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Aims: Distal femoral osteotomies (DFOs) are commonly used for the correction of valgus deformities and lateral compartment osteoarthritis. However, the impact of a DFO on subsequent total knee arthroplasty (TKA) function remains a subject of debate. Therefore, the purpose of this study was to determine the effect of a unilateral DFO on subsequent TKA function in patients with bilateral TKAs, using the contralateral knee as a self-matched control group. Methods: The inclusion criteria consisted of patients who underwent simultaneous or staged bilateral TKA after prior unilateral DFO between 1972 and 2023. The type of osteotomy performed, osteotomy hardware fixation, implanted TKA components, and revision rates were recorded. Postoperative outcomes including the Forgotten Joint Score-12 (FJS-12), Tegner Activity Scale score, and subjective knee preference were also obtained at final follow-up. Results: A total of 21 patients underwent bilateral TKA following unilateral DFO and were followed for a mean of 31.5 years (SD 11.1; 20.2 to 74.2) after DFO. The mean time from DFO to TKA conversion was 13.1 years (SD 9.7) with 13 (61.9%) of DFO knees converting to TKA more than ten years after DFO. There was no difference in arthroplasty implant systems employed in both the DFO-TKA and TKA-only knees (p > 0.999). At final follow-up, the mean FJS-12 of the DFO-TKA knee was 62.7 (SD 36.6), while for the TKA-only knee it was 65.6 (SD 34.7) (p = 0.328). In all, 80% of patients had no subjective knee preference or preferred their DFO-TKA knee. Three DFO-TKA knees and two TKA-only knees underwent subsequent revision following index arthroplasty at a mean of 12.8 years (SD 6.9) and 8.5 years (SD 3.8), respectively (p > 0.999). Conclusion: In this self-matched study, DFOs did not affect subsequent TKA function as clinical outcomes, subjective knee preference, and revision rates were similar in both the DFO-TKA and TKA-only knees at mean 32-year follow-up. Cite this article: Bone Jt Open 2024;5(11):1013–1019.

Purpose: To determine the relationship between cam morphology of the hip and ipsilateral sacroiliac motion compared to the native hip in a cadaveric model. Methods: A simulated cam state was created using a 3-dimensional printed cam secured to the head-neck junction of 5 cadaveric hips. Hips were studied using a computed tomography–based optic metrology system and a 6 degree-of-freedom robot to exert an internal rotation torque at 3 different torque levels (6 N-m, 12 N-m, 18 N-m). Outcomes included translational and rotational movement about 3 axes and composite (total) translational motion at the ipsilateral sacroiliac (SI) joint. Statistical analysis included a linear mixed model regression with repeated measures. Results: The presence of a simulated cam was associated with medial motion in the coronal plane (P = .03) and posterior motion in the sagittal plane (P < .01) but not composite motion (P = .37). Motion in the axial plane was in an inferior direction (P = .08). Cam morphology significantly changed rotation in the sagittal plane (P < .01) but not in the coronal (P = .63) or axial plane (P = .18). Composite motion was related to the amount of torque applied to the hip (P < .01). The amount of torque applied to the hip was related to rotation in the coronal plane (P < .01), axial plane (P < .01), and sagittal plane (P < .01) with increased effects as torque increased. Torque was not associated with translation movement in any of the anatomic planes. Conclusions: The presence of simulated cam morphology is associated with motion in a more medial, inferior, and posterior direction at the ipsilateral SI joint relative to a native state. Increasing torque affects the magnitude of translation, but not its direction, which in this study is primarily influenced by cam morphology. Clinical Relevance: This biomechanical connection between cam-type femoroacetabular impingement syndrome and the ipsilateral SI joint provides insight into SI joint dysfunction in patients with femoroacetabular impingement syndrome.

Background: Patients with persistent symptomatic iliopsoas tendonitis following total hip arthroplasty may benefit from iliopsoas fractional lengthening. We present an arthroscopic approach utilizing an air bursogram that provides safe and predictable access to the iliopsoas tendon for efficient tendon lengthening without violating the capsule or unintentional instrumentation of the nearby medial neurovascular bundle. Indications: Arthroscopic iliopsoas fractional lengthening is indicated for patients with clinical evidence of symptomatic iliopsoas tendonitis following total hip arthroplasty and have no radiographic evidence of frank acetabular malpositioning. A diagnosis of iliopsoas tendinitis amenable to surgical management can be established with substantial but nondurable relief following image-guided anesthetic injection to the iliopsoas bursa. Technique Description: Under fluoroscopic guidance, an air bursogram is employed in the anatomic plane of the iliopsoas tendon to accurately identify its course. This allows for hip portal placement with precise subsequent instrumentation. This technique is preferred in the setting of postarthroplasty anatomy because it avoids capsular violation and the challenge of working in an altered anatomic space with a nearby, medially based neurovascular bundle. Results: Arthroscopic and endoscopic approaches to iliopsoas release have been shown to provide excellent functional and patient-reported outcomes in >85% of patients, and several studies have shown that an arthroscopic approach not only provides a less invasive technique but also results in comparable or improved clinical outcomes with lower revision rates compared to open release or acetabular cup revision. Our technique for arthroscopic iliopsoas fractional lengthening using the air bursogram is both safe and reproducible and offers distinct advantages, including maintenance of an intact capsule, visual confirmation of the correct anatomic structure to be released, and percutaneous access with standard arthroscopic access cannulas without the need for hip distraction. Conclusions: Arthroscopic fractional iliopsoas lengthening is a minimally invasive and successful treatment option for patients with persistent groin pain after total hip arthroplasty, especially without substantial acetabular component malpositioning. This technique includes using an air bursogram to safely identify and navigate to the iliopsoas tendon without violating the hip capsule, thereby reducing the risk of inadvertent instrumentation of adjacent critical neurovascular structures. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

In the standard approach to hip arthroscopy, access to the joint is achieved using fluoroscopic guidance to enter the central compartment of the hip using the Seldinger technique, penetrating the capsule with a needle and subsequently cannulating and obtaining direct visualization of the joint. In such a way, arthroscopists then proceed with accessory portal creation and capsulotomy, as desired, under direct intra-articular visualization. In cases with severe pincer morphology or coxa profunda, it may not be possible to safely access the central compartment under fluoroscopic guidance due to significant lateral overcoverage of the femoral head. We present an outside-in arthroscopic approach for accessing the hip joint in such patients, allowing for safe visualization, osseous pincer resection, and improved central compartment access while minimizing the risk to cartilage and labral tissue.

Unstable osteochondritis dissecans lesions of the medial femoral condyle have classically been treated with open reduction and fixation under direct visualization through an open arthrotomy. Given the value of avoiding open arthrotomies, we present an arthroscopic approach for lesion elevation, debridement, and fixation. The lesion is first elevated using an arthroscopic elevator, leaving a laterally based osseous hinge. Once elevated, fibrous debris is debrided from the base of the lesion. Subsequently, the fragment is reduced, and percutaneous transpatellar instrumentation is used for fixation. The use of this technique allows for excellent mobilization, debridement, and fixation of the osteochondritis dissecans lesion while minimizing violation of periarticular soft tissues.

ABSTRACT: Introduction: This study evaluates the inter-rater reliability and accuracy of radiographs in assessing healing of osteochondral allografts (OCA) in the knee compared with computed tomography (CT) imaging is currently unknown. Methods: A retrospective review patients who underwent OCA transplantation with postoperative knee radiographs obtained at three and six months, and CT scans obtained at six months was conducted. Three board-eligible orthopaedic surgeons independently graded postoperative radiographs, utilizing the grading scale established by Oladeji et al (2017), and the CT scans utilizing the grading scale established by Gelber et al (2021). Their consensus measurements served as a comparative gold standard. Results: Among 44 prospectively imaged grafts, 13 (29.5%) had radiographs at three months and 28 (63.6%) had radiographs available for evaluation at six months. Assessment of radiographic integration demonstrated low reliability (Intraclass correlation coefficient (ICC): -0.02 to 0.14). On CT scan, this improved to fair reliability (κ = 0.29, P

Purpose: To investigate the feasibility and accuracy of 3-dimensional (3D) iPhone scans using commercially available applications compared with computed tomography (CT) for mapping chondral surface topography of the knee. Methods: Ten cadaveric dysplastic trochleae, 16 patellae, and 24 distal femoral condyles (DFCs) underwent CT scans and 3D scans using 3 separate optical scanning applications on an iPhone X. The 3D surface models were compared by measuring surface-to-surface least distance distribution of overlapped models using a validated 3D-3D registration volume merge method. The absolute least mean square distances for the iPhone-generated models from each scanning application were calculated in comparison to CT models using a point-to-surface distance algorithm allowing regional “inside/outside” measurement of the absolute distance between models. Results: Only 1 of the 3 scanning applications created models usable for quantitative analysis. Overall, there was a median absolute least mean square distance between the usable model and CT-generated models of 0.18 mm. The trochlea group had a significantly lower median absolute least mean square distance compared with the DFC group (0.14 mm [interquartile range, 0.13-0.17] vs 0.19 mm [0.17-0.25], P = .002). iPhone models were smaller compared with CT models (negative signed distances) for all trochleae, 83% of DFCs, and 69% of patellae. Conclusions: In this study, we found minimal differences between a 3D iPhone scanning application and conventional CT scanning when analyzing surface topography. Clinical Relevance: Emerging 3D iPhone scanning technology can create accurate, inexpensive, real-time 3D models of the intended target. Surface topography evaluation may be useful in graft selection during surgical procedures such as osteochondral allograft transplantation.

Purpose: To report the clinical outcomes and reoperation rates of arthroscopic and endoscopic iliopsoas release at short-term follow-up after ipsilateral total hip arthroplasty (THA) at 2 separate medical institutions and to evaluate whether demographic and radiographic parameters are associated with postoperative patient-reported outcomes (PROs). Methods: Patients with iliopsoas tendinitis in the setting of prior THA who underwent arthroscopic iliopsoas fractional lengthening from 1988 to 2023 at 2 academic institutions were reviewed. Patients were included if they had 12 months of follow-up and underwent evaluation of preoperative anterior acetabular component overhang, surgery satisfaction, postoperative subjective hip flexion strength and anterior groin pain improvement, modified Harris Hip Score, Single Assessment Numeric Evaluation score, Tegner activity scale score, visual analog scale (VAS) score, and revision hip arthroplasty. Results: Sixty hips in 58 patients (19 male and 39 female patients) were followed up for a mean of 39.3 months (range, 12.0-105.9 months) postoperatively. Of the patients, 77% reported feeling “much better” or “slightly better,” 75% reported improved anterior groin pain, and 60% reported improved subjective hip flexion strength. The surgery satisfaction rating was 7.2 ± 3.3 (scale of 0 to 10). The mean postoperative modified Harris Hip Score, VAS score for pain at rest, VAS score for pain with use, and Single Assessment Numeric Evaluation score were 73.9 ± 19.4, 1.3 ± 2.4, 3.8 ± 2.9, and 71.9 ± 21.9, respectively. Preoperative anterior acetabular component overhang was 3.3 ± 6.5 mm and did not significantly correlate with postoperative PROs (P ≥ .45). The Tegner score improved from 2.5 ± 1.7 preoperatively to 2.9 ± 1.4 postoperatively (P = .0253). Three patients underwent revision arthroplasty at a mean of 25.3 months (range, 11.6-40.4 months) postoperatively, with an acetabular component revision rate of 3.3%. Conclusions: Satisfactory outcomes and low revision arthroplasty rates were observed in patients undergoing arthroscopic iliopsoas lengthening after THA. There was no statistically significant relation between anterior acetabular component overhang and final PROs. Level of Evidence: Level IV, therapeutic case series.

The hip capsule is the primary stabilizer of the hip joint. At the time of hip arthroscopy, the capsule is disrupted to obtain intra-articular access and proper joint visualization. With the number of patients undergoing primary and revision hip arthroscopy continuing to increase, it is not uncommon for surgeons to encounter patients with iatrogenic capsular deficiency from prior hip arthroscopy. In cases where substantial capsular defects beyond the scope of capsular repair are visualized, reconstruction may be required to obtain satisfactory closure and restore hip stability. We present a step-by-step workflow for efficient hip capsular reconstruction with rectus overlay while allowing for facile incorporation of other revision procedures such as labral repair and femoral osteochondroplasty.

Anterior cruciate ligament (ACL) reconstruction using the quadriceps tendon (QT) autograft is an increasingly utilized technique that confers less donor site morbidity and comparable outcomes to other historically used graft options. The graft harvest and implantation process present vast variability—particularly regarding the achievement of adequate graft site visualization, consistently attaining a uniform and appropriately sized graft, and subsequent reconstruction of the ACL with the all-soft tissue graft. The purpose of this Technical Note and video is to describe and demonstrate minimally invasive quadriceps tendon autograft harvesting using the Quadriceps Tendon Harvest Guide System (QUADTRAC), and its subsequent implantation within a single-bundle ACL reconstruction with suspensory fixation.

Capsular management in hip arthroscopy has recently become a popular topic in the literature. Various approaches have been developed around the critical balance between safe and satisfactory exposure while maintaining hip joint stability and the restoration of capsular integrity at the conclusion of the case. Advocates for capsular closure recognize the role of the capsule in providing hip joint stability and aim to reestablish normal hip biomechanics through capsule preservation. Several recent studies have also shown capsular management strategies to influence both clinical outcomes and risk of revision surgery. We present an effective method for capsular management in hip arthroscopy that consistently allows excellent exposure and working space while allowing for facile, anatomic closure.

Background: Lateral meniscal oblique radial tears (LMORTs) are the most common type of lateral meniscal tears and occur concomitantly with anterior cruciate ligament (ACL) tears in up to 12% of cases. Four types of LMORTs have been classified in the literature based on proximity to the meniscal root and extent of the tear. Type 1 and 2 LMORTs represent partial and complete posterior root tears less than 10 mm from the root insertion. Type 3 and 4 LMORTs are partial and complete posterior radial meniscus tears greater than 10 mm from the root insertion. Indications: Type 3 and 4 LMORTs can and should be addressed with an all-inside side-to-side repair at the time of ACL reconstruction. LMORTs that are not repaired at the time of ACL reconstruction can contribute to persistent instability and meniscal extrusion. Technique Description: Diagnostic arthroscopy is performed to evaluate the posterior aspects of both the medial and lateral meniscus. The medial leaflet is commonly flipped into the notch and scarred to ACL remnant. After identifying and isolating the medial leaflet, an arthroscopic suture passer is used to pass a suture from inferior to superior through the medial leaflet. A second suture is passed from inferior to superior through the lateral leaflet. This is used to shuttle the suture pass through the medial leaflet to the bottom of the meniscus, where it can be tied in a horizontal mattress fashion. The sutures are tied down with aide of an arthroscopic knot pusher. A second set of sutures is passed and used to shuttle a second suture that would be tied posterior to the first suture, again in a horizontal mattress fashion. This allows reduction of the fragments in apposition across the tear. Postoperatively, patients are allowed range of motion from 0° to 90° and to toe touch weightbearing for the first 4 weeks. Patients are advanced to weightbearing as tolerated at 5 weeks. Typical return to sport ranges from 6 to 9 months postoperatively. Results: Results have been published for 2-year outcomes of type 3 and 4 LMORT repairs and have demonstrated persistent improved patient-reported outcomes as well as healing rates that are greater than 80% and in some series approach nearly 100%. Discussion/Conclusion: Arthroscopic all-inside side-to-side surgical repair is a durable and reliable treatment option for patients presenting for ACL reconstruction with concomitant type 3 or 4 LMORT. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Quadriceps tendon autografts are an increasingly popular choice for anterior cruciate ligament (ACL) reconstruction, with decreased donor-site morbidity alongside good patient outcomes. Although harvesting of the tendon can be done in a minimally invasive fashion, this introduces some difficulty with visualization and consistency of graft sizing. The purpose of this Technical Note and video is to provide a method of quadriceps tendon autograft harvesting using the Quadriceps Tendon Harvest Guide System (QUADTRAC) in a single-bundle ACL reconstruction.

The medial collateral ligament serves as the primary stabilizer to valgus stress on the medial side of the knee and is the most commonly injured ligament in the knee. Medial collateral ligament reconstruction can provide improved stability and clinical outcomes for patients. Advancements in techniques, including the use of an adjustable-length-loop suspensory fixation device through a longitudinal incision, have been introduced in recent years. The purpose of this Technical Note and video is to provide a minimally invasive method for medial collateral ligament reconstruction with adjustable-loop femoral fixation and posteromedial corner plication.

Iliopsoas tendinitis following total hip arthroplasty has been linked to retroverted acetabular cup position with associated anterior overhang. For severely malpositioned components, preferred treatment is in the form of revision arthroplasty. However, for a substantial number of cases, iliopsoas tendinitis as well as associated pain and disability are observed in the presence of modest acetabular overhang. In such cases, patients may benefit substantially from arthroscopic iliopsoas fractional lengthening. Given altered postarthroplasty anatomy, we present an arthroscopic approach employing an iliopsoas air bursogram. In such a way, safe and predictable access can be provided for efficient tendon lengthening without capsular violation or inadvertent instrumentation of the nearby medial neurovascular bundle.

Purpose: To (1) evaluate the efficacy of surgery for arthrofibrosis (AF), as measured by preoperative and postoperative range of motion (ROM), and (2) evaluate patient-reported outcomes at mid- to long-term follow-up. Methods: We performed a retrospective review of a prospectively collected database including patients who sustained multiligamentous knee injuries (MLKIs) managed surgically, sustained loss of ROM after surgical intervention, and underwent subsequent lysis of adhesions (LOA) and/or manipulation under anesthesia (MUA). Loss of ROM was defined as clinically symptomatic loss of terminal extension (flexion deformity) and/or flexion compared with the contralateral side. Results: In total, 12 patients (6 male and 6 female patients; age, 36.0 ± 8.7 years; body mass index, 36.3 ± 8.7) met the inclusion criteria and underwent LOA and/or MUA at a mean of 14 ± 27 months (median, 4.0 months; interquartile range, 3.5-9.3 months) after MLKI surgery. Prior to AF intervention, patients showed mean flexion of 75.9° ± 36.0° (range, 30°-129°), mean extension of 3.2° ± 5.2° (range, 0°-12°), and a mean arc of motion of 72.7° ± 34.1° (range, 30°-117°). At a mean follow-up of 7.0 ± 3.9 years (range, 2.4-16.6 years) after AF intervention, patients showed a significant increase in knee flexion of 49° (P = .003), a significant increase in arc of motion of 51° (P = .002), and an increase in extension of 3° (P = .086). The mean final International Knee Documentation Committee score was 59.5 ± 23.9; Lysholm score, 72.1 ± 20.6; Tegner activity scale score, 5.6 ± 2.8; visual analog scale score at rest, 1.0 ± 1.6; and visual analog scale score with use, 3.3 ± 2.5. At final follow-up, 2 patients (17%) had undergone conversion to total knee arthroplasty (TKA) at 10.3 and 24.8 years after MLKI surgery. Of the 10 patients who did not go on to TKA, 9 (90%) reported that they were satisfied or very satisfied with their AF knee surgery. Conclusions: At mid-term follow-up, LOA and/or MUA for symptomatic AF after multiligamentous knee surgery results in high rates of patient satisfaction and improved knee ROM and pain scores, as well as durable and satisfactory functional outcomes in patients not undergoing TKA. Level of Evidence: Level IV, therapeutic case series.

Introduction: Tibial osteotomy has a role in various aspects of joint preservation. Proper diagnosis and addressing all aspects of alignment both for focal cartilage lesions to support restorative repair procedures as well as in treatment of earlier phases of knee osteoarthritis in well selected patients. Malalignment of the leg axis is known to result in chronic overloading and thus contributing to the development of focal lesions as well as osteoarthritis. Objectives: To provide a comprehensive summary of the current state of utilization of tibial osteotomies in conjunction with other joint preserving procedures and to synthesize the current scientific evidence for the use of osteotomies in the setting of cartilage injuries. Methods: PubMed, Medline, Cochrane Systematic Reviews, and Clinical Keys were searched by the first author (M.H.) to validate that all papers of relevance to the area studied were included. Databases were searched comprehensively, and original research, systematic reviews, and meta-analysis were included at the authors’ discretion. References of selected articles were analyzed manually. Data from selected publications focused on tibial osteotomy were summarized. Results: Leg axis and patellofemoral alignment must be considered as important risk factors for failure of restorative cartilage procedures in the knee joint. Alignment-correcting osteotomies play a crucial role in enhancing clinical results of cartilage repair surgeries especially in the long-term. Through the redistribution of load, the biomechanical environment of the joint is optimized, and the induced or transplanted repair tissue is protected against overloading, facilitating enhanced tissue maturation. Recent evidence suggests that even small deviations from a neutral axis (

Purpose: To compare the clinical efficacy in the resolution of patellar instability, patient-reported outcomes (PROs), and complication and reoperation rates between patients who underwent grooveplasty (proximal trochleoplasty) and patients who underwent trochleoplasty as part of a combined patellofemoral stabilization procedure. Methods: A retrospective chart review was performed to identify a cohort of patients who underwent grooveplasty and a cohort who underwent trochleoplasty at the time of patellar stabilization. Complications, reoperations, and PRO scores (Tegner, Kujala, and International Knee Documentation Committee scores) were collected at final follow-up. The Kruskal-Wallis test and Fisher exact test were performed when appropriate, and P < .05 was considered significant. Results: Overall, 17 grooveplasty patients (18 knees) and 15 trochleoplasty patients (15 knees) were included. Seventy-nine percent of patients were female, and the average follow-up period was 3.9 years. The mean age at first dislocation was 11.8 years overall; most patients (65%) had more than 10 lifetime instability events and 76% of patients underwent prior knee-stabilizing procedures. Trochlear dysplasia (Dejour classification) was similar between cohorts. Patients who underwent grooveplasty had a higher activity level (P = .007) and a higher degree of patellar facet chondromalacia (P = .008) at baseline. At final follow-up, no patients had recurrent symptomatic instability after grooveplasty compared with 5 patients in the trochleoplasty cohort (P = .013). There were no differences in postoperative International Knee Documentation Committee scores (P = .870), Kujala scores (P = .059), or Tegner scores (P = .052). Additionally, there were no differences in complication rates (17% in grooveplasty cohort vs 13% in trochleoplasty cohort, P > .999) or reoperation rates (22% vs 13%, P = .665). Conclusions: Proximal trochlear reshaping and removal of the supratrochlear spur (grooveplasty) in patients with severe trochlear dysplasia may offer an alternative strategy to complete trochleoplasty for the treatment of trochlear dysplasia in complex cases of patellofemoral instability. Grooveplasty patients showed less recurrent instability and similar PROs and reoperation rates compared with trochleoplasty patients. Level of Evidence: Level III, retrospective comparative study.

Background: Medial patellofemoral ligament (MPFL) injury occurs in up 96% of lateral patellar dislocations, commonly affecting those less than 20 years old. The MPFL can be reconstructed using either a double-limb or single-limb technique. While both techniques achieve similar patient outcomes, a single-limb technique may require less operative time. Indications: The MPFL reconstruction is indicated in patients with recurrent patellar subluxations, dislocations, or unresolved apprehension. Care should be exercised in identifying whether patients require additional procedures in addition to MPFL reconstruction such as tibial tubercle osteotomy or trochleoplasty. These considerations include TT-TG >17 to 20 mm and Dejour B/D trochlear dysplasia. Technique Description: Following diagnostic arthroscopy, a medial peripatellar incision is made. Layers 1 and 2 are sharply dissected over the patellar periosteum, and tissue planes are subsequently developed using Metzenbaum scissors. A plane between layers 2 and 3 extending from the medial patella to the medial femoral epicondyle is developed. Using fluoroscopy, Schöttle point is identified, and a femoral tunnel is drilled. Two PEEK anchors are placed at the junction of the proximal one-third and distal two-thirds of the patella. In parallel, a tibialis anterior graft is sized, whipstitched, and tensioned on the back table. One end of the prepared graft is secured in the femoral tunnel with a PEEK tenodesis screw. The graft is then shuttled between layers 2 and 3, followed by fixation on the patellar side using the previously placed suture anchors. Isometry of the graft is confirmed under direct and arthroscopic visualization. Results: In multiple systematic reviews of single-limb versus double-limb MPFL reconstruction, no differences were observed in terms of patient-reported outcome scores, repeat dislocation, and reoperation. Furthermore, a recent meta-analysis suggests a trend toward less postoperative stiffness (1.2% vs 3.5%, P = .09) for single-bundle techniques. Discussion/Conclusion: Single-limb MPFL reconstruction is reproducible and effective, with clinically satisfactory outcomes and low failure rates. Single-limb MPFL reconstruction demonstrates similar outcomes as double-limb reconstruction, with a potential decrease in surgical time and postoperative stiffness. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Background: Patellofemoral anatomy allows for substantial freedom of motion. Medial patellofemoral ligament (MPFL) tears occur in up to 96% of lateral patellar dislocations. Risk factors for subsequent instability include maltracking and increased tibial tubercle to trochlear groove (TT-TG) distance. Indication: Medial patellofemoral ligament reconstruction (MPFLR) with concurrent tibial tubercle osteotomy (TTO) is indicated in patients with recurrent dislocation or unresolved apprehension. Concurrent TTO should be considered for TT-TGs 15-20 mm depending on overall clinical picture and risk factors. We strongly consider TTO for TT-TGs ≥20 mm and for revision procedures. Technique Description: Following diagnostic arthroscopy, a midline incision is made from the inferior patellar pole to 3 cm beyond the tibial tubercle. The anterior compartment is incised and retracted laterally. An osteotomy guide is affixed to the tibia and an osteotomy cut is made with a saw, leaving a small bridge of periosteum distally. The osteotomy is competed proximally with osteotomes, then medialized and held in place with two 4.5-mm screws. An incision is made on the superomedial patella and two 0.045 inch guidewires are placed at the MPFL insertion and overdrilled with a 3.5-mm drill. A 22-cm semitendinosus allograft is prepared and fixed to the patella using two 3.5-mm anchors. An incision is made over the medial epicondyle and a 2.4-mm beath pin is placed at Schöttle point. Isometry is confirmed and the pin is overdrilled with a 6-mm reamer. The allograft is passed just superficial to capsule from the peripatellar incision to the medial incision, docked into the femur, and secured with a 6-mm interference screw at 30° of flexion after confirmation of appropriate graft length. Results: Studies have demonstrated improved outcomes for patients undergoing MPFLR + TTO compared with isolated MPFL in the setting of maltracking and increased TT-TG distance. In addition, a recent meta-analysis demonstrated no negative effect of concurrent TTO on return to sport timeline. Discussion/Conclusion: MPFLR with concurrent TTO is effective, with surgical correction of underlying maltracking and satisfactory return to sport. Consideration to MPFL + TTO should be given to patients with recurrent instability and pathologically increased TT-TG. The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Background: Current joint-sparing treatment options for massive, irreparable rotator cuff tears aim to prevent superior migration of the humeral head and maintain the subacromial space. Although options such as superior capsular reconstruction and posterosuperior tendon transfer may appropriately restore function and reduce pain, these procedures harbor significant comorbidity and intense postoperative rehabilitation. Recently, studies have demonstrated excellent results from a subacromial balloon spacer composed of a biocompatible copolymer that degrades over the 12 months following implantation. This spacer enables a more anatomic position of the humeral head to restore normal shoulder biomechanics. Indications: The subacromial balloon spacer is primarily indicated in patients with massive, irreparable rotator cuff tears who demonstrate proximal humeral migration. Contraindications include subscapularis or teres minor tendon tears, deltoid dysfunction, and pseudoparalysis. Technique Description: Standard arthroscopic portals are established, and a diagnostic arthroscopy is performed to assess the glenohumeral joint space and subscapularis tendon. A subacromial bursectomy is performed without proceeding medial to the superior glenoid rim. The subacromial space is measured utilizing an arthroscopic measurement probe to ensure that the selected spacer will lie slightly medial to the glenoid. The rotator cuff is then reapproximated from the lateral to medial aspect of the tear and repaired via a side-to-side manner with high strength, nonabsorbable tape, and a self-capturing suture device. Following repair, the deployment device is inserted through the lateral portal, placed slightly medial to the glenoid, and inflated with saline. Results: Utilization of the described subacromial balloon augmentation provides significant pain relief by restoring glenohumeral biomechanics, improvements in range of motion, and an enhancement in quality of life. Discussion: This case report and video review of a technique for utilizing a subacromial balloon spacer demonstrates an effective, simple, and safe treatment for massive, irreparable rotator cuff tears. Positive results rely on appropriate inflation and secure fixation. Recent clinical trial data suggest that functional outcomes for the subacromial balloon spacer are noninferior to that of partial rotator cuff repair. These promising results suggest that the subacromial balloon spacer may prove an essential tool for joint-preserving surgery following massive, irreparable rotator cuff tears.

Background: Cartilage defects are treated with a wide array of non-operative and surgical procedures. Optimal choice of treatment depends on lesion depth and size. Objectives: To review and summarize current data on the management of cartilage injuries in joints as it relates to defect size. Data sources: MEDLINE, Cochrane Central Register of Controlled Trials & Cochrane Library, CINHAL. Study eligibility criteria, participants, and interventions: Inclusion: (1) Studies investigating patients who underwent cartilage repair of the shoulder, elbow, hip, knee, and ankle. (2) Studies reporting outcome measures and treated lesion size. Exclusion: (1) No mention of defect size. (2) Joints not mentioned above. (3) 1.5 cm2 mostly addressed with cell-based therapies such as autologous cartilage implantation (ACI), or matrix associated cartilage implantation (MACI). Large lesions often are the domain of osteochondral autograft transfer system (OATS). Limitations: Prospective randomized controlled studies are not available for every joint and many studies represent case studies with limited implications for treatment decisions. Conclusions and implications of key findings: Evidence-based treatment selection based on cartilage defect size can be beneficial. Systematic review registration number: 276559.

Background: Patients with recalcitrant anterior knee pain and isolated patellofemoral osteoarthritis (PFOA) may benefit from patellofemoral arthroplasty. Arthroplasty with an inlay implant may be beneficial given recreation of native biomechanics and potentially avoiding anterior overstuffing. Indications: Patellofemoral arthroplasty is indicated in patients with anterior knee pain from isolated PFOA in patients with neutral alignment and intact menisci and ligaments. To highlight these indications, we present a 32-year-old female with severe anterior knee pain from PFOA, not resolved by conservative measures. Preoperative imaging demonstrated full-thickness chondral loss of the lateral patellar facet and trochlea, with neutral alignment and no significant trochlear dysplasia. Technique Description: This technique utilized the HemiCap Wave Implant manufactured by Anika Therapeutics (Franklin, MA, USA). A standard midline approach and medial parapatellar arthrotomy is performed. The patella is everted, and the trochlea is exposed. A guide pin is placed perpendicular to the trochlear bony surface and centrally in the defect. The pin is advanced, and the surrounding area is reamed. A guide block is placed over the pin in the trochlea and over-reamed. The area is prepared and centrally drilled, then tapped. A taper post is implanted. The trochlear implant is then secured to the taper post with an impactor and mallet. On the patellar side, a guide pin is placed in the center of the patella. Consideration is given to medialization of the button to decrease Q-angle. The patella is reamed to the diameter of an appropriately sized patellar button. A trial button is used to ensure satisfactory tracking. A real patellar implant is then cemented into place. Standard closure is performed. Results: Overall outcomes following inlay patellofemoral arthroplasty have been positive, with up to 89% of patients engaging in sports at 2 years status post surgery and 83% survival free of total knee arthroplasty at 5 years postoperatively. Discussion/Conclusion: Patellofemoral arthroplasty can provide good satisfaction and high rates of return to sport in patients with symptomatic, isolated patellofemoral arthritis. The surgical technique video presented provides reproducible steps, tips, and tricks for performing this procedure.

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.

Background: Hamstring injuries at the musculotendinous junction are relatively common. However, injuries to the proximal hamstring account for just 12% of hamstring injuries. Surgical repair of these injuries including both open and endoscopic techniques are becoming increasingly more common. Indications: Surgical intervention is generally reserved for cases with 2 or more torn tendons and at least 2 centimeters of retraction. Technique Description: The combined open and endoscopic technique utilizes direct posterior and posterolateral portals. After visualizing the posterior femoral cutaneous (PFCN) and sciatic nerves (SN), the proximal hamstring tear is identified, and the shaver is used to remove any surrounding adhesions and aid in clearing any hematoma. The ischial tuberosity is prepared using a shaver, radiofrequency ablation, and a 5.5 mm, round arthroscopic burr. Two, 4.5 mm, doubled-loaded anchors are placed into the ischium. The incision for the open portion of the case is created by incising the skin between the direct posterior and posterolateral portals. A dissection is continued down to the gluteal fascia, and the gluteal fascia is incised in line with the surgical incision. The gluteus maximus is retracted then the hamstring stump is secured with a stay suture and brought outside the surgical incision for inspection. The double-loaded sutures are passed in a running locking technique. The other suture limbs are then passed through the central aspect of the tendon and tensioned to reduce the proximal hamstring onto the prepared tuberosity. Results: Significant postoperative improvements in patient-reported outcomes have been reported for open and endoscopic repairs in isolation, but to date there are no outcomes studies on the combined “Scopen” technique. Postoperative complications may include numbness or neuropraxia, re-rupture, infection, and deep vein thrombosis (DVT). Discussion: The endoscopic portion allows an improved view and preservation of the SN and PFCN, as well as a detailed view of the ischial tuberosity for decortication and anchor placement in comparison with a purely open approach. In comparison with a purely endoscopic approach, this combined approach can be used in patients with retraction >4 cm, and can also be utilized for chronic, retracted tears as well.

Background: At the time of hip arthroscopy, some patients are found to have irreparable labral tears that are not amenable to primary repair. For these patients, treatment with segmental reconstruction is a surgical option to restore labral tissue and biomechanics. Indications: Patients with segmental irreparable hip labral tears that are technically not amenable for primary labral repair should be considered for labral reconstruction with allograft. Technique Description: Standard hip arthroscopic portals are established. An interportal capsulotomy is performed, and acetabular rim trimming is performed to remove the pincer deformity. Visualized segmental labral defects are measured using a piece of suture to allow for measurement of a curved surface and 1.4-mm polyether ether ketone (PEEK) anchors are placed in anticipation of labral fixation. On the back table, the tibialis anterior allograft is prepared for labral reconstruction. We mark a central portion of the graft tissue based on the measured defect size. A 3-0 vicryl suture is used to place a running stitch from one end to the other of the marked portion of the allograft and the marked, prepared graft is sharply divided from the rest of the tissue. Stitches from the anterior and posterior anchors are passed through the graft using a free needle. The graft is then placed through the distal accessory anterolateral portal and positioned into place. The posterolateral and then medial-most anchors are secured and tied using arthroscopic knots, followed by sequential tying of the middle anchors. Any additional arthroscopic procedures, such as cam resection, are performed, and capsular/skin closure is performed using standard methods. Results: Published outcomes support reconstruction of the labrum using allograft, with 2 series consisting of a total of 141 segmental/circumferential reconstructions demonstrating similar outcome scores at 2 years of follow-up as compared to matched cases of primary labral repairs. Discussion/Conclusion: Hip segmental labral reconstruction with tibialis anterior allograft provides a viable surgical option for patients with labral defects precluding primary labral repair. The presented material demonstrates a readily employable technique as well as clear, step-by-step postoperative rehabilitation protocols, and satisfactory published short- and mid-term outcomes literature.

Background: Cartilage defects of the humeral capitellum most frequently present as osteochondritis dissecans (OCD) in young overhead athletes, such as baseball players. Historically, surgical options have included debridement, marrow stimulation, and osteochondral autograft transplantation. Fresh osteochondral allograft (OCA) transplantation comprises an additional treatment option that can structurally restore osteochondral defects and has demonstrated satisfactory outcomes without the donor-site morbidity associated with osteochondral autograft transplantation. Indication: OCA transplantation provides structural restoration of the articular surface and can be used for large (>1 cm diameter) lesions not amenable to refixation. Additionally, OCA transplantation can address both chondral and subchondral pathology and is suited for the treatment of failed previous surgical interventions, such as debridement or marrow stimulation. Technique Description: Following diagnostic arthroscopy, an anconeus splitting mini-open approach was performed to expose the capitellar defect. The defect was measured to be 10 mm, and a central guide pin was placed. A 10-mm reamer was used to prepare the defect bed to a depth of 8 mm. An OCA plug was then cut from a fresh femoral hemicondyle to match the prepared defect. The graft was soaked in bone marrow aspirate concentrate harvested from the iliac crest, and the plug was then inserted into the defect and tamped to be concentric with the surrounding articular cartilage. Results: OCA transplantation of the capitellum allows for the restoration of the articular surface with a structural graft and can be used for large defects and revision cases. While OCA transplantation is well described in the knee with long-term efficacy, the application of this technique to the capitellum is relatively recent. Recent case series for the capitellum have displayed significant improvements in patient-reported outcome measures and predictable return to sports. Discussion/Conclusion: OCA transplantation for the humeral capitellum provides an effective treatment option for large, unstable cartilage lesions not amenable to refixation. The procedure allows for restoration of the articular surface and can provide improvements in pain and function as well as return to sport.

Background: Prior literature has demonstrated variability in the preparation of platelet-rich plasma (PRP) for knee osteoarthritis, but it is unclear if study design and postoperative outcomes have been standardized for this intervention. Objective: To determine the variability in study design and outcome reporting across randomized controlled trials (RCTs) examining intra-articular PRP injections for knee osteoarthritis. Data source: The Cochrane Database, PubMed, EMBASE, and MEDLINE. Study eligibility criteria, participants, and interventions: Level I and II RCTs examining intra-articular PRP injections for knee osteoarthritis were included. Study appraisal and synthesis methods: The Jadad score was utilized. Results: Twenty-seven studies were included. Five studies conducted repeat imaging postoperatively. Visual Analog Scale (VAS) Pain (63%) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) (59.3%) were the 2 most utilized PROMs, followed by Knee Injury and Osteoarthritis Outcome Score (KOOS) (29.6%). Twelve (44%) RCTs reported 3 or more PROM (ie, VAS, KOOS, WOMAC). Most RCTs did not report objective outcome measures (70.4%). Limitations: The findings were largely descriptive in nature with limited utilization of statistical evaluation. Conclusions and implications of key findings: RCTs examining outcomes after intra-articular PRP injection for knee OA demonstrate substantial variability. Standardizing the population of most benefit with respect to arthritis grade may help in limiting population heterogeneity for future study comparison and pooling. In addition, PROs should be reported in a domain-specific manner allowing for assessment of pain, function, and health-related quality of life. Systematic review registry number: This review was not registered with PROSPERO. Level of Evidence: II; Systematic Review of Level I-II RCTs.

Introduction: Whole Leg Radiographs (WLR) are the gold standard for diagnosing malalignment and for pre-operative osteotomy planning. Positioning can affect the reproducibility of the measured hip knee angle (HKA), resulting in insufficient diagnostics and preoperative plans. We developed an easy-to-use WLR protocol by standardizing patient positioning and focusing on reproducibility. Objectives: This study aims on testing this reproducibility of the novel WLR protocol. Methods: This study enrolled 30 patients for a test-retest analysis. Each patient underwent two bilateral WLRs on the same day using the investigated positioning protocol. Three observers measured the HKA, mechanical medial proximal tibial angle (mMPTA), mechanical lateral distal femoral angle (mLDFA), and joint line convergence angle (JLCA) on the two radiographs. Twice each, with one week between. Results: The intra-observer and inter-observer reliabilities were excellent, with intraclass correlation coefficients (ICCs) between 0.990 and 0.996. The ICCs between the measured HKA (0.985), mMPTA (0.922), and mLDFA (0.903) on the two separate radiographs were excellent. The ICC between the JLCA measured on the first and second WLR was moderate with 0.632. The mean absolute error between the HKA, mMPTA, mLDFA, and JLCA measurements on the first and second WLR were respectively: 0.442°, 0.783°, 0.828°, and 0.794°. Conclusions: The investigated novel WLR positioning protocol produced excellent and reproducible HKA measurements, with clinically acceptable degrees of error. We recommend applying this easy-to-use protocol when obtaining WLRs for osteotomy planning. Physicians still need to be aware of possible rotational and fixed flexion deformities in the lower limb present on WLRs and during physical examination.

Background: Ischiofemoral impingement is a rare but increasingly recognized as a source of hip pain. Its etiology is often multifactorial and can be due to congenital, iatrogenic, or extra-articular pathology. Prior literature has described lesser trochanter osteoplasty and iliopsoas release for the treatment of ischiofemoral impingement, but postoperative hip flexor weakness has been noted with this technique. We present a novel technique for the treatment of ischiofemoral impingement, with resection of the ischial tuberosity. Indications: Patients with ischiofemoral impingement that remain symptomatic despite nonsurgical management, or patients with persistent gait abnormalities, are considered for surgery. Technique Description: In the prone position, direct posterior and posterolateral arthroscopic portals are created in the gluteal fold. The posterior femoral cutaneous and sciatic nerve are identified. Fluoroscopy is used to identify the region of impingement on the ischial tuberosity and the overlying hamstring tendon is elevated off the tuberosity. An arthroscopic burr is used to resect the tuberosity. Fluoroscopy is utilized to confirm adequate resection. This is combined with a dynamic examination under direct arthroscopic visualization with the hip in an extended, adducted, and externally rotated position. To repair the hamstring tendon, 2 double-loaded anchors are placed into the ischium, the sutures of which are used to repair the hamstring tendons using a horizontal mattress configuration. Patients undergo a stepwise postoperative physical therapy protocol, followed by a functional testing profile prior to return to competitive sport. Results: Significant improvements in patient-reported outcomes have been reported following treatment of ischiofemoral impingement, with some studies reporting Hip Outcome Score—Activities of Daily Living (HOS-ADL) >90 at 2 years postoperatively. Athletes have been able to return to sport at a mean 5.6 months after surgery. Large studies have yet to report on outcomes compared with nonsurgical or open techniques. Discussion/Conclusion: Recent advancements in endoscopic techniques have allowed for adequate visualization and release of ischiofemoral impingement. We present our endoscopic technique of ischial tuberoplasty, which, compared to lesser trochanter osteoplasty and iliopsoas release, may reduce the incidence of postoperative hip flexor weakness.

ABSTRACT: Introduction: The frequency of adverse outcomes after revision ACLR emphasizes the importance of the primary reconstruction regarding intra-articular graft healing and tunnel osteointegration. Objectives: The objective was to generate a functionalized suture based on peptide attachments that spatially recruits VEGFs and BMPs for graft healing. It was hypothesized that the suture would capture cytokines with favorable graft-bone integration in an ACLR rabbit model. Methods: Suture functionalization with established peptides was tested by immunofluorescence (IF) for recombinant VEGFA and BMP2. Three rabbit groups (n = 12/group) underwent ACLR using either a dual functionalized, plain suture (DF vs suture groups) or no suture (tendon group). Outcomes were assessed by μCT, molecular analysis, histology, and biomechanics at 4 to 12 weeks postoperatively. Results: Adequate functionalization was verified by IF for both growth factors. In vivo, the bone mineral density trended towards an increase at 4 weeks in the DF group (P > .194) but not at 12 weeks. Healing was better in the mid-section bone tunnel areas of the tendon group at 12 weeks compared to the suture (P = .026), or DF group (P = .011). Molecular analysis was inconclusive. Accumulation of growth factors was not evident by immunohistochemistry. Biomechanics showed no intergroup difference. Conclusions: The study established the development of a suture capable of capturing BMP2 and VEGFA by a peptide-binding strategy. This technology did not show superior tissue response or changes in biological parameters of ingrowth in vivo but seems to be interfering with bone tunnel closure at 12 weeks. The current model and technology should be further optimized.

Introduction: Improving ligament reconstruction biology may potentially be achieved through capturing autologous circulating factors such as vascular endothelial growth factor (VEGF) using commercially available biomaterials. Objectives: To evaluate anterior cruciate ligament reconstruction (ACLR) using a VEGF functionalized suture tape in a rabbit model of ACLR with a semitendinosus autograft. Methods: VEGF-binding peptides were covalently bonded to polyethylene suture tape (ST) to generate functionalized constructs. Forty-six female New Zealand white rabbit ACLs were reconstructed with semitendinosus hamstring autograft (n = 6), hamstring + ST (n = 16), hamstring + scrambled peptide ST (n = 17), and hamstring + VEGF-functionalized ST (n = 17). Healing was evaluated at 2to 4 weeks using PCR, RNA sequencing, micro CT, histology, and biomechanical testing. Results: All rabbits successfully underwent ACLR, with no adverse events. ACLR with VEGF ST demonstrated significant decreases in inflammatory response (CD14, CD163), catabolism (MMP1, MMP3), and apoptosis (TNFSF10, Caspase-10) markers as compared to nonfunctionalized ST (P ≤ .04). µCT demonstrated similar bone tunnel mineral density in hamstring + VEGF ST rabbits as compared to hamstring + scrambled ST controls (P ≥ .31). Histology and biomechanical testing similarly demonstrated no adverse effects of VEGF-based immunomodulation on the tendon grafts. Conclusions: Using a rabbit model, ACLR performed with VEGF-functionalized suture tape demonstrated significantly decreased markers of inflammation, catabolism, and apoptosis as compared to ACLR with nonfunctionalized suture tape. No adverse effects of functionalization were noted. Future studies should further investigate the utility of functionalized suture tape in ACLR.

Background:. Evidence-based, procedure-specific guidelines for prescribing opioids are urgently needed to optimize pain relief while minimizing excessive opioid prescribing and potential opioid diversion in our communities. A multidisciplinary panel at our institution recently developed procedure-specific guidelines for discharge opioid prescriptions for common orthopaedic surgical procedures. The purpose of this study was to evaluate postoperative opioid prescription quantities, variability, and 30-day refill rates before and after implementation of the guidelines. Methods:. This retrospective cohort study was conducted at a single academic institution from December 2016 to March 2018. Guidelines were implemented on August 1, 2017, with a recommended maximum opioid prescription quantity for 14 common orthopaedic procedures. Patients who underwent these 14 procedures during the period of December 2016 to May 2017 made up the pre-guideline cohort (n = 2,223), and patients who underwent these procedures from October 2017 to March 2018 made up the post-guideline cohort (n = 2,300). Opioid prescription quantities were reported as oral morphine equivalents (OME), with medians and interquartile ranges (IQRs). Four levels were established for recommended prescription maximums, ranging from 100 to 400 OME. Results:. In the pre-guideline cohort, the median amount of prescribed opioids across all procedures was 600 OME (IQR, 390 to 863 OME), which decreased by 38% in the post-guideline period, to a median of 375 OME (IQR, 239 to 400 OME) in the post-guideline cohort (p < 0.001). The 30-day refill rate did not change significantly, from a rate of 24% in the pre-guideline cohort to 25% in the post-guideline cohort (p = 0.43). Multivariable analysis demonstrated that guideline implementation was the factor most strongly associated with prescriptions exceeding guideline maximums (odds ratio [OR] = 9.9; p < 0.001). Age groups of

Focal cartilage defects lead to significant pain and disability, prompting the development of various options for biologic restoration of the articular surface. Although each technique and biologic implant provides various advantages and associated limitations, matrix-induced autologous chondrocyte implantation (MACI) has gained popularity given promising long-term results. We present a technique for the facile implantation of MACI membranes using cookie cutter instrumentation to aid in defect debridement and graft preparation. The technique described allows for efficient operative workflow while ensuring the creation of vertical, stable defect edges and a form-fitting MACI membrane in a readily implemented fashion.