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General awareness and clinical utilization of orthobiologic therapy has increased sharply in the recent years. Orthobiologics can be defined as "biological materials and substrates that promote bone, ligament, muscle, and tendon healing." There are 3 major strategies by which orthobiologics are thought to augment tissue repair or native biologic potential: factor-based, cell-based, and biomechanical augmentation. The purpose of this review is to synthesize the recent literature on orthobiologic techniques for surgical augmentation, with focus on several key areas including meniscus repair, osteochondral grafting, and rotator cuff repair.

Tibiofemoral rotation through the knee joint, specifically relative external tibial rotation, has been identified as a potential contributing factor to patellar instability. The purpose of this study is to investigate the relationship between severity of instability with degree of tibiofemoral rotation in three clinical cohorts: fixed or obligatory dislocators (in which the patella either is constantly laterally dislocated or laterally dislocates with every instance of knee flexion, respectively), standard traumatic instability patients, and normal controls. A retrospective study was performed with three cohorts from April 2009 to February 2019: fixed or obligatory dislocators, standard traumatic instability patients, and controls with normal magnetic resonance imaging (MRI) of the knee. All fixed or obligatory dislocation patients from the study time frame were analyzed; controls and standard traumatic instability patients were randomly selected. Inclusion criteria were age under 18 years and qualifying diagnosis; exclusion criteria were outside institution MRI and previous MPFL reconstruction or tibial tubercle osteotomy. Tibiofemoral rotation was measured blindly on initial axial MRI using the posterior femoral and tibial condylar lines. Tibial tubercle to trochlear groove distance (TT–TG) was measured. Intraclass correlation coefficient (ICC) was calculated among four measurers. A total of 100 patients were included, 20 fixed or obligatory dislocators, 40 standard traumatic instability patients, and 40 controls. Median age was 13.2 years (range 10–17 years), with 55 females. Age was significantly higher in the standard traumatic instability group than both the control (p

Objective. Quantification of meniscus vascularity has been limited with previous techniques, and minimal data exist describing differential vascular zones in the skeletally immature meniscus. The objective of this study is to use quantitative contrast-enhanced magnetic resonance imaging (MRI) to compare meniscal vascularity in neonatal specimens with adults. We hypothesized that the developing meniscus has greater and more uniform vascularity throughout all zones. Design. Ten fresh-frozen human cadaveric knees (5 neonatal, age 0-6 months; 5 adult, 34-67 years) underwent gadolinium-enhanced MRI using an established vascularity quantification protocol. Regions of interest corresponding to peripheral and central zones of the meniscus were identified on pre-contrast coronal images, and signal enhancement within the same regions (normalized against background tissue) was compared between pre- and post-contrast images. Results. The medial and lateral menisci had similar distribution of perfusion (45.8% ± 8.1% medial vs. 54.2% ± 8.1% lateral in neonatal knees; 50.6% ± 11.3% medial vs. 49.4% ± 11.3% lateral in adult knees, P = 0.47). Increased perfusion was demonstrated in the periphery compared with the central zone (2.3:1 in neonatal knees and 3.25:1 in adult knees, P = 0.31). Neonatal specimens demonstrated 6.0-fold greater overall post-contrast meniscal signal enhancement compared with adults ( P < 0.0001), with the 0-month specimen demonstrating the greatest proportional signal enhancement. Conclusions. While blood flow to the periphery is greater than to central zones in all menisci, younger menisci receive proportionally greater overall blood flow compared to adults, including to the central zone, suggesting that the immature meniscus is a more biologically active tissue than its adult counterpart.

Surgical reconstruction of the anterior cruciate ligament (ACL) is often indicated to restore functional stability and prevent early degeneration of the knee joint, as there is little biological healing capacity of the native ACL. Although a reconstructed ACL does not fully restore the original structure or biomechanics properties of the native ACL, the graft used for reconstruction must not only have structural and mechanical properties that closely resemble those of the native ligament, it must also have minimal antigenicity and enough biological potential to incorporate into host bone. There are several considerations in graft selection: autograft versus allograft, and soft tissue grafts versus grafts with bone plugs. Commonly used grafts include bone-patella tendon-bone, hamstring, and quadriceps; among allografts, options further include tibias anterior and posterior, Achilles, an peroneal tendons. Optimal graft selection is not only dependent on graft properties, but perhaps more importantly on patient characteristics and expectations. The purpose of this review is to summarize the relevant biological, biomechancial, and clinical data regarding various graft types and to provide a basic framework for graft selection in ACL reconstruction.

Elbow injuries are frequently seen in throwing and overhead athletes. This review provides a framework for diagnosis, treatment, and particularly rehabilitation of common elbow pathologies, including ulnar collateral ligament injury, valgus extension overload, and medial and lateral epicondylitis. Advanced rehabilitation facilitates complete return to functional sport-specific activity and is based on objective criteria. As diagnostic and therapeutic modalities improve our understanding of elbow pathologies in the athletic patient, continued research will further elucidate objective evidence-based rehabilitation techniques.

Anterior cruciate ligament (ACL) rupture is common in the general population, with an incidence of up to 75 per 100,000 person-years (Herzog et al., Sports Health 10(6):523–531, 2018), and is occurring more frequently in the young, active population with early sports participation (Beck et al., Pediatrics 139(3):e20161877, 2017). Following careful evaluation and accurate diagnosis with history, physical examination, and relevant imaging, surgical reconstruction of the ruptured ACL may be performed using various graft types and fixation techniques, with the goal of return to sport restoration of knee stability and prevention of degenerative changes (Sanders et al., Am J Sports Med 44(7):1699–1707, 2016; Sanders et al., Knee Surg Sports Traumatol Arthrosc 25(2):493–500, 2017). As incidence of ACL injury and ACL reconstruction continue to increase, it is imperative to define clear indications for who needs ACL surgery.

Posterolateral corner injuries can be challenging to diagnose and require a thorough evaluation of relevant history, physical exam, and imaging. If left untreated, these injuries can result in chronic knee pain, instability, and inability to return to work or sports. This chapter will review basic posterolateral corner anatomy and biomechanics, operative indications, surgical techniques, postoperative rehabilitation, outcomes, and potential complications to provide surgeons a framework for managing patients with these complex injuries. The authors’ preferred technique is a fibula-based posterolateral corner reconstruction utilizing a single Achilles tendon allograft to reconstruct the lateral collateral ligament, popliteus tendon and popliteofibular ligament, which is performed in conjunction with a posterolateral capsular shift. The technique is based on anatomic sockets and graft placement. Furthermore, since posterolateral corner injuries are often part of a multiligamentous injury pattern, it is important to address concurrent anterior cruciate and posterior cruciate ligament injuries at the time of surgery, because anteroposterior instability has been shown to increase forces on the posterolateral corner reconstruction and may result in graft failure. Postoperative rehabilitation follows a staged approach progressing from restoring knee range of motion to building muscular endurance, strength, and power. Short- to mid-term follow-up studies show excellent clinical and functional outcomes, and low risk for subsequent revision surgery.

Surgical reconstruction is the current standard for ACL rupture treatment in active individuals. Recently, there is renewed interest in primary repair of proximal ACL tears. Despite this, ACL biology and healing potential are currently not well understood. Vascularity is paramount in ACL healing; however, previous ACL vascularity studies have been limited to qualitative histological and dissection-based techniques. The study objective was to use contrast-enhanced quantitative-MRI to compare relative perfusion of proximal, middle, and distal thirds of the in situ ACL. We hypothesized perfusion would be greatest in the proximal third.Fourteen cadaveric knees were studied (8 females, 6 males), age 25-61 years. Superficial femoral, anterior tibial, and posterior tibial arteries were cannulated; without intraarticular dissection. Contrast-enhanced quantitative-MRI was performed using a previously established protocol. ACL regions corresponding to proximal, middle, and distal thirds were identified on sagittal-oblique pre-contrast images. Signal enhancement (normalized to tibial plateau cartilage) was quantified to represent regional perfusion as a percentage of total ACL perfusion. Comparative statistics were computed using repeated measures ANOVA, and pairwise comparisons performed using the Bonferroni method.Relative perfusion to proximal, middle, and distal ACL zones were 56.0% ±17.4%, 28.2% ±14.6%, and 15.8% ±16.3%, respectively (p = 0.002). Relative perfusion to the proximal third was significantly greater than middle (p = 0.007) and distal (p = 0.001). No statistically relevant difference in relative perfusion was found to middle and distal thirds (p = 0.281). Post-hoc subgroup analysis demonstrated greater proximal perfusion in males (66.9% ± 17.3%) than females (47.8% ± 13.0%), p = 0.036.Using quantitative-MRI, in situ adult ACL demonstrated greatest relative perfusion to the proximal third, nearly 2 times greater than the middle third and 3 times greater than the distal third. Knowledge of differential ACL vascular supply is important for understanding pathogenesis of ACL injury and the process of biological healing following various forms of surgical treatment.

CASE Two cases are presented to highlight the indications, surgical technique, and early clinical outcomes associated with proximal humerus corrective osteotomy using a 90° cannulated blade plate in adolescent patients. CONCLUSION A complex deformity of the proximal humerus in the adolescent patient poses an uncommon yet debilitating clinical condition that is challenging to manage. We report a unique method for surgical correction and fixation using an infant hip osteotomy 90° blade plate that restores native shoulder anatomy, improves function, and has led to early clinical success.

Purpose While predominant blood supply to the adult patella enters inferomedially, little is known about skeletally immature patellar perfusion. Improved knowledge of immature patella vascularity can further understanding of osteochondritis dissecans, dorsal defects of the patella and bipartite patella, and help ensure safe surgical approaches. We hypothesized that the immature patella would exhibit more uniform blood flow. The study purpose was to quantify immature patella regional perfusion in comparison with adults. Methods Ten cadaveric knees were utilized (five immature, five mature). The superficial femoral artery was cannulated proximally. Signal enhancement increases were compared from pre- to post-contrast MRI to assess relative arterial contributions to patella regions (quadrants, anterior/posterior, superior/inferior, medial/lateral, and outer/inner). Results Quantitative-MRI analysis revealed similar distribution of enhancement between the immature and mature patella. The inferior pole exhibited significantly higher arterial contribution versus superior pole in both immature and mature groups (p = 0.009; both groups), while the inferomedial quadrant had the highest arterial contribution of all quadrants in both groups. The superolateral quadrant demonstrated the lowest arterial contribution in the immature group and second lowest in the adult group. The patella outer periphery had significantly greater arterial contribution than the inner central region in both immature (p = 0.009) and mature (p = 0.009) groups. Conclusion Distribution of arterial contributions between the immature and mature patella was similar. Our results highlight the importance of inferior and inferomedial blood supply in both immature and mature patellas. These findings have implications for paediatric and adult patients; surgical damage to inferior patellar vessels should be avoided to prevent associated complications.

Purpose: Injury to or abnormality of developing distal femoral chondroepiphysis blood supply has been implicated in osteochondritis dissecans development. Progressive decrease in epiphyseal cartilage blood supply occurs in normal development; however, based on animal studies, it is hypothesized that there is greater decrease in regions more prone to osteochondritis dissecans lesions. We aimed to quantify differential regional perfusion of the immature distal femoral chondroepiphysis. We hypothesized there is decreased perfusion in the lateral aspect of the medial femoral condyle, the classic osteochondritis dissecans lesion location. Methods: Five fresh-frozen human cadaveric knees (0–6 months old) were utilized. The superficial femoral artery was cannulated proximally and contrast-enhanced magnetic resonance imaging performed using a previously reported protocol for quantifying osseous and soft tissue perfusion. Regions of interest were defined, and signal enhancement changes between pre- and post-contrast images, normalized to background muscle, were compared. Results: When comparing average normalized post-contrast signal enhancement of whole condyles, as well as distal, posterior, and inner (toward the notch) aspects of the medial and lateral condyles, no significant perfusion differences between condyles were found. In the medial condyle, no significant perfusion difference was found between the medial and lateral aspects. Conclusion: We quantified immature distal femoral chondroepiphysis regional vascularity in the early post-natal knee. In specimens aged 0–6 months, no distinct watershed region was detected. Despite possible limitations, given small sample size, as well as resolution of magnetic resonance imaging and analysis, our results suggest the hypothesized vascular abnormality predisposing osteochondritis dissecans either does not occur universally or occurs after this developmental age.

Background: Fresh osteochondral allograft transplant (OCA) has good outcomes in the knee. However, donor tissue for patellar OCA is limited. Outcomes after nonorthotopic OCA of the patella using more readily available femoral condylar allograft (FCA) tissue have not been previously reported. Purpose: To assess short-term magnetic resonance imaging (MRI) and minimum 2-year clinical outcomes of nonorthotopic patellar OCA using an FCA donor. Study Design: Case series; Level of evidence, 4. Methods: A prospective institutional cartilage registry was reviewed to identify patients treated with patellar OCA using an FCA donor between August 2009 and June 2016. OCA plugs were obtained from the FCA at its trochlear-condylar junction and implanted into the recipient patellar lesion. Early postoperative MRI scans were graded by a blinded musculoskeletal radiologist using the Osteochondral Allograft MRI Scoring System (OCAMRISS). International Knee Documentation Committee Subjective Knee Evaluation Form (IKDC), Knee Outcomes Survey–Activities of Daily Living (KOS-ADL), and pain visual analog scale (VAS) scores were collected preoperatively and at minimum 2 years postoperatively, and outcomes were compared using the paired t test. Results: A total of 25 patients were included for clinical outcome analysis and 20 patients for MRI analysis. MRI scans obtained at a mean of 11.4 months (range, 6-22 months) postoperatively showed a mean total OCAMRISS score of 9.0 (range, 7-11); mean bone, cartilage, and ancillary subscores were 2.6, 3.7, and 2.6, respectively. At the latest follow-up (mean, 46.5 months; range, 24-85 months), postoperative improvements were noted in IKDC (from 45.0 to 66.2; P = .0002), KOS-ADL (from 64.3 to 80.4; P = .0012), and VAS (from 5.1 to 3.4; P = .001) scores, with IKDC and KOS-ADL scores above the corresponding previously reported minimal clinically important difference. Conclusion: In this study, patellar OCA using nonorthotopic FCA led to significant short-term improvements in pain and patient-reported outcomes. The majority of nonorthotopic patellar grafts demonstrated full osseous incorporation and good restoration of the articular surface on MRI at short-term follow-up.

The published article contained four sentences with incorrect reference citations. Here, those sentences and the reference list are corrected.

Tibiofemoral rotation through the knee joint, specifically relative external tibial rotation, has been identified as a potential contributing factor to patellar instability. The purpose of this study is to investigate the relationship between severity of instability with degree of tibiofemoral rotation in three clinical cohorts: fixed or obligatory dislocators (in which the patella either is constantly laterally dislocated or laterally dislocates with every instance of knee flexion, respectively), standard traumatic instability patients, and normal controls.A retrospective study was performed with three cohorts from April 2009 to February 2019: fixed or obligatory dislocators, standard traumatic instability patients, and controls with normal magnetic resonance imaging (MRI) of the knee. All fixed or obligatory dislocation patients from the study time frame were analyzed; controls and standard traumatic instability patients were randomly selected. Inclusion criteria were age under 18 years and qualifying diagnosis; exclusion criteria were outside institution MRI and previous MPFL reconstruction or tibial tubercle osteotomy. Tibiofemoral rotation was measured blindly on initial axial MRI using the posterior femoral and tibial condylar lines. Tibial tubercle to trochlear groove distance (TT-TG) was measured. Intraclass correlation coefficient (ICC) was calculated among four measurers.A total of 100 patients were included, 20 fixed or obligatory dislocators, 40 standard traumatic instability patients, and 40 controls. Median age was 13.2 years (range 10-17 years), with 55 females. Age was significantly higher in the standard traumatic instability group than both the control (p 0.001) and fixed or obligatory dislocator groups (p = 0.003). ICC for TT-TG and tibiofemoral rotation were 0.92 and 0.96, respectively. Fixed or obligatory dislocator patients averaged 8.5° external tibiofemoral rotation, standard traumatic instability patients 1.6° external tibiofemoral rotation, and controls 3.8° internal tibiofemoral rotation. Both tibiofemoral rotation and TT-TG were highest in the fixed or obligatory dislocator cohort, followed by the standard traumatic instability cohort, and lowest in the controls (p 0.0001 for tibiofemoral rotation and TT-TG). Multivariate analysis showed no correlation between age and tibiofemoral rotation.Measurement of tibiofemoral rotation was reproducible with excellent interrater reliability. The degree of tibiofemoral rotation is correlated with severity of patellar instability, with the greatest external tibiofemoral rotation in fixed or obligatory dislocator patients, followed by standard traumatic instability patients, and slight internal tibiofemoral rotation in controls. High external tibiofemoral rotation may be an important pathoanatomic factor in fixed or obligatory dislocators, and with further understanding may become a prognostic factor or surgical target.III.

PURPOSE OF REVIEW: Injuries to the elbow ulnar collateral ligament (UCL) are especially common in the overhead throwing athlete. Despite preventative measures, these injuries are occurring at increasing rates in athletes of all levels. UCL reconstruction techniques generally require a prolonged recovery period and introduce the potential for intraoperative complications prompting investigations into more conservative treatment measures based on specific patient and injury characteristics. The purpose of this review is to describe the current literature regarding the use of biologic augmentation in the management of UCL injuries. Specifically, this review will focus on the basic science background and clinical investigations pertaining to biologic augmentation utilizing platelet-rich plasma (PRP) and autologous stem cells. RECENT FINDINGS: Despite some evidence supporting the use of PRP therapy in patients with partial UCL tears, there is no current consensus regarding its true efficacy. Similarly, due to a lack of clinical investigations, no consensus exists regarding the utilization of autologous stem cell treatments in the management of UCL injuries. SUMMARY: Management of UCL injuries ranges from non-operative treatment with focused physical therapy protocols to operative reconstruction. The use of biologic augmentation in these injuries continues to be investigated in the orthopedic community. Currently, no consensus exists regarding the efficacy of either PRP or autologous stem cells and further research is needed to further define the appropriate role of these treatments in the management of UCL injuries.

Background: Despite advances in surgical techniques, implant technology, and biological augmentation, one innate limitation to meniscus healing is lack of vascularity. Ability to quantify meniscal vascularity has been limited with previous techniques, and minimal data exists describing differential vascular zones in the skeletally immature meniscus. Purpose/Hypothesis: The objective of this study is to use quantitative contrast-enhanced magnetic resonance imaging (MRI) to compare meniscal vascularity in pediatric cadaveric specimens to adults. We hypothesize that the developing meniscus has greater and more uniform vascularity throughout all zones. Methods: We utilized 10 fresh-frozen human cadaveric knees (5 immature knees, age 0-6 months; 5 mature knees, age 34-67 years). Gadolinium-enhanced MRI was performed using a previously established vascularity quantification protocol. Regions of interest corresponding to peripheral and central zones of the meniscus were identified on pre-contrast coronal images, and signal enhancement (normalized against background tissue) was compared between pre-and post-contrast images (Figure 1). Results: Quantitative MRI demonstrated increased perfusion in the peripheral zones compared to the central zones (2.3:1 in immature knees and 3:1 in mature knees) in the medial and lateral menisci separately, and both menisci aggregated. Overall, the medial and lateral menisci had similar levels of perfusion in all specimens (45.9% ± 8.3% medial vs. 54.1% ± 8.3% lateral in immature knees; 50.5% ± 11.3% medial vs. 49.5% ± 11.3% lateral in mature knees). Immature specimens demonstrated greater overall normalized meniscal signal uptake, with the 0-month specimen demonstrating the greatest proportional signal enhancement. Conclusion: While blood flow to peripheral zones is greater than to central zones in both immature and adult menisci, younger menisci receive proportionally greater overall blood flow compared to adults, including greater blood flow to the inner zone, challenging the conventional wisdom of the central zone being avascular. As younger patients become increasingly active in sports, thorough understanding of the immature meniscus is required. Greater overall vascularity, including centrally, to the developing meniscus suggests improved healing potential following injury, and further encourages meniscal preservation when possible. Figure 1. Analysis of meniscal vascularity using contract-enhanced magnetic resonance imaging. A:Schematic drawing of peripheral and central zones of the medial and lateral menisci used for quantification.B:Mid-coronal images showing pre-and post contract images with ROIs delineated in adult and pediatric specimens; there is significatly increased perfusion to the epiphysis in the immature knee. Figure 2. Quantification of mensical vascularity in each specimen Comparsion of relative vascularity of peripheral versus central zones shows significantly greater blood flow to outer zone across all specimens.Quantification of total vascular contribution from the medial and lateral menisci aggregated showed a trend towards greater proportional blood flow in younger specimens.

Background:Poor osseous integration after fresh osteochondral allograft transplantation (OCA) may be associated with graft subsidence and subchondral bone collapse after implantation. The augmentation of OCA with bone marrow aspirate concentrate (BMAC) has been hypothesized to improve osseous incorporation of the implanted allograft.Purpose:To evaluate the effect of autogenous BMAC treatment on osseous integration at the graft-host bony interface after OCA.Study Design:Cohort study; Level of evidence, 3.Methods:A retrospective review of patients treated with OCA+BMAC or OCA alone for full-thickness chondral defects of the distal femur from March 2015 to December 2016 was conducted. Seventeen knees treated with OCA+BMAC and 16 knees treated with OCA alone underwent magnetic resonance imaging (MRI) in the early postoperative phase (mean, 6 months). Eighteen knees treated with OCA+BMAC and 16 knees treated with OCA alone underwent MRI in the late postoperative phase (mean, 12 months). Bone, cartilage, and ancillary features on MRI were graded using the Osteochondral Allograft MRI Scoring System (OCAMRISS) by a musculoskeletal radiologist blinded to the patient’s history and treatment.Results:There were no significant differences in the demographics or lesion characteristics between treatment groups in either postoperative phase. In the early postoperative phase, the mean OCAMRISS bone score was 3.0 ± 0.7 and 3.3 ± 0.7 for the OCA+BMAC group and OCA alone group, respectively ( P = .76); 71% (OCA+BMAC) and 81% (OCA alone) of MRI scans demonstrated discernible clefts at the graft-host junction ( P = .69), and 41% (OCA+BMAC) and 25% (OCA alone) of MRI scans demonstrated cystic changes at the graft and graft-host junction ( P = .46). In the late postoperative phase, the mean OCAMRISS bone score was 2.7 ± 0.8 and 2.9 ± 0.8 for the OCA+BMAC group and OCA alone group, respectively ( P = .97); 44% (OCA+BMAC) and 63% (OCA alone) of MRI scans demonstrated discernible clefts at the graft-host junction ( P = .33), and 50% (OCA+BMAC) and 31% (OCA alone) of MRI scans demonstrated the presence of cystic changes at the graft and graft-host junction ( P = .32). The mean OCAMRISS cartilage, ancillary, and total scores were not significantly different between groups in either postoperative phase.Conclusion:OCA augmented with BMAC was not associated with improved osseous integration; decreased cystic changes; or other bone, cartilage, and ancillary feature changes compared with OCA alone.

Objectives: Tibial tubercle to trochlear groove distance (TT-TG) and external tibiofemoral rotation (TFR) through the knee joint have been identified as potential contributing factors to patellar instability. In patients with a fixed or obligatory lateral patella dislocation (FOD), the normal force vector of the extensor mechanism is altered, so instead of a direct axial pull to cause extension, it exerts a lateralizing and external rotatory force on the tibia via the tibial tubercle. The purpose of this study is to investigate postoperative changes in TT-TG and TFR after medial patellofemoral ligament reconstruction (MPFLR) in two clinical cohorts: standard traumatic patellar instability (SPI) patients and FOD patients. We hypothesized that by surgically relocating the patella in the trochlea, and re-establishing medial sided soft tissue tension, the increased medializing force vector on the patella may exert enough force to alter resting rotation of the tibia in relation to the femur in the FOD group. Methods: A retrospective study was performed from April 2009 to February 2019. FOD and SPI patients under 18 years with available magnetic resonance imaging (MRI) of the knee before and after MPFLR were eligible. All FOD patients in the time frame were analyzed and SPI patients were randomly selected. Exclusion criteria were outside institution MRI, concomitant alignment procedures done at the time of MPFLR, and prior MPFLR or tibial tubercle osteotomy. TT-TG and TFR (using the posterior femoral and tibial condylar lines) were measured blindly on initial axial MRI. Statistical analysis using a paired sample t-test was performed with significance set at pResults: A total of 30 patients were included, 14 in the FOD group and 16 in the SPI group. The mean age at time of surgery was 13.9 years (range 10-17 years), 53% of the cohort was female, and the mean time from surgery to follow-up MRI was 2.0 years. Demographics by group are shown in Table 1. TT-TG and TFR were not significantly different preoperatively versus postoperatively in the SPI group (Table 2). In the FOD group, both TT-TG (17.7 vs 13.7, P=.019) and TFR (8.6 vs 3.1, P=.025) decreased significantly on postoperative MRI. Conclusions: The postoperative decrease in TT-TG and TFR in the FOD group suggests that MPFLR in fixed or obligatory dislocators can improve the external rotation deformity through the level of the joint, and thus may help normalize the forces acting through the extensor mechanism. [Table: see text][Table: see text]

Background: Tibial tubercle to trochlear groove distance (TT-TG) and external tibiofemoral rotation (TFR) through the knee joint have been identified potential contributing factors to patellar instability. In patients with a fixed or obligatory lateral patella dislocation (FOD), the normal force vector of the extensor mechanism is altered, so instead of a direct axial pull to cause extension, it exerts a lateralizing and external rotatory force on the tibia via the tibial tubercle. Hypothesis/Purpose: The purpose of this study is to investigate postoperative changes in TT-TG and TFR after medial patellofemoral ligament reconstruction (MPFLR) in two clinical cohorts: standard traumatic patellar instability (SPI) patients and FOD patients. We hypothesized that by surgically relocating the patella in the trochlea, and re-establishing medial sided soft tissue tension, the increased medializing force vector on the patella may exert enough force to alter resting rotation of the tibia in relation to the femur in the FOD group. Methods: A retrospective study was performed from April 2009 to February 2019. FOD and SPI patients under 18 years with available magnetic resonance imaging (MRI) of the knee before and after MPFLR were eligible. All FOD patients in the time frame were analyzed and SPI patients were randomly selected. Exclusion criteria were outside institution MRI, concomitant alignment procedures done at the time of MPFLR, and prior MPFLR or tibial tubercle osteotomy. TT-TG and TFR (using the posterior femoral and tibial condylar lines) were measured blindly on initial axial MRI. Statistical analysis using a paired sample t-test was performed with significance set at pResults: A total of 30 patients were included, 14 in the FOD group and 16 in the SPI group. The mean age at time of surgery was 13.9 years (range 10-17 years), 53% of the cohort was female, and the mean time from surgery to follow-up MRI was 2.0 years. Demographics by group are shown in Table 1. TT-TG and TFR were not significantly different preoperatively versus postoperatively in the SPI group (Table 2). In the FOD group, both TT-TG (17.7 vs 13.7, P=.019) and TFR (8.6 vs 3.1, P=.025) decreased significantly on postoperative MRI. Conclusion: The postoperative decrease in TT-TG and TFR in the FOD group suggests that MPFLR in fixed or obligatory dislocators can improve the external rotation deformity through the level of the joint, and thus may help normalize the forces acting through the extensor mechanism. Tables/ Figures [Table: see text][Table: see text]

To investigate return to play (RTP) and functional performance after anterior cruciate ligament reconstruction (ACLR) in National Basketball Association (NBA) players and to perform a systematic review of the literature to understand RTP after ACLR in professional basketball.NBA players undergoing ACLR between 2008 and 2014 by two surgeons were identified. RTP and performance were assessed based on a review of publically available statistics. A systematic review of the literature was performed using the MEDLINE database. Inclusion criteria were: English language, ACL surgery outcome, professional basketball and RTP outcome. We reviewed studies for RTP rates and RTP performance.Our study included 12 professional basketball players with NBA level experience. Eleven of the 12 players returned to their prior level of play. Eight of the 9 (88.9%) players actively playing in the NBA returned to play in the NBA at a mean 9.8 months. Among players returning to NBA play, during RTP season 1, mean per game statistics decreased for the following: minutes, points, rebounds, assists, steals, blocks, turnovers and personal fouls - none of these changes reached statistical significance. Player efficiency ratings significantly declined from pre-injury (12.5) to the first RTP season (7.6) (p = 0.05). By RTP season 2, player performance metrics approximated pre-injury levels and were not significantly different. Six studies met inclusion criteria; reported RTP rates ranged from 78-86%. Identified studies similarly found a decline in functional performance after RTP.There is a high rate (89%) of return to NBA play for NBA players undergoing ACLR. After RTP, however, there is a quantitative decline in initial season 1 RTP statistics with a significant decrease in player efficiency rating. By RTP season 2, performance metrics demonstrated an improvement compared to RTP season 1 but did not reach pre-injury functional performance, though performance metrics are not significantly different between pre-injury and RTP season 2.

Objectives: Tibiofemoral rotation (TFR), specifically external tibial rotation, has been recently identified as a potential contributing factor to patellar instability. However, no previous studies have explored the clinical effects of differing degrees of TFR in relation to patellar instability. The purpose of this study is to investigate the relationship between severity of instability with degree of TFR. Our hypothesis is that fixed or obligatory dislocators (FOD) are more likely to have increased external TFR (tibial external rotation compared to femur) than standard patellar instability (SPI) patients requiring medial patellofemoral ligament (MPFL) reconstruction, who will have similar or slightly increased external TFR compared to normal controls. Methods: A retrospective study was performed with patients from 3 cohorts from April 2009 to February 2019: FOD, SPI, and controls with normal magnetic resonance imaging (MRI) of the knee. All FOD patients from the study time frame were analyzed, while controls and SPI patients were randomly selected. Patients were included for age under 18 years and diagnosis corresponding to one of the three cohorts, and excluded for outside institution MRI, and previous MPFL reconstruction or tibial tubercle osteotomy. TFR was measured on preoperative axial MRI using the posterior femoral and tibial condylar lines (Figure 1). Tibial tubercle to trochlear groove distance (TT-TG) was measured. Intraclass correlation coefficient (ICC) was calculated among 3 measurers. Statistical analysis using ANOVA and t-test was performed with significance set at α=0.05. Results: A total of 57 patients were included, 19 in each cohort. Average age was 13.2 years (range 10-17 years), with 31 females (54%). ICC for TT-TG and TFR were 0.90 and 0.72, respectively. TT-TG differed between the controls and SPI patients (both PConclusions: The degree of TFR is correlated with severity of patellar instability, with greater external tibial rotation seen in FOD than SPI patients, while TT-TG was not different. Further information on the relationship of TFR and patellar instability will not only improve understanding of pathogenesis and prognosis, but may also direct surgical treatment strategies in refractory or severe cases.

Background: Tibiofemoral rotation (TFR), specifically external tibial rotation, has been recently identified as a potential contributing factor to patellar instability. However, no previous studies have explored the clinical effects of differing degrees of TFR in relation to patellar instability. Purpose and Hypothesis: The purpose of this study is to investigate the relationship between severity of instability with degree of TFR. Our hypothesis is that fixed or obligatory dislocators (FOD) are more likely to have increased external TFR (tibial external rotation compared to femur) than standard patellar instability (SPI) patients requiring medial patellofemoral ligament (MPFL) reconstruction, who will have similar or slightly increased external TFR compared to normal controls. Methods: A retrospective study was performed with patients from 3 cohorts from April 2009 to February 2019: FOD, SPI, and controls with normal magnetic resonance imaging (MRI) of the knee. All FOD patients from the study time frame were analyzed, while controls and SPI patients were randomly selected. Patients were included for age under 18 years and diagnosis corresponding to one of the three cohorts, and excluded for outside institution MRI, and previous MPFL reconstruction or tibial tubercle osteotomy. TFR was measured on preoperative axial MRI using the posterior femoral and tibial condylar lines (Figure 1). Tibial tubercle to trochlear groove distance (TT-TG) was measured. Intraclass correlation coefficient (ICC) was calculated among 3 measurers. Statistical analysis using ANOVA and t-test was performed with significance set at α=0.05. Results: A total of 57 patients were included, 19 in each cohort. Average age was 13.2 years (range 10-17 years), with 31 females (54%). ICC for TT-TG and TFR were 0.90 and 0.72, respectively. TT-TG differed between the controls and SPI patients (both P

Case A 17-year-old boy had persistent knee pain 1 year after medial meniscal root repair augmented with bone marrow aspirate concentrate injection. Radiographs and magnetic resonance imaging (MRI) demonstrated an intrameniscal ossicle which was not present on MRI performed before 6 months. He underwent arthroscopic excision of the meniscal ossicle. At the 7-month follow-up, he had complete relief of his pain. Conclusions It is possible that the meniscal ossicle developed because of osteoinductive cells and cytokines from the injected bone marrow or the drill hole for root repair and should be considered as a possible complication of this procedure.

Objectives: Fresh osteochondral allograft transplantation (OCA), which transfers viable, mature hyaline cartilage and subchondral bone into full-thickness chondral defects, has demonstrated good long-term results in the knee. However, incomplete osseous trabecular integration of allograft bone with the host bone is correlated with inferior patient-reported outcomes (Williams et al, JBJS, 2007) and can lead to graft failure. As a result, augmentation of OCA with bone marrow aspirate concentrate (BMAC) has been hypothesized to improve osseous incorporation of the allograft compared to OCA alone. The purpose of this study was to compare the appearance of osseous integration at the host-graft junction on magnetic resonance imaging (MRI) in patients treated with BMAC+OCA versus patients treated with OCA alone. Methods: Between February 2013 and June 2016, 29 patients with full-thickness cartilage defects were treated with BMAC+OCA (n = 10) or OCA alone (n = 19) and followed prospectively with an MRI at approximately 12 months after surgery. Intraoperatively, bone marrow aspirate was harvested from the ipsilateral iliac crest (Magellan, Arteriocyte), and the allograft plug was soaked in BMAC prior to implantation. No patients received a concomitant meniscus allograft transplantation, realignment osteotomy, or anterior ligament reconstruction. Bone, cartilage, and ancillary features on postoperative MRI were assessed and graded using the Osteochondral Allograft MRI Scoring System (OCAMRISS) by a blinded musculoskeletal radiologist. This is a system that scores subchondral bone plate congruity, bone marrow signal intensity, osseous integration, and cystic changes of the graft and host-graft junction as part of the bone features assessment (Meric et al, Cartilage, 2015) (Table 1). Comparisons of demographic characteristics and OCAMRISS scores between groups were performed with the Mann-Whitney test. Results: The mean ages of the BMAC and control groups were 32.9 and 33.4 years, respectively (p = 0.95). Males comprised 60% of the BMAC group and 68% of the control group (p = 0.70). MRIs for the BMAC and control groups were obtained at a mean of 11.2 (range, 9-14) and 11.3 (range, 8-15) months after surgery, respectively (p = 0.87). Mean total OCAMRISS scores were not significantly different between groups (BMAC - 7.8, control - 8.0; p = 0.93). Furthermore, mean bone (BMAC - 2.3, control - 2.8; p = 0.22), cartilage (BMAC - 3.3, control - 3.0; p = 0.55), and ancillary (BMAC - 2.2, control - 2.3; p = 0.92) feature scores were not significantly different between groups. Imaging for 5 patients (50%) in the BMAC and 11 patients (59%) in the control groups (p = 0.71) demonstrated a persistent discernible cleft without crossing trabeculae at the host-graft junction (Figure 1). Almost all grafts (over 90%) demonstrated persistent subchondral marrow edema relative to the epiphyseal bone. Conclusion: The addition of autogenous BMAC to OCA did not enhance osseous integration and bony features at the host-graft junction compared to OCA alone at 12 months. Although more MRI follow-up of patients treated with BMAC+OCA is needed to confirm this finding, these results suggest that any augmentative biologic effect of BMAC for OCA, if one exists, is likely to be small. Table 1. Osteochondral Allograft Magnetic Reponance Imaging Scoring System (OCAMRISS) (adapted from Metric et al) MRI Feature MRI Score Bone Features 1. Subchondral bone plate congruity of graft and host-graft junction 0: Intract and flush; 1: Disrupted or not flush by >1 subchondral thickness 2. Subchondral bone marrow signal intensity of graft relative to epiphyseal bone 0: Normal; 1: Abnormal (bone marrow edema pattern or hypointensity on all sequences) 3. Osseous integration at host-graft junction 0: Crossing trabeculae; 1: Discernible cleft 4. Presence of cystic changes of graft and host-graft junction 0: Absent; 1: Present Cartilage Features 5. Cartilage signal of graft 0: Normal; 1: Altered intensity (either hypointense of hyperintense, but not fluid); 2: Fluid signal intensity on all sequences 6. Cartilage “fill” of graft (percentage of volume) 0: 76-100%; 1: 51-75% or >100%; 2: 1 mm 8. Cartilage surface congruity of graft and host-graft junction 0: Flush; 1: 50% offset of host cartilage 9. Calcified cartilage integrity of graft 0: Intract, thin, and smooth; 1: Altered (disrupted, thickened or blurred) Ancillary Features 10. Opposing cartilage 0: Normal; 1: Abnormal (bone marrow edema pattern or hypointensity on all sequences) 11. Meniscal tears 0: Absent; 1: Present 12. Synovitis 0: Absent; 1: Present 13. Fad pad scarring 0: Absent; 1: Present Figure 1. Representative 12-month coronal and sagittal MRI sections in a (A,B) 20-year-old male, demonstrating crossing trabeculae and minimal subchondral marrow edema, and (C,D) 16-year-old-male, demonstrating discernible clefts at the host-graft junction and significant subchondral marrow edema. Both were treated with BMAC+OCA

Rotator cuff disease affects a large proportion of the overall population and encompasses a wide spectrum of pathologies, including subacromial impingement, rotator cuff tendinopathy or tear, and calcific tendinitis. Various injection therapies have been used for the treatment of rotator cuff disease, including corticosteroid, prolotherapy, platelet-rich plasma, stem cells, and ultrasound-guided barbotage for calcific tendinitis. However, the existing evidence for these therapies remains controversial or sparse. Ultimately, improved understanding of the underlying structural and compositional deficiencies of the injured rotator cuff tissue is needed to identify the biological needs that can potentially be targeted with injection therapies.

Objectives: While various techniques for distal biceps repair have been described, biomechanical studies have shown cortical button fixation to outperform bone tunnels, intraosseous screws, and suture anchors. Furthermore, numerous studies have shown no difference in complication rate between single- and dual-incision approaches. Thus, it follows that a single-incision approach with cortical button fixation may provide superior clinical outcomes with minimal complications. The purpose of this study is first to investigate intra-operative and short-term complications of distal biceps tendon repair through a single-incision approach using unicortical button fixation, and secondly to assess clinical outcomes. Methods: 52 patients who underwent distal biceps repair with unicortical button fixation (Figure 1) at a single institution from 2014 to 2017 were identified. Exclusion criteria included age less than 18 or greater than 75 years, prior ipsilateral biceps repair, concomitant ipsilateral surgical procedure, and most recent follow-up less than 2 months. Postoperative nerve deficits, flexion and supination strength by manual testing, range of motion, Mayo Elbow Performance Score (MEPS) and radiographs for identification of heterotopic ossification (HO) were obtained and analyzed retrospectively. Results: Fifty-two patients with 53 distal biceps ruptures were included, with mean age 48 years (range 25-71 years). Median time from injury to surgery was 2 weeks (range 1 day to 16 weeks), with 15 patients being treated at greater than 3 weeks from injury. Forty-four patients (83%) had complete tears. Following surgery, average time to final follow-up was 22.8 weeks (range 8-65 weeks). Postoperatively, 49 patients (92.5%) had full range of motion, 48 patients (90.6%) had return of full supination and flexion strength by manual muscle testing (the remaining patients had strength graded as 5-/5). There was no difference in outcomes between those patients treated < 3 weeks from injury compared to those treated > 3 weeks from injury. Two patients (3.8%) initially reported sensory deficit in the lateral antebrachial cutaneous nerve distribution, both cases of which fully resolved by 7 and 11 weeks postoperative. Two patients (3.8%) displayed radiographic evidence of heterotopic ossification, Hastings and Graham class I (Figure 2). One of these was an incidental finding without any clinical symptoms, the other had mild pain but normal strength and neurovascular function. Mean postoperative MEPS was 93.9 (range 60-100), corresponding to “excellent” function (MEPS>90). Conclusion: Distal biceps repair using single incision, unicortical button fixation yields a low rate of complications with good clinical results compared to other techniques reported in the literature. The single incision approach in patients treated between 3 and 16 weeks from injury is safe and resulted in outcomes no different than in those patients treated

Objectives:. The purpose of this study was to compare bone marrow aspirate concentrate (BMAC) with cancellous allograft to iliac crest bone graft (ICBG) in the treatment of long bone nonunions. Design:. Retrospective cohort study. Setting:. A single level I trauma center. Patients:. 26 patients with long bone diaphyseal or metaphyseal nonunions with defects >2 mm and treated with open repair and BMAC, compared to 25 patients with long bone diaphyseal or metaphyseal nonunions with defects >2 mm and treated with open repair and ICBG. Intervention:. Open repair of long bone nonunion using either autologous ICBG or BMAC with cancellous allograft. Main outcome measure:. Nonunion healing, radiographically measured by the modified Radiographic Union Score for Tibia (mRUST) score. Secondary outcomes included risk factors associated with failed repair. Results:. The union rates for the BMAC and ICBG cohorts were 75% and 78%, respectively (P = .8). Infection was the only risk factor of statistical significance for failure. Conclusion:. In this study, we found no significant difference in union rate for long bone nonunions treated with ICBG or BMAC with allograft. BMAC and allograft led to 75% successful healing in this series. Given the heterogeneity of the control group and loss to follow-up, further prospective investigation should be conducted to more rigorously compare BMAC to ICBG for nonunion treatment. Level of evidence:. III, retrospective cohort.

A patient's activity level is increasingly recognized as an important factor that can influence orthopaedic outcomes. Validated, reliable activity measurement tools now exist for the shoulder, hip, knee, and ankle. These tools can be directly applied as outcome measures that determine whether interventions restored function. It is now evident that activity level is a powerful prognostic factor for outcomes in orthopaedic procedures such as anterior cruciate ligament reconstruction, articular cartilage repair, and total joint arthroplasty. Yet despite the recent increase in studies that have made use of quantitative, joint-specific activity scales, much room remains for further understanding of the exact role of activity level in the progression, treatment, and patient perception of musculoskeletal disorders, particularly in the shoulder and ankle, as well as in pediatric patients.