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Massive rotator cuff tears are particularly challenging to treat and severely limit the function of the shoulder. Compared with a small rotator cuff tear, massive tears are more unpredictable and usually present with low tendon quality. When performing an anatomical repair of the rotator cuff, the surgical treatment is often associated with failure of the construct. An alternative procedure that can be performed in the setting of a massive tear is superior capsular reconstruction (SCR), using an autograft or allograft. This procedure has been shown to be effective and is associated with positive treatment outcomes. Moreover, the combination of an SCR with an anatomic repair of the rotator cuff tendon may provide a stronger fixation for the rotator cuff and ultimately lead to a lower likelihood of retear and failure. The purpose of this Technical Note is to describe our preferred procedure for the treatment of a massive rotator cuff tear through SCR with superimposition of the repair of the native rotator cuff tendons.

Purpose: To perform a systematic review on clinical and radiologic outcomes for meniscus tears treated nonoperatively with platelet-rich plasma (PRP). Methods: A literature search was performed according to the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using keywords and Boolean operators in SCOPUS, PubMed, Medline, and the Cochrane Central Register for Controlled Trials in April 2023. Inclusion criteria were limited to Level I to IV human studies reporting on outcomes of meniscus tears treated nonoperatively with PRP. Results: A total of 6 studies, consisting of 184 patients, were identified. There was 1 Level I study and 5 Level IV studies. Mean patient age was 47.8 ± 7.9 years, with 62% (n = 114/184) being female. The medial meniscus was treated in 95.7% (n = 157/164) of patients. Mean follow-up ranged from 75.9 days to 31.9 months. Meniscus tears were generally described as chronic, degenerative, or intrasubstance. In 4 studies, magnetic resonance imaging revealed variable improvement in meniscus grade with complete healing in 0% to 44% of patients and partial healing in 0% to 40% of patients. Four of 5 studies reported significant statistical improvement in pain from baseline to final follow-up. Studies reporting on clinical outcomes showed significant improvements Lysholm score (2 studies), Knee injury and Osteoarthritis Outcome Score total score (2 studies), and Tegner score (1 study). Successful return to sport occurred in 60% to 100% of patients. Two studies reported that most patients were either very satisfied or satisfied following treatment. Conclusions: The use of PRP injections for the treatment of meniscus tears led to variable results based on postoperative magnetic resonance evaluation and improvements in clinical outcomes, although the clinical significance remains unclear. The heterogeneity of PRP protocols, short-term follow-up, and lack of comparative studies limit findings. Level of Evidence: Level IV, systematic review of Level I to IV studies.

Appropriate management of radial meniscal tears is complex, with continued efforts focused on optimizing diagnostic methods for identification to help dictate treatment, especially as surgical indications for repair have expanded, coupled with improvements in surgical techniques and instrumentation. Currently, no standardized classification system for radial meniscal tears exists, limiting the ability to accurately characterize injury patterns and guide surgical decision-making.

Purpose: To compare revision rates and residual postoperative instability after anterior cruciate ligament (ACL) reconstruction based on biological sex. Methods: A systematic review was conducted according to the 2020 PRISMA guidelines. PubMed, Embase, MEDLINE, and Cochrane library databases were queried from database inception through October 2022. Level I and II prospectively-enrolling human clinical studies that compared revision rates and physical examination of postoperative stability after ACL reconstruction between male and female patients were included. Outcomes were stratified by patient sex and quantitatively compared using a χ2 test. Study quality was assessed using the MINORS criteria. Results: Four studies consisting of 406 patients (50% males) with a mean age of 25 years (range, 13.9-62 years) were identified. Mean follow-up time was 34.4 months (range, 22-60 months). Hamstring tendon autografts were used in 62% of ACL reconstructions in males and in 65% of ACL reconstructions in females, whereas bone-patellar tendon-bone autografts were used in 38% and 35% of procedures in males and females, respectively. A residual positive Lachman test result was more frequently reported among females compared to males (5.8% vs 0.6%; P = 0.03). No significant difference in revision rates or residual pivot-shift on examination was observed between males and females (P = 0.38 and P = 0.08, respectively). Conclusion: Female patients undergoing ACL reconstruction have higher reported rates of residual anterior instability with Lachman than male patients. However, no sex-based differences were identified with residual pivot-shift on examination or rate of revision ACL surgery. Level of Evidence: II; Systematic Review of level II studies.

Purpose: To systematically examine the effects of radiofrequency (RF) ablation or coblation (controlled ablation) on chondrocyte viability following knee chondroplasty in preclinical literature to determine the effectiveness and safety of RF-based techniques. Methods: A literature search was performed in September 2022 using PubMed and Scopus using the following search terms combined with Boolean operators: “chondroplasty,” “radiofrequency,” “thermal,” “knee,” “chondral defect,” “articular cartilage,” and “cartilage.” The inclusion criteria consisted of preclinical studies examining the effect of RF ablation or coblation on chondrocytes during knee chondroplasty. Exclusion criteria consisted of studies reporting chondroplasty in joints other than the knee, clinical studies, in vitro studies using animal models, case reports, non–full-text articles, letters to editors, surveys, review articles, and abstracts. The following data were extracted from the included articles: author, year of publication, chondral defect location within the knee and chondral characteristics, RF probe characteristics, cartilage macroscopic description, microscopic chondrocyte description, and extracellular matrix characteristics. Results: A total of 17 articles, consisting of 811 cartilage specimens, were identified. The mean specimen age was 63.4 ± 6.0 (range, 37-89) years. Five studies used monopolar RF devices, 7 studies used bipolar RF devices, whereas 4 studies used both monopolar and bipolar RF devices. Time until cell death during ablation at any power was reported in 5 studies (n = 351 specimens), with a mean time to cell death of 54.4 seconds (mean range, 23.1-64) for bipolar RF and 56.3 seconds (mean range, 12.5-64) for monopolar RF devices. Chondrocyte cell death increased with increased wattage, while treatment time was positively correlated with deeper cell death. Conclusions: In this systematic review, histologic analysis demonstrated that RF-based chondroplasty creates a precise area of targeted chondrocyte death, with minimal evidence of necrosis outside the target zone. Caution must be exercised when performing RF-based chondroplasty due to the risk of cell death with increased application time and wattage. Clinical Relevance: Although RF ablation has demonstrated favorable results in preliminary trials, including smoother cartilage and less damage to the surrounding healthy tissue, the risks versus benefits of the procedure are largely unknown. Caution must be exercised when performing RF-based chondroplasty in the clinical setting due to the risk of cell death with increased application time and wattage.

Purpose: To evaluate reported clinical outcomes and complications following radiofrequency (RF) ablation for the treatment of knee chondral lesions. Methods: A literature search was performed according to the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines by querying EMBASE, PubMed, and Scopus computerized databases from database inception through October 2022. Level I to IV clinical studies that reported outcomes or complications following RF-based chondroplasty were included. Postoperative outcome scores and complications were aggregated. Study quality was assessed via the Newcastle–Ottawa Scale. Results: Ten articles from 2002 to 2018 consisting of 1,107 patients (n = 1,504 lesions) were identified. Four studies were of Level I evidence, 3 studies were Level II, 1 study was Level III, and 2 studies were Level IV. The mean patient age was 41.8 ± 6.3 years (range, 12-87). Seven studies (n = 1,037 patients) used bipolar RF devices, and 3 studies (n = 70 patients) used monopolar RF devices. The overall mean postoperative Lysholm, Tegner, and IKDC scores ranged from 83 to 91, 3.8 to 7, and 49 to 90, respectively, in lesions ranging from grade I-IV according to the Outerbridge Classification. Monopolar RF devices reported qualitatively similar mean changes in Lysholm scores (83), Tegner scores (3.8), and IKDC scores (range, 49-69) compared with bipolar RF devices (range, 86.4-91, 4.5-7, 90, respectively). The incidence of complications ranged from 0% to 4%. The most commonly reported complication was osteonecrosis (range, 0% to 4%). The incidence rate of patients undergoing additional surgery ranged from 0% to 4.5%. Conclusions: The available literature on RF-based chondroplasty shows its efficacy and safety for the treatment of knee chondral lesions, with good clinical outcome scores and low complication and reoperation rates. Level of Evidence: Level IV, systematic review of Level I-IV studies.

Although historically overlooked, medial meniscus posterior root (MMPR) tears are now increasingly recognized as a substantial cause of biomechanical impairment and morbidity. MMPR tears, when left untreated, are strongly correlated to meniscal extrusion and ultimately lead to altered kinematics and loading functionally equivalent to a total meniscectomy. To prevent progressive joint degeneration and alleviate pain while re-establishing native joint kinematics, MMPR repair is generally recommended in appropriately selected patients. In this Technical Note, the authors describe a detailed checklist with 10 crucial points of emphasis when performing the gold-standard transtibial pull-out repair of the MMPR, with an additional centralization stitch, providing technical pearls backed up by previous literature and ample experience treating this condition.

Osteochondral allograft transplantation provides components of both cartilage and subchondral bone and can be used in large and multifocal defects where autologous procedures are limited by donor-site morbidity. Osteochondral allograft transplantation is particularly appealing in the management of failed cartilage repair, as larger defects and subchondral bone involvement are often present, and the use of multiple overlapping plugs might be considered. The described technique provides our preoperative workup and reproducible surgical approach for patients who have undergone previous osteochondral transplantation with graft failure and are young, active patients who would not be otherwise suited for a knee arthroplasty procedure.

Purpose: To investigate the type of questions patients undergoing hip arthroscopy for femoroacetabular impingement (FAI) are searching online and determine the type and quality of the online sources from the top results to each query by the “people also ask” Google algorithm. Methods: Three search strings pertaining to FAI were carried out through Google. The webpage information was manually collected from the “People also ask” Google algorithm. Questions were categorized using Rothwell’s classification method. Each website was assessed using Journal of the American Medical Association Benchmark Criteria for source quality. Results: A total of 286 unique questions were collected with their associated webpages. The most common questions included: “How do you treat femoroacetabular impingement and labral tears without surgery?” “What is the recovery process after hip arthroscopy and are there limitations after surgery?” and “How do you diagnose hip impingement and differentiate from other causes of hip pain?” The Rothwell Classification of questions were fact (43.4%), policy (34.3%), and value (20.6%). The most common webpage categories were Medical Practice (30.4%), Academic (25.8%), and Commercial (20.6%). The most common subcategories were Indications/Management (29.7%) and Pain (13.6%). Government websites had the highest average Journal of the American Medical Association score (3.42), whereas Single Surgeon Practice websites had the lowest (1.35). Conclusions: Commonly asked questions on Google regarding FAI and labral tears pertain to the indications and management of pathology as well as pain control and restrictions in activity. The majority of information is provided by medical practice, academic, and commercial sources, which have highly variable academic transparency. Clinical Relevance: By better understanding which questions patients ask online, surgeons can personalize patient education and enhance patient satisfaction and treatment outcomes after hip arthroscopy.

Purpose: To compare social media attention and citation rates between technique articles and matched original research articles (ORAs) regarding surgical procedures. Methods: All technique articles published from August 2019 through July 2020 in the free, electronic versions of Arthroscopy Techniques and JBJS Essential Surgical Techniques were matched by topic to articles in the “Original Research” sections of Arthroscopy, Sports Medicine, and Rehabilitation and JBJS Open Access in a 4:1 ratio within this time frame. The primary outcome was the Altmetric Attention Score (AAS). Secondary outcomes included citations, bibliometrics, and social media metrics. Independent t tests were used to compare primary and secondary outcomes between technique articles and ORAs. A multivariate linear regression analysis was performed to determine the association between article type and social media attention while controlling for confounding bibliometric characteristics. Results: A total of 285 matched research articles (n = 57, 20.0%) and technique articles (n = 228, 80.0%) were included. The mean AAS among all technique articles was 3.63 ± 10.08 (range, 0-96) whereas the mean AAS among all ORAs was 1.30 ± 3.98 (range, 0-25), representing a statistically significant difference (P = .016). The mean citation rate among all technique articles was not significantly different from that among ORAs (P = .73). Multivariate linear regression analysis showed a statistically significant positive association between AAS and article type, with an additional mean increase in the AAS of 2.91 (95% confidence interval, 0.04-5.77; P = .047) for every technique article compared with an ORA. Furthermore, a significant positive relation was noted between the article origin and the AAS, with an increase in the AAS of 3.00 (95% confidence interval, 0.82-5.17; P = .007) for every article published in North America compared with an article originating from another continent. Conclusions: Technique articles resulted in significantly greater AASs and social media attention in comparison with open-access ORAs on similar topics. Publications that described technical procedures in a technique journal and studies from North America were positively associated with greater AASs and greater numbers of citations received by articles. Clinical Relevance: An improved understanding of how much attention is given to technique articles versus matched ORAs by social media may influence the methods authors and journals use for distributing content. The present study suggests that one option to increase the amount of social media attention received for a particular study may be to utilize an accompanying surgical technique video or illustrations as these are easily shareable on social media and offer rapid dissemination of knowledge, similar to that of an infographic. However, physicians who view multimedia within technique articles should be encouraged to review the accompanying articles and the supporting original research as a primary source before making changes in their clinical practice.

Purpose: To compare the early postoperative outcomes of patients undergoing inpatient versus outpatient hip arthroscopy and identify any characteristics that may serve as predictors of these complications Methods: The PearlDiver Mariner insurance database was queried for all patients who underwent hip arthroscopy from 2010 to 2019. Patients were matched based on Charlson Comorbidity Index, age, and sex. Outcomes recorded included postoperative complications and return to care within 90 days. Predictors of complications were assessed via multivariable logistic regression controlling for age, sex, Charlson Comorbidity Index, comorbidities, surgical setting, and procedure type Results: The final matched cohort included 832 inpatients and 1,356 matched patients. Fifty-eight patients (7.0%) who underwent inpatient surgery versus 25 patients (1.8%) who underwent outpatient surgery were readmitted (P < .01). Of the readmitted patients, 31 inpatients (3.7%) and 5 outpatients (0.4%) were readmitted for hip-related reasons (P < .01). No significant differences were observed in emergency department visits (67 inpatients [8.1%] vs 84 outpatients [6.2%], P = .11), intensive care unit admissions (3 [0.4%] vs 1 [0.1%], P = .31), or revision hip arthroscopies (43 [5.2%] vs 65 [4.8%], P = .77). A multivariable model of complications correcting for baseline differences in chronic obstructive pulmonary disease, coronary artery disease, diabetes, hypertension, ischemic heart disease, tobacco use, and inpatient status found that age (adjusted odds ratio [OR], 0.92; 95% confidence interval [CI], 0.85-0.99; P = .03), coronary artery disease (adjusted OR, 12.82; 95% CI, 1.18-140.02; P = .03), and inpatient setting (adjusted OR, 20.59; 95% CI, 3.48-401.65; P = .01) were significantly associated with complications. No procedure type was associated with complication rates Conclusions: Compared with the outpatient setting, inpatient hip arthroscopy is associated with higher rates of readmission in a cohort matched for age, sex, and comorbidities. Complications after inpatient hip arthroscopy appear to be related to comorbidities rather than procedure-related factors. The decision to conduct an inpatient hip arthroscopy should prioritize consideration of patient comorbidities over the type of procedure Level of Evidence: Level III, retrospective cohort study.

The lateral patellofemoral ligament acts to resist medial displacement of the patella. When medial subluxation occurs, it usually has an iatrogenic cause such as prior lateral release, an over-tightened medial patellofemoral ligament reconstruction, or detachment of the vastus lateralis from the patella. The justification for lateral retinacular release has historically been to address extensor mechanism issues such as imbalance of the mechanism due to increased retinacular tension. We present a Technical Note on the treatment of chronic medial patellar instability due to a previous lateral retinacular release using a soft-tissue reconstruction approach with a semitendinosus allograft.

Abstract: As elective surgery slowly reopens across the country, it is paramount that surgeons recognize and take responsibility for their roles in protecting patient safety during the coronavirus disease 2019 pandemic. Namely, these include (1) to prevent further spread of the severe acute respiratory syndrome-CoV-2 virus, (2) to understand the shift in injuries that has occurred as a result of altered lifestyles led by our patients, and (3) to leverage our platforms to disseminate information regarding how individuals can maintain musculoskeletal health during the pandemic. Efforts taken to reduce the spread of severe acute respiratory syndrome-CoV-2 virus can be focused on 3 broad categories of provider–patient interaction: preoperative and clinic visits, surgical encounters, and postoperative care.

In the past decade, the number of hip arthroscopy procedures has exponentially increased, primarily for the treatment of femoroacetabular impingement syndrome and labral lesions. As the techniques have evolved, so has the acknowledgment of the potential complications, including iatrogenic instability that may result from soft-tissue laxity, subtle dysplastic morphologies, or residual defects from capsulotomies in which the capsular closure is insufficient. In most cases, direct capsular repair or plication can be performed at the conclusion of the procedure; however, larger defects, poor-quality tissue, or cases of gross ligamentous laxity may require reconstruction or augmentation. In such instances, several options exist. The purpose of this technical note is to describe a capsular repair augmentation with a bioinductive implant during revision hip arthroscopy.

Greater trochanteric pain syndrome can be caused by gluteus medius and minimus tendinopathy/tears and chronic trochanteric bursitis. Specifically, moderate-to-severe abductor tendon tears can cause severe lateral hip pain, limp, and abnormal gait. A variety of open and endoscopic techniques to treat glut abductors hip tears have been described. The use of scaffolds, such as acellular human dermal allograft, to augment tendon repair, already has been successfully reported in rotator cuff repairs of the shoulder. Still, the use of acellular human dermal allograft in the hip has been limited. However, there are some clinical scenarios in which augmentation of abductors hip tendon repair with scaffold is indicated. Chronic or massive gluteus tears or revision cases may benefit from augmentation with a scaffold. The purpose of this technical note and accompanying video is to describe our indications, pearls, and pitfalls of repair of moderate to severe gluteus tears via a minimally invasive technique augmented with acellular human dermal allograft.

Preserving labral integrity has become a guiding principle in hip preservation surgery given the recent understanding of the importance of the acetabular labral suction seal. When labral tissue is deficient, a labral reconstruction may be indicated to re-create the suction seal and improve hip biomechanics. One of the main challenges of segmental labral reconstruction techniques is obtaining an accurate measurement of the defect because incorrect sizing of the graft could result in incomplete restoration of the labral seal or an oversized graft that requires amputation. In this report, we present a kite measurement technique that allows for easy, accurate measurement of the segmental defect during segmental labral reconstruction.

Glenoid chondral injuries constitute challenging injuries to treat because of the limited access and the limited options and evidence available for their resolution. The purpose of this Technical Note is to describe the procedure, pearls, and pitfalls of implantation of a cryopreserved osteochondral allograft (Cartiform) for the treatment of full-thickness cartilage defects of the shoulder. Cartiform is a cryopreserved osteochondral allograft composed of chondrocytes, chondrogenic growth factors, and extracellular matrix proteins that can be implanted through a single-stage procedure.

A snapping biceps tendon is an infrequently seen and commonly misdiagnosed pathology, leaving patients with persistent symptoms that can be debilitating. Patients will present with a visible, audible, and/or painful snap over the lateral aspect of their knee when performing squats, sitting in low seats, or participating in activities with deep knee flexion. A thorough knowledge of the anatomy is essential for surgical treatment of this pathology, which is caused by a detachment of the direct arms of the long and short heads of the biceps femoris off the fibular styloid. This Technical Note provides a diagnostic approach, postoperative management, and details of a surgical technique to treat a snapping biceps tendon with an anatomic repair of the long and short head attachments of the biceps femoris to the posterolateral fibular styloid.

BioCartilage (BC) is dehydrated, minced human hyaline articular cartilage that was developed as an adjunct to microfracture surgery to help stimulate the bone marrow and stem cells to form hyaline-like tissue in full-thickness chondral defects. The minced pieces of BC require a dry environment for application and can easily be disrupted by residual moisture of saline solution in the surrounding tissues. We present a technique of carbon dioxide insufflation during knee arthroscopy as a means of maintaining a dry environment for preparation of the bony bed during BC augmentation of microfracture surgery. This technique is safe and provides more than adequate visualization, as well as a dry environment, to make the arthroscopic application of BC significantly more efficient.

Meniscal ramp lesions have been reported to be present in 9% to 17% of patients undergoing anterior cruciate ligament reconstruction. Detection at the time of arthroscopy can be accomplished based upon clinical suspicion and careful evaluation without the use of an accessory posteromedial portal. Options for surgical treatment include arthroscopic repair using an all-inside or inside-out technique. The purpose of this Technical Note is to detail our arthroscopic inside-out repair technique for meniscal ramp lesions.

Over the past decade, hip-preservation strategies have gained momentum, resulting in a notable increase in the use of hip arthroscopy for diagnostic and therapeutic interventions in hip-related pathology. In this 3-part series, the authors will aim to comprehensively review the fundamentals of hip arthroscopy in the setting of femoroacetabular impingement. This Technical Note will thoroughly review the senior authors’ approach to managing the central compartment of the hip in the context of femoroacetabular impingement.

Over the past decade, hip-preservation strategies have gained momentum, resulting in a notable increase in the use of hip arthroscopy for diagnostic and therapeutic interventions in hip-related pathology. In this 3-part series, the authors will aim to comprehensively review the fundamentals of hip arthroscopy in the setting of femoroacetabular impingement. While considering the advantages and disadvantages of post versus postless hip arthroscopy, this Technical Note will review the preferred patient and portal positioning approach used by the senior authors.

Over the past decade, hip preservation strategies have gained momentum, resulting in a notable increase in the use of hip arthroscopy for diagnostic and therapeutic interventions for hip-related pathology. In this 3-part series, we aim to comprehensively review the fundamentals of hip arthroscopy in the setting of femoroacetabular impingement. This Technical Note will thoroughly review the senior authors’ approach to managing the peripheral compartment of the hip in the context of femoroacetabular impingement.

Achievement of appropriate mechanical knee alignment is crucial to ensure optimal clinical outcomes following osteotomy procedures about the knee. The use of patient-specific instrumentation (PSI) to assist in preoperative planning and intraoperative realignment has gained increasing popularity. The purpose of this article is to describe a surgical technique involving a medial closing wedge high tibial osteotomy performed using three-dimensional (3D) PSI and cutting guide to revise residual valgus deformity following failed distal femoral osteotomy. The correction angle, 3D position of the hinge and wedge, as well as final plate and screw position are planned preoperatively using virtual software and computed tomography imaging to allow precise surgical execution.

Purpose: To establish a better understanding of the variations in pain management protocols and prescribing patterns for pediatric patients undergoing anterior cruciate ligament (ACL) reconstruction or repair. Methods: A 20-question multiple-choice survey was distributed to 3 professional orthopaedic societies to assess the pre-emptive and postoperative pain management prescribing patterns for pediatric patients undergoing ACL reconstruction or repair. Clinical agreement (defined as agreement between >80% of participants) and general agreement (defined as agreement between >60% of participants) were calculated based on responses as previously reported. Results: Clinical agreement was observed among the 68 respondents in use of a single shot nerve block before induction of anesthesia versus continuous use when a peripheral nerve block was used, “always” counseling patients on postoperative pain control, the prescribing of opioids postoperatively, and a lack of change in postoperative protocol when concomitant meniscal repair or meniscectomy was performed. General agreement was observed in the use of a peripheral nerve block, some pre-emptive analgesia practices, and the lack of counseling patients with regard to disposal of unused opioid pain medication postoperatively. Opioids were prescribed by 88% of participants postoperatively, with 48% prescribing 11 to 19 pills and 15% prescribing ≥20 pills. Conclusions: While pain management practices before and following ACL reconstruction and repair in the pediatric population remain varied, opioids are frequently prescribed postoperatively with many providers neglecting to provide instruction on excess opioid disposal. Clinical Relevance: ACL reconstruction and repair is becoming increasingly common in the pediatric population. Clinical guidelines that establish pre-emptive and postoperative pain-control protocols should be considered to determine safe and optimal pain control throughout the duration of care while minimizing opioid prescribing and consumption.

Purpose: To determine whether 3-dimensional (3D)–reconstructed proximal femoral bone models can be used to quantify femoral osteochondroplasty and to determine whether the 3D-based metrics are related to clinical alpha angle measures. Methods: Six cadaveric specimens with cam-type morphology underwent open femoral osteochondroplasty. Alpha angles were measured on the oblique axial computed tomography slice before and after femoral osteochondroplasty. Preoperative and postoperative computed tomography–based 3D reconstructed femur models were generated for each cadaveric specimen. A 3D-3D registration technique was used to merge the preoperative and postoperative models to measure the surface-to-surface distance between the model surfaces. Bivariate correlation analyses were used to determine the correlations between the preoperative, and the difference between the preoperative and postoperative alpha angle (Δ alpha angle) measures and each of the femoral osteochondroplasty variables of surface area (mm2), volume (mm3), maximum height (mm), and mean height (mm). The strength of the bivariate correlations was defined as follows: weak 0.1 to 0.3, moderate 0.3 to 0.5, and strong as 0.5 to 1.00. Results: Bivariate correlations revealed a strong positive correlation between preoperative alpha angle with femoral osteochondroplasty volume (r = 0.899, P = .007) and surface area (r = 0.899, P = .007). No significant correlations were found between the change in alpha angle and the osteochondroplasty variables. Conclusions: In this study, pre- and postoperative 3D bone models could be used to quantify femoral osteochondroplasty and to determine if the 3D-based metrics are related to clinical alpha angle measures. Clinical Relevance: 3D-reconstructed image bone models may be helpful to ensure that adequate femoroplasty is performed intraoperatively, in particular with arthroscopic approach in which visualization may be challenging due to capsular management issues and surgeon experience.

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.

Arthroscopic reduction–internal fixation (ARIF) is an increasingly popular option for surgical management of displaced tibial eminence fractures. Although a variety of ARIF techniques have been described, anatomic reduction and stable fixation remain challenging. As a result, complications such as malunion, nonunion, anterior instability, arthrofibrosis, and hardware issues persist. In an effort to reduce complications and improve outcomes, modern suture-based ARIF techniques have been developed. However, the optimal technique and construct remain elusive. This article presents a technique for ARIF of tibial eminence fractures using a transosseous suture bridge construct with extracortical fixation. This technique uses a commercially available suture-passage device and meniscal root repair system for accurate tunnel placement, efficient suture management, and reliable fixation.

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.

The hip capsule and acetabular labrum are critical structures that function to protect and stabilize the hip joint. As the use of hip arthroscopy increases, there is increasing interest in the integrity of the hip capsule and labrum in optimizing postoperative function and outcomes. In this report, we describe the surgical technique for capsular reconstruction with dermal allograft and labral augmentation with tibialis anterior allograft for the treatment of gross instability after hip arthroscopy. This technique may be applied in situations with large capsular defects and deficient labral tissue.

Purpose: The purpose of this study is to identify and summarize the current utility of intraoperative ultrasound (US) during hip arthroscopy. Methods: A systematic database query of the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, EMBASE, PubMed (1980 to 2019), and Ovid MEDLINE (1980 to 2019) was performed. After article identification, descriptions of the surgical procedure, use of intraoperative US, procedural complications, and conclusions from each article were recorded and summarized. Results: Five studies met inclusion criteria, all of which were surgical techniques or technical notes. Four of the 5 studies described US used for placement of arthroscopic portals, and 1 described the use of an intraarticular US catheter for the assessment of an osteochondritis dissecans (OCD) lesion. Of the 4 studies using US for portal placement, 3 were performed supine and 1 was performed in the lateral decubitus position. All studies recognized the need for additional US training or the required assistance of a radiologist to incorporate US into a surgical practice. Conclusion: Descriptions of intraoperative US during hip arthroscopy are limited in the literature. However, existing technique reports demonstrate the feasibility of US for both portal placement with superficial probes and limited evaluation of cartilage using intraarticular US catheters. Level of Evidence: V, systematic review.

Purpose: The purpose of this study was to evaluate the reliability and educational content of YouTube videos concerning injuries to the posterior cruciate ligament (PCL) of the knee. Methods: The first 50 videos specific to the PCL identified through the YouTube query posterior cruciate ligament were evaluated by a method of video selection demonstrated to be feasible in prior YouTube studies. Videos were classified by content and upload source. Video reliability was assessed using the Journal of the American Medical Association (JAMA) benchmark criteria (score range 0-5). Video educational content was assessed using the Global Quality Score (GQS) (range 0-4) and the PCL Score (PCLS) (score range 0-18). Analysis of variance was used to determine differences in video reliability and educational content quality based on video content and upload source. Multivariate linear regressions were used to identify predictors of video reliability and educational content quality. Results: The mean number of views per video was 50,477.9 ± 15,036. Collectively, the 50 videos were viewed 14,141,285 times. Video content was classified primarily as information about disease (62.0%). The most common upload sources were physicians (24.0%) and nonphysician health care providers (26.0%). Significant between-group interactions were found between video source and the JAMA score, with physicians and medical sources having significantly higher mean JAMA scores (P = 0.037). Videos uploaded by physicians were an independent positive predictor of greater JAMA scores (β:1.27; P = 0.008). Videos uploaded by a medical source (β:2.06; P = 0.038) were an independent positive predictor of a greater GQS. There were no independent associations between video content category or upload source and the PCLS. Conclusions: Videos concerning the PCL were frequently viewed on YouTube, but the educational quality and reliability of these videos were low. Clinical Relevance: Physicians and health care providers treating PCL pathology should take the initiative to counsel patients about which outside resources are reliable to better inform patients about their treatment decisions. With regard to YouTube videos specifically, providers should caution their patients that this source of information may be unreliable.

Multiple different techniques exist for performing a biceps tenodesis, and the literature has yet to define a particular technique as superior with respect to outcomes. Factors as the center of various clinical and biomechanical studies include analyzing arthroscopic versus open techniques, optimal fixation sites, and the use specific fixation devices (i.e., anchor, screw). This article details an all-arthroscopic approach for proximal tenodesis of the long head of the biceps tendon (LHBT) using a 2-portal method in a minimally invasive manner. Optimal biomechanical fixation of the LHBT is achieve by using 2 suture anchors in the creation of a dual lasso-loop configuration at the level of the bicipital groove. Technical pearls with respect to optimal arthroscopic viewing, efficient identification of the LHBT and subsequent release from the bicipital groove, and appropriate use of suture anchors for lasso-loop creation are presented for review. Two specific technical advantages of this technique include 2 fixation points for the LHBT to minimize failure risk, and smaller drill holes when compared with commonly performed tenodesis screw techniques to theoretically limit humeral fracture risk.

Medial meniscal root tears are often disabling injuries that can occur in isolation during low-velocity, deep knee flexion maneuvers in middle-aged patients. The most common meniscal root tear pattern is a radial tear near the root attachment (type II). Root tears are often associated with meniscal extrusion, identified on magnetic resonance imaging. Relocation of the meniscal root to its anatomic center is a reported current difficulty faced by surgeons during surgical repair. However, this can be achieved via sufficient peripheral release of the posteromedial capsular attachment of the medial meniscus. The purpose of this Technical Note is to describe the authors' current surgical technique for medial meniscus root repair with a peripheral release for addressing meniscal extrusion. Classifications: level I (knee); level II (meniscus).

Revision quadriceps tendon repair presents a challenging problem for the treating surgeon because of associated anatomic defects such as large tendon-gap deficits and preexistent poor tissue quality. Current methods for revision quadriceps tendon repair use tendon autograft, which may predispose to additional morbidity because the repair relies only on soft tissue fixation. In this Technical Note, we describe a technique for revision of a failed quadriceps tendon repair with a large tendon gap using a trapezoidal plug Achilles tendon allograft. This technique constitutes a safe and effective approach to revising failed primary quadriceps tendon repairs, is suitable for large-gap defects, and has the ability to withstand large force transmissions.

Hip arthroscopy is commonly performed for the treatment of femoroacetabular impingement and labral pathology. When arthroscopy for femoroacetabular impingement is performed, a capsulotomy is often utilized to maximize access and allow for improved visualization. When an extended interportal or T capsulotomy is performed, the iliofemoral ligament is transected, which can lead to micro or gross instability. The purpose of this Technical Note is to describe an alternative approach to the standard T capsulotomy using a pie crusting technique, which provides improved visualization of the femoral head–neck junction during the femoroplasty without the need for an extended capsulotomy and can also serve to create venting holes that prevent hematoma formation within the capsule.

Anterior cruciate ligament (ACL) reconstruction is one of the most common procedures studied in the orthopaedic literature. In this regard, graft preparation is a key factor for successful outcomes. Although current methods to reconstruct the ACL are generally perceived to be successful, recent studies indicate that normal structure and function of the knee are fully restored in less than half of the patients. Therefore, biologically augmenting these scaffolds could provide a potential solution for improving healing times and biomechanical properties of the graft. The purpose of this Technical Note is to describe our preferred technique for an ACL graft preparation (quadriceps tendon) augmented with platelet-rich plasma.

Meniscal injuries and meniscal loss are associated with changes in knee kinematics and loading, ultimately leading to poor functional outcomes and increased risk of progression to osteoarthritis. Biomechanical studies have shown restored knee function, and clinical studies have reported improved outcomes and decreased risk of osteoarthritis after meniscal repair. This has led orthopaedic surgeons to try and save the meniscus by repair whenever possible, as shown by increasing incidence of meniscal repair surgeries. Historically, meniscal lesions, particularly those greater in size and located in the white-white region of the meniscus, have been shown to have poor healing. In recent years, there has been an increasing interest in the use of biologic agents to help stimulate and expedite healing in traditionally more avascular tissue. Preliminary results for biologic therapeutic agents, such as platelet rich plasma and bone marrow aspirate concentrate, have been encouraging. However, these options are more demanding in regard to time, financial burden, resources, and regulations than some more classic agents such as fibrin clots. Fibrin clot is readily available, easy to use, affordable, and minimally invasive. This Technical Note describes a step-by-step and reproducible technique for harvesting, preparation, and using a fibrin clot to augment healing of meniscal repairs.

Quadriceps tendinopathy in an increasingly recognized diagnosis can lead to quadriceps tendon rupture, especially in the older population. It can be caused by repeated micro trauma or also predisposed by systemic diseases such as diabetes mellitus and connective tissue disorders that can in turn lead to extensor mechanism deficits. Although a trial of conservative treatment is advocated, operative treatment should be performed in cases of persistent pain, extension deficit, or complete rupture of the tendon. The purpose of this Technical Note is to describe in detail a procedure for open repair of a quadriceps tendon, with significant degeneration due to quadriceps tendinopathy, using suture anchors and semitendinosus tendon allograft augmentation.

Anterior cruciate ligament reconstruction is one of the most commonly performed procedures in orthopaedics, with more than 125,000 performed in the United States per year. There are several reconstruction graft choices that can be used to reconstruct the native anterior cruciate ligament, with autograft hamstring tendons being one of the most commonly used. Preparation of a hamstring autograft varies depending on patient characteristics and physician preference. The purpose of this Technical Note is to describe in detail different variants of hamstring graft preparation techniques that are commonly used in practice.

A thorough evaluation of the hip must include a comprehensive medical and surgical history focused on the hip joint, surrounding soft tissues, and the associated structures of the spine, pelvis, and lower extremities. These details can guide the physical examination and provide insight into the cause of the patient's chief complaints. A proper examination includes physical examination while the patient is in the upright, supine, prone, and lateral position, as well as an evaluation of gait. Guided by a thorough history, the physical examination enables the surgeon to distinguish between intra-articular and extra-articular contributors to hip pain, selection of appropriate imaging modalities, and ultimately supports medical decision making.

The use of hip arthroscopy to treat various forms of hip pathology continues to grow. As part of a standard evaluation for eligibility for hip arthroscopy, we routinely obtain standard radiographs to assess the hip joint. These include orthogonal projections of the acetabulum and proximal femur, which can be obtained with a standing false profile, supine anteroposterior pelvis, and a lateral view of the proximal femur (either Dunn 45° or 90°, frog-leg lateral, or cross-table lateral). A comprehensive analysis of the radiographs is of utmost importance in order to indicate a patient for hip arthroscopy, for preoperative planning, and to determine prognosis. The purpose of this Technical Note is to provide a comprehensive guide of how our group performs qualitative and quantitative analysis of hip radiographs in a potential candidate for hip arthroscopy.

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

Radiologic imaging is an essential supplement to the physical examination in the evaluation of a patient with femoroacetabular impingement. Plain radiographs are the initial modality of choice for the evaluation of bony anatomy and pathology. Magnetic resonance imaging supplements the physical examination and standard radiographs by enabling qualitative and quantitative evaluation of both articular cartilage and soft tissues about the hip. Magnetic resonance imaging also provides improved 3-dimensional characterization of the bony anatomy owing to the multiplanar nature of this technique. This article describes a comprehensive approach to interpretation of magnetic resonance examination of the hip.

Bucket-handle tears of the meniscus comprise nearly 10% of all meniscus tears and commonly affect the young male population. Displacement of the free segment can lead to significant pain and disability, necessitating reduction and surgical treatment. General contraindications include malalignment, severe arthritis, significant comorbidities, or chronic asymptomatic tears, but otherwise repair should almost always be performed. Options for surgical treatment include partial meniscectomy and arthroscopic repair using an all-inside, outside-in, or inside-out technique. The purpose of this Technical Note is to detail our arthroscopic inside-out repair technique augmented with bone marrow aspirate concentrate.

Chondral lesions of the knee can affect the young, active population, thereby causing severe morbidity and a large economic burden. Although numerous approaches have been described in the literature, restoration of hyaline cartilage has yet to be shown. Specifically, larger, full-thickness cartilage defects remain a challenge. This Technical Note details our technique for biologic unicompartmental osteochondral allograft transplantation for the treatment of large femoral condyle articular cartilage defects.

An anterior cruciate ligament (ACL) tear is one of the most common orthopaedic injuries. Optimal results are not always achieved after surgical reconstruction after a surgical technical error, namely, tunnel malposition. Understanding of the anatomy is vital, and several anatomic landmarks can be used to aid in an optimal reconstruction technique. The purpose of this Technical Note is to describe our preferred technique for an arthroscopic single-bundle anteromedial ACL reconstruction, using a bone–patellar tendon–bone autograft fixed with interference screws.

Biological augmentation and therapeutics are being increasingly used in musculoskeletal and orthopaedic care. Platelet-rich plasma (PRP) is produced from centrifugation of peripheral blood, a process that concentrates platelets within autologous plasma. The process of PRP preparation is fundamental in controlling the contents, and it influences its therapeutic potential. Platelets contain alpha granules that store and release a variety of growth factors and other proteins that may augment the healing environment; PRP also has the added benefit of promoting postsurgical hemostasis. The purpose of this report was to detail our institutional preparation protocol and method of administration of PRP during hip arthroscopy.