury to the anterior superior or inferior iliac spine (ASIS or AIIS), or the iliac crest (IC)], and the athlete's RTS status were included. RTS was analyzed by injury acuity, location, mechanism of injury, and management, whereas complications were recorded. Seventy studies comprising 286 avulsions (169 ASIS, 87 AIIS, and 30 IC) were included. The mean age of athletes was 14.5 + 1.3 years (range, 8-18 years). Sprinting (n = 103/286; 36.0%) and soccer (n = 97/286; 33.9%) were the most common sports during which injuries occurred. A total of 96.5% (n = 276/286) of athletes reported successful RTS at an average of 16.2 + 19.3 weeks. The RTS rate for patients sustaining ASIS, AIIS, and IC avulsions was 95.3, 97.7, and 100%, respectively. Acute trauma was responsible for 89.8% (n = 158/176) of injuries, which demonstrated a significantly faster (13.3 + 9.3 weeks) and higher RTS rate (99.4%) compared with those with chronic avulsions (74.4 + 40.9 weeks and 83.3%, respectively). Those with complications (18.2%) had a significantly lower RTS rate (90.4%) and longer recovery (23.7 weeks) compared with athletes without complications (97.9% and 14.5 weeks, respectively). Outcomes were not significantly different based on sex or management. However, chronic avulsions and postoperative complications sustained worse RTS results. An accurate and timely diagnosis is crucial when presented with these rare injuries to avoid increasing the chronicity of injury.

Specialty: Orthopedics Traumatology Objective: Rare disease Background: Posterior meniscal root avulsions can cause meniscal extrusion, joint space narrowing, and progressive knee arthritis. Iatrogenic posterior meniscal root avulsions after malpositioning of the transtibial tunnels during an-terior cruciate ligament (ACL) reconstruction can account for poor long-term outcomes seen in some patients following ACL reconstruction. Therefore, correct transtibial tunnel placement during ACL reconstruction is es-sential to avoid iatrogenic meniscal damage. Case Report: A 32-year-old man presented with 1 year of right knee pain and instability following a non-contact twisting injury sustained while playing soccer. An ACL tear with no meniscal involvement was diagnosed at an outside institution. A double-bundle reconstruction was performed at that time. Three months after surgery, a medial partial meniscectomy was performed after a medial meniscal tear and failure to reduce initial symptoms dur-ing the index procedure. Advanced imaging at our institution 6 months later demonstrated an iatrogenic later-al posterior meniscal root avulsions after malpositioning of the transtibial tunnels. Given the ACL graft integ-rity upon arthroscopic evaluation, the root tear was repaired using a 2-tunnel transtibial pull-out technique. Advanced imaging 1 year after surgery showed a well-maintained meniscal repair with no extrusion. Conclusions: Accurate transtibial tunnel placement during ACL reconstructive surgery is vital to avoid meniscal root detach-ment and the associated complications resulting in poor patient outcomes from this iatrogenic injury. Clinicians treating patients with a history of cruciate ligament reconstruction presenting with postoperative pain and in-stability should consider this pathology in their differential diagnosis.

To compare social media attention and citation rates between infographics (visual abstracts) and original research articles.All infographics in 2019 from electronic versions of Arthroscopy were matched by topic to articles in the "Original Research" section of the journal in a 4:1 ratio within the same year. The primary outcome was the Altmetric Attention Score (AAS), a cumulative measure of social media attention from various platforms such as Twitter and Facebook. Secondary outcomes included citation rates, article characteristics, and number of shares on social media platforms. Independent t tests and χA total of 60 matched research articles (n = 48, 80.0%) and infographics (n = 12, 20.0%) published in 2019 in Arthroscopy were included. The mean AAS among all infographics was 29.75 ± 32.84 (range, 3-118), whereas the mean AAS among all control research articles was 5.75 ± 8.90 (range, 0-41), representing a statistically significant difference (P.001). Infographics had significantly more Twitter mentions (100% vs 70.8%, P.001) and Facebook mentions (75% vs. 6.2%, P.001) compared with original articles. Multivariate linear regression analysis demonstrated a statistically significant and positive association between AAS and article type, with an additional mean increase in the AAS of 33.7 (95% confidence interval 11.6-50.6; P = .003) for every infographic article compared with an original research article. The mean citation rate among all infographics was 2.4 ± 2.4 (range, 0-7), whereas the mean citation rate among all control research articles was 2.2 ± 4.0 (range, 0-27), which was not a significant difference (P = .69).Infographics resulted in significantly greater AAS and social media attention in comparison with original research articles of similar topics. We recommend the routine creation of infographics by journals to increase the social media attention that their research and chosen topics of interest receive. However, viewers of infographics should read them out of interest but turn their attention toward the original article or a source of more detailed information before making changes in clinical decision-making or practice, as they can be oversimplified.Infographics are an increasingly used by journals as a form of depicting research findings from select studies. By producing infographics, journals may increase the amount of social media attention received for a particular study or topic of interest.

Purpose: The purpose of this study is to determine the safety of elective, outpatient orthopaedic sports procedures during the Coronavirus (COVID-19) pandemic at a high-volume orthopaedic practice. Methods: All patients who were scheduled for elective, outpatient orthopaedic sports medicine procedures at one of two of outpatient surgical centers between July 1, 2020 and December 31, 2020 were asked to complete a custom survey during a post-operative clinic visit or phone call at a minimum of two-weeks or were subject to a routine screening questionnaire and temperature screen at the time of the first post-operative follow-up visit. The survey questionnaire assessed for any COVID-19-related symptoms. Surgical case logs were retrieved to review for any cancelled surgeries due to a positive pre-operative COVID-19 test. Results: A total of 3.5% of patients (n=39/1119) scheduled for surgery were diagnosed with COVID-19 during preoperative testing, resulting in surgical cancellation. Patients with a positive pre-operative COVID-19 test were found to be significantly younger (46 ± 20 years) when compared to all other patients with a negative test (51 ± 21 years; p=0.002). No patient was diagnosed with COVID-19, reported symptoms concerning for COVID infection, underwent additional testing, or reported close contact with another individual with a positive test or possessed symptoms concerning for COVID-19 at a minimum of two-weeks post-operatively. Conclusion: This study found that 3.5% of patients tested positive for COVID-19 and were significantly younger when compared to patients testing negative. No patient investigated for potential infection post-operatively reported the development of any symptoms related to COVID-19 or reported a positive test post-operatively. Using current protocols for pre-operative screening, elective outpatient orthopaedic surgery performed in an ASC is safe with no documented cases of COVID-19 transmission in this cohort.

Hip arthroscopy is an increasingly popular procedure used to treat femoroacetabular impingement. However, the procedure is technically challenging with a steep learning curve. To prevent complications and to optimize patient outcomes, proper patient positioning, correct portal placement, and adequate capsular closure are necessary. For central compartment procedures, creation of a minimal interportal capsulotomy, placement of traction stitches, adequate rim trimming, and balanced labral repair are recommended. For peripheral compartment procedures, adequate osteochondroplasty should be performed and assessed intraoperatively. The purpose of this technical note is to describe the senior author's top 10 pearls for a successful hip arthroscopy procedure to treat femoroacetabular impingement., Technique Video Video 1 Pearls of successful hip arthroscopy. This video describes the key aspects of a successful hip arthroscopy in a left hip. Pearl 1 is proper patient positioning in slight Trendelenburg with the foot on the operative side secured with Coban, the leg adducted, and the foot internally rotated. The pink pad positioning device may be used to provide post-free distraction. After initial traction is confirmed with fluoroscopy, an air arthrogram is performed to disrupt the suction seal. Pearl 2 is perfect portal placement to allow for adequate access to the joint for central and peripheral compartment procedures. The modified mid-anterior portal (mMAP) is made at the 2-o'clock position under direct visualization to ensure atraumatic entry into the joint into the arthroscopic triangle. Pearl 3 is minimal interportal capsulotomy creation through first creating the anterolateral (AL) periportal capsulotomy and second the mMAP periportal capsulotomy. The interportal capsulotomy is performed through the mMAP. Pearl 4 is placement of traction stitches to assist in creation of a defined plane between the capsule and labrum and for preservation of capsular tissue during closure. The first traction stitch is placed through the MAP, and the second through the AL. Pearl 5 is performing rim trimming and subspinal decompression where labral pathology exists. Pearl 6 is balanced labral repair, beginning at the 12 o'clock position through the AL portal, and finishing on the anterior portion of the labrum through the distal anterolateral accessory. Pearl 7 is atraumatic labral repair through cartilage visualization during anchor placement and use of small instrumentation during labral repair. Pearl 8 is proper osteochondroplasty through accessing the peripheral compartment with fat pad debridement, iliocapsularis, and gluteus minimus dissection off of the capsule, and T-capsulotomy. Pearl 9 is ensuring proper cam lesion resection through use of intraoperative commercial tools such as the Stryker HipCheck, which allows for real-time assessment of resection under fluoroscopy. Pearl 10 is creation of a watertight seal during capsular closure, which is started at the portion of the T-capsulotomy parallel to the femoral neck.

The hip suction seal plays a key role in distractive stability and maintenance of intra-articular fluid pressure of the hip. Preservation of the suction seal relies on the acetabular labrum and the congruence between the labrum and the femoral head−neck junction. During the treatment of cam-type impingement, iatrogenic over-resection in the femoral head−neck junction or labrum deficiency can cause loss of this suction seal. In this technical note, we describe a remplissage procedure performed in addition to labral reconstruction in a patient with loss of the suction seal due to a dysfunctional labrum and previous over-resection of a cam deformity., Technique Video Video 1 This video describes the key aspects of a labral reconstruction and remplissage technique correlated with dynamic hip examination to restore suction seal in revision hip arthroscopy of a left hip. According to preoperative examination and imaging of a patient with previous hip arthroscopy, over-resection in the anterior part of femoral head−neck junction and a dysfunctional labrum are detected. After these findings are confirmed with diagnostic arthroscopy and an intraoperative dynamic hip examination, labral reconstruction and the remplissage procedure are planned. Both procedures are performed using the kite technique, with the graft prepared from the same semitendinosus allograft in accordance with the defect size. In the labral reconstruction procedure with the defect between 11 and 2 o’clock, the anchors at the 11 and 12 o’clock positions are placed through the anterolateral portal, whereas the anchors at the 1 and 2 o’clock positions are placed through the distal anterolateral accessory (DALA) portal. A proximal modified mid-anterior portal is created to prevent suture tangling during labral reconstruction. During the remplissage procedure, anchors are placed through the DALA portal while viewing from modified mid-anterior portal (mMAP). A mid-body anchor is placed in line with the convexity of the femoral head and acetabulum by using same portal configuration. After remplissage and labral reconstruction, dynamic hip examination is performed to evaluate the reestablished suction seal in the joint while viewing through the mMAP. Finally, the capsule is closed.

Distraction is essential during hip arthroscopy to allow for adequate working space during central and peripheral compartment procedures. Pudendal posts are frequently used with traction boots to achieve distraction, but use of these posts is believed to be associated with the iatrogenic pudendal area and perineal nerve injuries seen with hip arthroscopy. Current post-free distraction tables are costly and cumbersome. The pink pad positioning device allows for post-free distraction through the creation of friction between the patient, the pad, and the bed. This device can be used with a standard hip arthroscopy table, is easy to learn, allows for adequate distraction, and allows for greater access to the femoral neck during osteochondroplasty, as there is less restriction of the patient’s range of motion without a post present. The purpose of this Technical Note is to describe a method of post-free distraction using the pink pad positioning device., Technique Video Video 1 This video describes the key aspects of use of the pink pad positioning device during left hip arthroscopy. The pink pad is placed on top of a standard hip arthroscopy bed, with the widest portion of the pad matching up with the widest portion of the bed attachment. After the distal portion of the pad is secured to the bed attachment using the wide purple Velcro straps, the remainder of the pad is secured to the Bucky arms of the bed using the thin white Velcro straps. A draw sheet is placed onto of the bed, and safety straps are attached to the Bucky arms. The patient is moved onto the bed, anesthetized, and moved in the caudad direction until the anterior superior iliac spine is in line with the widest portion of the pad. The draw sheet is removed from under the patient, and the patient’s arms are secured in position with tape and safety straps. The arms may both be folded across the chest, or the arm contralateral to the surgery side may rest on an arm board. The patient’s feet are placed in traction boots, and the operative side is secured with Coban. The patient is placed in 10-15° Trendelenburg position with the leg adducted and the foot internally rotated. After a clear fluoroscopic field is confirmed with a C-arm, the patient is prepped and draped in sterile fashion. An air arthrogram is performed to disrupt the suction seal under fluoroscopy. Maximum traction is then achieved through adjustment of the distal traction arm. An interportal capsulotomy is created, and central compartment procedures (rim trimming, labral repair) are performed. Traction is released, and a T-capsulotomy is created to access the peripheral compartment. The procedure is completed with capsular and portal closure.

Multiple treatment options are available for patients presenting with a torn or deficient acetabular labrum. Biomechanical studies have demonstrated that the acetabular labrum may play a role in decreasing the risk of osteoarthritis and in maintaining long-term hip kinematics and stability. As such, repair or reconstruction of the labrum is often preferred over resection or debridement. In instances of a hypoplastic labrum, labral reconstruction or augmentation may be necessary even in a primary setting. Although reconstruction is a technique that should be in any hip arthroscopist’s toolkit, allografts can be expensive and may not always be available when needed. In this Technical Note, we describe a labral augmentation with capsular autograft that diminishes donor-site morbidity associated with fascia lata autografts. This technique enables incorporation of healthy capsular tissue that allows for the recreation of the suction seal while avoiding some of the technically challenging aspects and costs of the conventional allograft labral reconstruction., Technique Video Video 1 This video describes our technique for a capsular autograft augmentation during acetabular labral reconstruction. Advanced labrum degeneration during diagnostic arthroscopy is visualized between 1- and 3-o’clock positions. With the help of a radiofrequency ablator, the capsular tissue intended to be used for reconstruction is separated from the indirect head rectus femoris (IHRF) tendon and is tagged and exposed. Suture anchors are evenly placed through the distal anterolateral (DLA) portal at the 1- to 3-o’clock positions of the acetabulum, adjacent to the anterior border of the damaged labral tissue to be reconstructed. Using a suture passer, one thread of each anchor is passed and aligned with the anchors in a mediolateral plane. After, an approximately 3 cm portion of the capsule is dissected for use during reconstruction. Reconstruction performed with the capsular tissue is reinforced with anchors placed on the acetabular rim from the DLA portal. Anchors are sequentially tied fully, reducing the capsule to the acetabular rim. Final debridement is performed as necessary.

Background: Patella alta is a known risk factor for patellar instability and, in the setting of recurrent patellar instability with significant patella alta, correction of patellar height with a tibial tubercle osteotomy (TTO) may help decrease the failure of soft tissue–based stabilization. Purpose: To perform a systematic review and meta-analysis of radiographic and clinical outcomes after TTO for patella alta. Study Design: Systematic review and meta-analysis; Level of evidence, 4. Methods: PubMed, OVID/Medline, and Cochrane databases were queried in June 2020 for studies reporting outcomes of TTO for patella alta. Data pertaining to study characteristics and design, radiographic and clinical outcome values, and incidence of complications and reoperations were extracted. DerSimonian-Laird continuous and binary random-effects models were constructed to (1) perform subgroup-based analysis of mean changes in radiographic indices after TTO and (2) quantify the pooled incidence of complications and reoperations. Results: Eight studies including 340 patients (420 knees) with a mean age of 24.7 ± 8.4 years were included. The mean follow-up was 53.1 months (range, 3-120 months), with 1 study reporting a mean follow-up of less than 2 years. The pooled mean anterior transfer was 5.6 mm; the mean medial transfer was 8.7 ± 1.3 mm; and the pooled mean distalization of the tibial tubercle was 12.2 ± 4.5 mm. Continuous random-effects meta-analysis determined that significant reductions in the mean Insall-Salvati ratio (1.40 vs 0.98, P < .001), Caton-Deschamps index (1.26 vs 0.97, P < .001), and tibial tubercle to trochlear groove ratio (18.27 vs 10.69, P < .001) were observed after TTO. The overall incidence of complications was 7.6% (95% CI, 4.8%-10.5%), while the overall incidence of reoperations was 14.3% (95% CI 6.2%-22.4%). Conclusion: TTO for patellar instability in the setting of patella alta results in a significant decrease in patellar height with varying degrees of medialization depending on the utilized technique. A mean postoperative complication rate of 7.6% was reported with a reoperation incidence of 14.3%, related primarily to hardware removal.

Residual femoroacetabular impingement syndrome due to incomplete resection of a cam deformity is the leading cause of failed hip arthroscopy. The reliability of the alpha angle has been shown for quantifying cam deformities in femoroacetabular impingement syndrome. An intraoperative navigation tool that provides the ability to compare alpha angle measurements side by side on pre- and post-resection fluoroscopic images has recently been introduced. This tool uses fluoroscopic images obtained in 6 different hip positions. The reliability of these standardized hip positions has been shown by correlation with computed tomography in localization and visualization of cam deformities. The purpose of this Technical Note is to give technical tips about the application of this tool., Technique Video Video 1 Key aspects of hip arthroscopy in right hip with patient in supine position with intraoperative navigation tool based on alpha angle measurement. The navigation monitor is placed below the level of the arthroscopy monitor and between the C-arm and arthroscopy monitor so that it does not disrupt the existing operating room setup. Once joint distraction of nearly 1 cm is observed, the anterolateral portal and then the modified midanterior portal are created. An interportal capsulotomy is performed between these portals. In this right-sided hip arthroscopy, after the distal anterolateral portal is created, 3 anchors are placed at the 12-, 1-, and 2-o’clock positions. For the labral repair, sutures are passed and tied accordingly with the aid of arthroscopic instruments. Next, traction is released, a T-capsulotomy is made through the distal anterolateral portal, and suspension sutures are passed through each side of the capsule for a better vantage. To start the HipCheck application, the surgeon identifies the femoral head and neck on a random fluoroscopic image on the navigation touchscreen. Before osteochondroplasty is started, pre-resection measurements are obtained in 6 different hip positions with the HipCheck system. During the procedure, the amount of resection can be instantly checked by taking fluoroscopic images in the desired hip positions at any time. When the cam resection is considered adequate, the 6 fluoroscopic images obtained before resection are obtained once more in the same order, and the new alpha angle values are recorded as the post-resection measurements. Finally, the capsule is closed.

A select subset of patients can present with anterior knee pain in the setting of normal patellar tracking, no significant cartilage damage, and the presence of a bone marrow lesion (BML) involving the patella on advanced imaging. One novel treatment option for this condition is patellar subchondroplasty, where calcium phosphate is injected into the subchondral bone under fluoroscopic guidance. The purpose of this study is to report preliminary outcomes of patients who have undergone subchondroplasty of the patella. The surgical log of the senior author was retrospectively reviewed to identify patients who had undergone patellar subchondroplasty from January 2014 to June 2019. Indications for surgery included the presence of retropatellar pain refractory to conservative management without significant arthritis with a related focal BML on magnetic resonance imaging. International Knee Documentation Committee, Knee Injury and Osteoarthritis Outcome Score (KOOS), and Veterans Rand 12-item Health Survey (VR-12) were obtained preoperatively, at 6 months and at final follow-up. Eight patients (nine knees) who underwent patellar subchondroplasty with minimum 1-year follow-up participated in the study. On preoperative magnetic resonance imaging, patients had a mean BML that was 2 cm in diameter. Patients had a median Kellgren–Lawrence grade of 2 both preoperatively and at final radiographic follow-up (15.50 ± 20.52 months). No patient underwent subsequent surgery or conversion to arthroplasty. Compared with baseline, VR-12 mental (p = 0.046) and physical (p = 0.003), KOOS joint replacement (p = 0.024), KOOS pain (p = 0.033), and KOOS sports (p = 0.034) scores were significantly increased at final follow-up (24.00 ± 13.55 months). In addition, on a scale of 0 to 100, patient-reported satisfaction was 73.88 ± 33.90. This study introduces patellar subchondroplasty as a surgical treatment for patients with symptomatic BMLs of the patella without significant arthritis after failure of conservative management. Our results demonstrated good outcomes and patient satisfaction. In addition, no patients converted to patellofemoral or total knee arthroplasty. This study suggests that patellar subchondroplasty may be a reasonable treatment option in the correct patient population.

Operative treatment of anterior glenohumeral instability is challenging, particularly with the presence of an anterior glenoid rim fracture, also called an “osseous Bankart lesion.” Successful reduction and fixation of the lesion has been shown to greatly reduce the risk of recurrent dislocations while achieving osseous union and normalization of glenoid anatomy(1). DESCRIPTION: The current surgical video article outlines a technique for an osseous Bankart repair in a patient with a displaced fracture as well as substantial pain and instability. First, the amount of bone loss is measured on 3-dimensionally reconstructed computed tomography (CT) imaging, with the humeral head digitally subtracted(2). The procedure is then performed arthroscopically with the patient in the lateral decubitus position. A diagnostic evaluation, beginning with posterior and anterior portal placement in the rotator interval, is completed to assess any rotator cuff injury and the extent of labral tearing and osseous displacement. Next, the bone fragment is elevated into its anatomical position. This fragment is then reduced with use of a double-row suture technique, followed by concomitant capsulolabral repair. ALTERNATIVES: Nonoperative treatment with a sling can be utilized as long as post-reduction CT scans reveal anteroposterior centering of the humeral head on the glenoid(3). Rehabilitation can include active-assisted and passive glenohumeral mobilization, as well as daily pendulum exercises and physiotherapy. RATIONALE: Osseous Bankart repair has been shown to effectively improve patient-reported outcomes and normalize glenoid morphology(1,3,4). Failure to recognize and appropriately treat an osseous Bankart fracture may lead to osseous erosion caused by repetitive episodes of subluxations or dislocations, along with substantial pain and weakness(5). Indications for arthroscopic Bankart repair include young, active patients with a reducible fracture fragment, an anterior glenoid deficit of >10%, and a history of failed nonoperative treatment(3-8). EXPECTED OUTCOMES: Clinical outcomes following the osseous Bankart repair procedure have been shown to be highly successful, with high rates of return to sport, minimal reduction in range of motion, and restoration of shoulder function and stability(4). Additionally, long-term follow-up has shown successful osseous union and normalization of glenoid anatomy(1). IMPORTANT TIPS: Apply tension to sutures with a suture retriever before the PushLock anchors (Arthrex) are placed during fracture reduction. Utilize a trans-subscapularis portal for anchor placement medial to the fracture on the glenoid neck. Perform adjustable tensioning during labral repair with knotless all-suture anchors. Utilize a lateral distraction device with the patient in the lateral decubitus position to completely visualize the anteroinferior glenoid. Chronic onset and late intervention may cause difficulties in the reduction of the bone fragment. Suture management may be difficult, particularly for surgeons at an early stage of the learning curve. A defect that is wide (from medial to lateral) may be difficult to maneuver around and reduce. ACRONYMS AND ABBREVIATIONS: GH = glenohumeral. GHL = glenohumeral ligament. Pts = patients. PMH = previous medical history. FE = forward elevation. ER = external rotation. IR = internal rotation. ABD = abduction. EXT = external rotation. XR = radiographic imaging. MRI = magnetic resonance imaging. CT = computed tomography. ROM = range of motion. FU = follow-up. RTS = return to sports. RTPP = return to previous level of play.

Tibial plateau chondral defects can be difficult to diagnose and treat. Although grafting of femoral and patella chondral defects has become relatively commonplace, the tibial plateau offers unique challenges for some of the grafting techniques used in these locations, mostly because of limitations with exposure even in an open approach. Arthroscopic surgery makes treatment of these lesions more feasible, as it affords better access and visualization of tibial defects. The purpose of this article is to describe the arthroscopic management of a lateral tibial plateau chondral defect via autologous chondrocyte bone grafting. The technique consists of harvest of autologous cartilage from the intercondylar notch and repair of the tibial plateau defect with a slurry of autologous chondrocytes and bone marrow aspirate concentrate. In addition, CO2 is used as a medium to distend the joint in a tight compartment to keep the chondral defect dry. This technique is technically simple and does not require an extensive open technique or an expensive osteochondral allograft. It also avoids the staged management required in other types of autologous chondrocyte implantation, which require cartilage biopsy to produce a final product for implantation., Technique Video Video 1 This video demonstrates our arthroscopic technique for treatment of a tibial plateau osteochondral lesion via minced autologous chondrocytes harvested from the intercondylar notch. CO2 is used to aid in joint distension as well as to dry the bed of the defect.

Background: Clinically significant outcome (CSO) thresholds for the Patient-Reported Outcome Measurement Information System–Upper Extremity (PROMIS–UE) score have been previously defined after arthroscopic rotator cuff repair (RCR). However, the time required to achieve CSOs for the PROMIS–UE score is unknown. Purpose: To (1) determine the time required to achieve the minimal clinically important difference (MCID), substantial clinical benefit (SCB), and Patient Acceptable Symptom State (PASS) score thresholds after RCR for the PROMIS–UE questionnaire and (2) identify patient factors associated with earlier or delayed achievement of these clinical benchmarks. Study Design: Case-control study; Level of evidence, 3. Methods: A prospectively maintained institutional database was retrospectively reviewed for consecutive patients who underwent RCR between January 2018 and January 2019. Patients were included if they completed the PROMIS–UE questionnaire both preoperatively and at standardized postoperative time intervals: 5 to 7 months (6-month time point), 11 to 13 months (1-year time point), and ≥23 months (2-year time point). Kaplan-Meier survival curves with interval censoring were used to define the cumulative percentage of patients who achieved the MCID, SCB, and PASS. Patient variables associated with earlier or delayed achievement of the MCID, SCB, and PASS were determined using Weibull parametric survival regression analysis. Results: Included were 105 patients undergoing RCR (age, 57.3 ± 10.3 years; body mass index, 31.5 ± 6.1 kg/m2). By 2-year follow-up, the cumulative percentage of patients achieving the MCID, SCB, and PASS was 86.7%, 76.2%, and 74.3%, respectively. The mean time required to reach the MCID, SCB, and PASS score thresholds was 9.5 ± 3.8, 10.3 ± 4.4, and 9.8 ± 4.6 months, respectively. Factors associated with delayed achievement of CSOs included greater baseline PROMIS–UE score (MCID and SCB) and workers’ compensation insurance (PASS). Greater baseline PROMIS–UE scores were associated with earlier achievement of the PASS. Conclusion: Most patients achieved CSOs for the PROMIS–UE within 12 months of RCR. Patient-specific factors found to be associated with earlier or delayed achievement of CSOs can be used to inform patient discussions on the expected timeline for recovery after RCR.