Search

To define the criteria for coverage for a cartilage restoration procedure and osteochondral allograft (OCA) transplantation and to investigate coverage for OCA procedures among private payer medical policies.A systematic search of private payer websites was conducted to identify publicly available 2018 OCA medical policies. Medical criteria related to patient demographics, defect characteristics, and previous treatment were analyzed. Trends in coverage for treatment of talus and patella and the extent of restrictiveness of medical policies were evaluated from 2016 to 2018. The extent of restrictiveness of a policy was defined by number of medical criteria established by payer policies. Policies with5, 3-5, and3 specified criteria for OCAs were considered strongly, moderately, and weakly restrictive, respectively.In total, 49 private payer medical policies for OCA transplantation were identified. Extracted criteria varied greatly between medical policies. Ten different defect size ranges were reported across payer policies. Criteria for patient body mass index was specified in 63% of policies. Criteria for failed arthroscopic or traditional surgical procedure were identified in 20% of the policies. More than one half of policies (51%) specified knee defect location to load-bearing surfaces. Analysis of trends in positive coverage statements and restrictiveness showed an increase from 4.7% in 2016 to 39.5% for talus, 4.7% to 7.0% for patella, and a slight shift (4.7% of payers) toward weakly restrictive medical policies.This study demonstrates wide variability and inconsistencies in published criteria among OCA medical policies.This study informs clinicians of the current state of coverage for OCA transplantation, providing insights into the variability of payer policies and potential impact.

Although osteochondral allograft (OCA) transplantation has been a standard treatment for patients with osteochondral lesions, there is a disagreement in commercial payers' medical criteria regarding the definition of medical suitability and thus authorization for OCA transplantation. The primary goal of this study was to understand where consensus between a committee of experienced cartilage restoration surgeon scientists and payer policies existed and where there was significant disagreement.U.S. private payers were identified by reviewing health insurance market research literature. Medical criteria were then obtained from publicly available payer medical polices. A literature review was conducted to identify supporting evidence for consensus statements based on private payer medical criteria. The MOCA (Metrics of Osteochondral Allograft) Committee, 30 experienced surgeons and subject-matter experts in OCA transplantation, used a Likert scale of 1 (strongly disagree) to 5 (strongly agree) to rank each statement. The extent of agreement and disagreement among participants was measured for each statement. Consensus was defined as agreement or disagreement of75%.Fifty-seven statements regarding relevant medical criteria for OCA transplantation were included in the survey. All 30 MOCA Committee members completed the survey (100% response rate). Over half of the statements (52.6%) did not reach consensus. Of the remaining 27 statements that reached consensus, respondents agreed or strongly agreed with 16 statements, and disagreed or strongly disagreed with 11 statements. Inconsistent voting was observed for statements related to osteoarthritis, inflammation, and degenerative changes.Commercial payers are not consistent in the medical criteria used to define patient eligibility for authorization of OCA transplantation. In contrast, an expert panel of cartilage surgeons reached a consensus that OCA transplantation was clearly suitable for a variety of specific indications. This study demonstrates the need to standardize medical criteria for cartilage restoration based on the most current literature, as well as in conjunction with experienced cartilage restoration experts.Therapeutic Level V . See Instructions for Authors for a complete description of levels of evidence.

Importance Glenoid bone loss can be associated with recurrent anterior shoulder instability and can lead to unsuccessful stabilisation procedures if not addressed. Objective The purpose of this study was to review the currently described techniques for arthroscopic anatomic glenoid reconstruction (AAGR) for anteroinferior shoulder instability and to analyse the results available to date. Evidence review A systematic literature search of three databases (PubMed, Embase and Scopus) was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify relevant articles. Any article describing a surgical technique and/or presenting results related to this technique was included. Quality appraisal was performed using the Risk Of Bias In Non-randomised Studies—of Interventions tool and the Institute of Health Economics Quality Appraisal of Case Series Studies Checklist. Findings Twenty-seven studies published between 2008 and 2019 were identified for inclusion. Clinical results were available for a total of 237 patients across all studies, with age range 16–67. Iliac crest autograft was used in 60% of patients. Iliac crest allograft and distal tibia allograft were used in 22% and 18% of patients, respectively. Distal clavicle autograft, lateral femoral autograft, glenoid allograft and synthetic graft were also described in cadaveric studies or technique papers without results. Capsuloligamentous repair was performed with suture anchors in 95% of patients, while 5% had no soft-tissue repair. Patient satisfaction was high (90%), with low rates of instability (5%). Clinical exam demonstrated satisfactory range of motion, with good outcomes when functional scores were assessed, including Rowe score, constant score, Walch-Duplay score, Western Ontario Shoulder Instability Index (WOSI) and subjective shoulder value. Radiographic evaluation revealed high union rates (97%), but also high rates of resorption. Graft resorption rates averaged between 10% and 32%. Conclusions Current evidence demonstrates that AAGR is a safe procedure with good short-term to medium-term results that is worthy of further study. Level of evidence Level IV, systematic review of level III and IV studies.

The purpose of this study was to compare glenohumeral stability following a Latarjet, a free bone block (FBB), and a FBB with remplissage for bipolar bone loss.Nine matched pairs of fresh frozen cadavers were tested in a custom biomechanical apparatus with rotation and progressive translational loading. The free bone block group consisted of a distal tibial allograft with an all-suture tape construct. The Latarjet group was performed with the native coracoid and two partially threaded cannulated screws. A bipolar bone loss model was created with 20% glenoid bone loss and an off-track Hill-Sachs lesion. Testing conditions included the 1) native state, 2) bipolar bone loss model, 3) Latarjet, 4) FBB with distal tibial allograft secured with cerclage sutures, and 5) FBB with remplissage. Each condition was tested for translation, humeral head apex shift, stiffness, and dislocation force.There were no differences in translation, stiffness, or dislocation forced between the FBB alone and Latarjet groups. The FBB with remplissage group demonstrated the lowest anterior-inferior translation at 90° of ER, which was statistically significant compared to Latarjet 20N (P = .013) and compared to the FBB alone at 40N (P = .024) and 50N (P = .011). The FBB with remplissage group was significantly stiffer compared to FBB alone at 90° ER with approximately 60% change in stiffness (P = .028). The force required to dislocate the humeral head after treatment was highest in the FBB with remplissage group, which was statistically significant compared to the FBB alone (P = .003) and Latarjet groups (P = .018).The addition of remplissage to a FBB restores translation and stiffness closer to the intact state compared to a FBB alone or Latarjet in a bipolar bone loss model with an off-track Hill-Sachs lesion. In this model, dislocation force significantly increased with the addition of remplissage to the FBB.This biomechanical study provides evidence that Latarjet and FBB are both acceptable forms of treatment for bipolar bone loss, but stability can be enhanced with the addition of remplissage following glenoid reconstruction.

Objectives: Synovial fluid profiles in the setting of intra-articular ligament injury remains largely undefined and may play a significant role in graft incorporation and the development of fibrosis and PTOA. Senescence, a characteristic of cellular aging, has been recently linked to the acceleration of osteoarthritis (OA), but has yet to be examined in the setting of acute knee injury. To our knowledge, the presence of senescent profiles, including senescent cells and their senescence associated secretory phenotype (SASP) factors, have not been evaluated following an acute intraarticular ligament injury in humans. The purpose of this study was to prospectively identify, measure and compare senescent profiles between synovial fluid and peripheral blood mononuclear cells (PBMCs) in patients that have sustained an acute knee injury within 48 hours. Methods: Eight subjects between 18-65 years of age who presented within 0-48 hours of an acute knee effusion with a confirmed ACL or posterior cruciate ligament tears on magnetic resonance imaging were prospectively enrolled in the study. Synovial fluid (4-30 mL) and peripheral blood (˜15 mL) samples were collected in anticoagulant at the time of initial evaluation, processed using RBC lysing buffer and/or separation gradient (LympoprepTM, Stem Cell Technologies) following manufacturer instructions, and then their senescent phenotype and SASP profile was quantified using flow cytometry (Guava EasyCyte, Luminex), multiplex (Luminex 200®) and qRT-PCR. Senescent cell burden was quantified in triplicate per sample using C12FDG (senescence stain)1, bafilomycin (reduces false positives), and DRAQ7® (viability stain) by flow cytometry (Guava EasyCyte, Luminex). Cells were gated to singlets and live/dead (viability) groups, then live cells were gated for senescence. Three distinct senescent cell populations were assessed including non-senescent (C12FDG-), bright (++, highly fluorescent), dim (+, moderately fluorescent) and total (dim+bright) cells are analyzed in percentages and count. We subsequently analyzed matrix metalloproteinases (MMPs; MMP-1,-2, -3, -9, -12, -13) and tissue inhibitors of MMPs (TIMPs; TIMP-1, -2) that have previously been described as part of the SASP complex2 using the Luminex 200® multiplexing technology according to manufacturer’s guidelines. Cellular expression of cell cycle regulators (p16, p21, p53) established as senescent markers and proinflammatory SASPs (IL-1β, IL-6, IL-8) were quantified using RT-PCR . Statistical analysis was performed using two-way ANOVA using Graphpad Prism followed by Tukey-post hoc and paired Wilcoxon Signed Rank testing. Results were reported as median and quartiles [1st quartile, 4th quartile]. Results: Patient demographics and injury details were collected and reported on 7 subjects, including age (median 43.0, range 21-61), gender (3 males, 4 females), knee laterality (3 right, 4 left), injury type (6 ACL, 1 PCL). Time from injury to synovial fluid aspiration/ venipuncture was 1.14 days (range 0-2 days). Using C12FDG to quantify senescent cells we found the total number of C12FDG was significantly different in synovial fluid (33.0 % [26.1, 66.6]) compared to PBMCs (31 % [27.1, 38.3]) (Fig. 1C, p12FDG subsets, bright (C12FDG++) and dim (C12FDG+) were not statistically different across tissue source (Fig. 1A&B). All MMP analytes (MMP-1,-2, -3, -9, -12, -13) were detectable in synovial fluid, plasma and serum samples (Fig. 2D). MMP-3 was significantly elevated in synovial fluid (median: 435404 pg/mL [349605.7, 581710]) compared to plasma (median: 12537 pg/mL [10970.9, 43637.1]) and serum samples (median: 15700.8 pg/mL [13231.1, 38228.1]) (Fig. 2A, pConclusions: Our results suggest that there is a significant presence of senescent cells and SASP within the synovial fluid local environment compared to the systemic environment within hours after an acute knee injury (within 48 hours) involving ligament tears. Of note, we did not find elevated senescence associated gene expression within the acute knee injury setting. Interesting, we found that there are two distinct senescent cell populations (bright and dim C12FDG+ populations) in synovial fluid samples, similar to that of senescent PBMC samples. This preliminary data may have a role in identifying strategies to modify the acute environment within the synovial fluid either at the time of acute ligament injury or during reconstruction surgery. To this end, reducing senescent cells, and downstream activation of inflammatory and degradative factor expression has the potential to decrease the rates of inflammation and scar tissue formation and improve graft incorporation and healing, with the goal to prevent the progression of PTOA. A larger sample size and comparing 48 hour senescent profiles to post-surgical time points will be necessary to improve our understanding of the potential changes in these profiles when comparing the systemic and local environments in an acute knee injury setting. [Figure: see text][Figure: see text][Figure: see text]

Objectives: The purpose of this study was to 1.) qualitatively and quantitatively analyze the interplay between glenoid bone loss (GBL) and Hill-Sachs lesions (HSL) in a cohort of anterior instability patients using 3-dimensional (3-D) imaging software and 2.) assess the relationships between GBL and HSL characteristics. Methods: Patients with anterior shoulder instability with a minimum of 5% GBL with evidence of HSL confirmed on computed tomography were identified. 3-D models of the unilateral proximal humeral head and en face sagittal oblique view of the glenoid were reconstructed using Mimics (Materialise NV, Leuven, Belgium) software. GBL as well as surface area (SA), width, defect length, and glenoid track width was quantified. The volume, SA, width, and depth of identified HSLs were quantified along with their location (medial, superior, and inferior extent) on the humeral head. The severity of glenoid bone loss was categorized by low grade (0-10%), moderate grade (>10% to 20%), high grade (>20% to 30%), and extensive (>30%). Analysis of variance was then computed to determine significance (p < 0.05) between severity of GBL and associated HSL parameters. Results: 100 patients met inclusion criteria (mean age: 27.9 years, range: 18 to 43 years), which included 58 right shoulders and 42 left shoulders (84 male, 16 female). Among groups, 32 patients presented with low grade GBL (μ GBL = 6.1%), 38 patients with moderate grade (μ GBL = 16.2%), 17 with high grade ( μ GBL = 23.7%), and 13 with extensive GBL (μ GBL = 34.0%), with an overall mean GBL of 18.1% (range 5% - 39%). Patients with 0-10% GBL had significantly narrower (average and max width) ( p < 0.03) and deeper (average depth) (p = 0.002) HSLs compared with all other GBL groups, while greater GBL was associated with wider and shallower HSLs. GBL width, percent width loss, defect length, and glenoid track width all significantly differed across the four GBL groups (p < 0.05). Conclusions: Hill-Sachs Lesions (HSLs) have different morphological characteristics depending on the amount of glenoid bone loss (GBL). GBL is directly related to the characteristics of HSLs. Smaller glenoid defect size is associated with narrower and deeper HSLs. Management of the humeral head and glenoid must be appropriately tailored given the distinct interplay between GBL severity and HSL.

Objectives: The Latarjet procedure has been shown to be effective in treating recurrent shoulder instability, especially in the setting of glenoid bone loss and after failed previous Bankart repair. Several studies have additionally shown a significant reduction in recurrent instability rates when compared to Bankart repair in contact athletes when the Latarjet procedure is performed in a primary setting. We have identified an additional population of patients that provides greater challenges beyond the common athlete including those involved in contact sports. Termed “consequence athletes,” these patients are defined as athletes who perform in high risk, uncontrolled environments for whom an injury is likely to threaten life or livelihood. This population includes elite military forces, law enforcement and federal agents, motocross, elite skiers/snowboarders, whitewater kayak and rafters, and rock climbers. The purpose of this study is to evaluate minimum 2-year outcomes of primary Latarjet procedure in consequence athletes with anterior shoulder instability. Methods: Consequence athletes who underwent open Latarjet by one of the three sports medicine trained senior surgeons between August 2006 and January 2018 were retrospectively reviewed from prospectively collected data. Minimum 24 follow up was obtained on all patients. Those younger than 18 at follow up, history of concomitant or prior remplissage procedure, glenoid reconstruction with allograft, severe glenohumeral arthritis, or hyperlaxity were excluded. Glenoid bone loss (GBL) was evaluated on preoperative MRI and the cohort divided into GBL 0-14% and ≥15%. Patient-reported outcome scores (PROs) were collected and included the American Shoulder and Elbow Surgeons (ASES) score, Single Numeric Assessment Evaluation (SANE) score, Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score, Short Form–12 (SF-12) Physical Component Summary (PCS), and numeric rating scale (NRS) for pain score (0 - 10, 10 = worst pain). Postoperative patient satisfaction (1 - 10, 10 = very satisfied) was evaluated. Complications and revision surgeries were recorded. Failure was defined as a postoperative dislocation or a revision surgery. Results: Sixty-five consequence athletes were included (54 males, 11 females). The mean age at surgery was 28.5 ± 8.7 years (range 15.8-56.4). The most frequent professions included 17 skiers (26.2%), 17 rock climbers (26.2%), 10 snowboarders (15.4%), 9 white water kayakers/rafters (13.8%), and 8 federal agents/military (12.3%). Primary latarjet was performed in 30 (46.2%) without prior history of soft tissue stabilization procedures. Mean GBL was 13.7%; 27 (41.5%) had 0-14% GBL and 32 (49.2%) had ≥15% GBL. Significant improvement in PROs at minimum 2-year follow was demonstrated for SANE (57.9 ± 24.5 to 91.0 ± 9.5), SF12 PCS (45.5 ± 8.7 to 54.4 ± 7.1), ASES pain (41.5 ± 9.7 to 47.4 ± 5.3), ASES function (31.8 ± 12.6 to 46.2 ± 6.8), ASES total (73.0 ± 19.8 to 93.7 ± 10.0), and quickDASH (27.0 ± 14.0 to 10.0 ± 28.8). Median patient satisfaction was 10. One patient sustained a recurrent dislocation (1.5%), 2 (3%) patients underwent revision surgery. There was no significant correlation between PROs and GBL, number of previous dislocations, or prior soft tissue stabilization procedures. Conclusions: The latarjet procedure a reliable and safe treatment for shoulder instability in the high demand “consequence athlete” population with a post-operative dislocation rate of 1.5% and revision rate of 3%. Significant improvement in PROs was demonstrated for SANE, SF12 PCS, ASES, and DASH with median patient satisfaction score of 10. These findings support treatment of this population with the latarjet procedure, even in the setting of minimal preoperative GBL, where a recurrent instability event could be catastrophic to the individual patient or those working or participating along with them.

Objectives: Though recognized as a risk factor, posterior glenoid bone loss has only recently been characterized and is distinctly different than anterior glenoid bone loss patterns. Existing biomechanical studies are limited by employment of anterior glenoid bone loss models which are different in both orientation and morphology than posterior glenoid bone loss, and testing in a single neutral arm position thus not fully accounting for the contribution of capsuloligamentous structures in various at-risk arm positions. The purpose of this study was to evaluate the biomechanical effectiveness of a posterior labral repair in the setting of a clinically relevant bone loss model using 3-dimensional computed tomography modeling of patients with recurrent posterior shoulder instability in various at-risk arm positions. Methods: Ten fresh-frozen cadaveric shoulders (mean age: 55.4 years, range: 39-65) were prepared by removing all tissue except the capsule and distal rotator cuff insertions. A joint coordinate frame was established, the specimens were potted, then mounted to a customized fixture on 6-degrees-of-freedom robotic arm. A posterior labral tear was created, then repaired with 3 horizontal mattress sutures and secured by drilling 6 transosseous holes along the peripheral glenoid face exiting the anterior glenoid neck. The sutures were secured for the labral repair states to the mounted fixture under maximal tension and released for the labral tear states and for creating the sequential bone loss models. Bone loss models were created based off a cohort of CT data on patients undergoing revision posterior labral repair surgery to develop 2 clinically relevant 3D models of glenoid bone loss: the first simulating the mean bone loss in this cohort and represented 7% or small bone loss; the second was the mean + 2SD representing 28% or large bone loss. The bone loss was created on each specimen with a 3mm round burr to match each respective 3D printed template (Figure 1). Each specimen was tested in 7 consecutive states: (1) native anatomy, (2) posterior labral tear (6-9 o’clock), (3) posterior labral repair, (4) mean posterior glenoid bone loss with labral tear, (5) mean posterior glenoid bone loss with labral repair, (6) large posterior glenoid bone loss with labral tear, and (7) large posterior glenoid bone loss with labral repair. Each state underwent 75N of posterior-inferior force and 75N of compression during the four tests at 60 and 90 degrees of flexion and 60 and 90 degrees of scaption. Posterior-inferior translation, lateral translation, and dislocation force were measured for each condition. Statistical analysis was performed using two-factor random-intercepts linear mixed-effects models. Results: Compared to the labral tear state, significant increases in dislocation forces occurred with labral repair independent of bone loss state or arm position with values as follows: 14.8N (60° scaption), 12.2N (90° scaption), 11.1N (60° flexion), and 10.1N (90° flexion) with mean 12.1 ± 2.0N across all arm positions (Figure 2). Dislocation force significantly decreased between no bone loss and small bone loss (mean 12.4 ± 0.7N) and between small bone loss and large bone loss (mean 11.8 ± 2.1N) regardless of labral state in all arm positions (table 1). Posterior-inferior translation significantly decreased with labral repair compared to labral tear states independent of bone loss state in all arm positions (Table 1). Lateral translation of the humeral head significant increased when the labrum was repaired independent of bone loss state in all arm positions except 90° scaption and decreased progressively in all bone loss states in all arm positions (table 1). In the native state, the shoulder significantly translated posterior-inferior in scaption at 60° and 90° elevation compared to flexion (pConclusions: This is the first study to biomechanically evaluate posterior glenoid bone loss using a clinical model in various at-risk arm positions on a 6 degree-of-freedom robot and through a precise linear effects model has established values for the increase in dislocation force posterior labral repair provides regardless of bone loss. The most significant finding of the study is that independent of bone loss, labral repair reduced posterior dislocation forces by 12.1 ± 2.0N and significantly decreased posterior-inferior translation. With a mean decrease in dislocation force of 12.4 ± 0.7N with small (7%) bone loss, labral repair alone may be enough to restore shoulder stability in most individuals. However, significant increases in posterior bone loss may require bony augmentation for adequate stability based on individual factors such as age and activity level. [Table: see text][Figure: see text][Figure: see text]

Objectives: The open Latarjet procedure has been demonstrated to be reliable in achieving acceptable patient reported outcomes (PROs). However, clinical predictors of outcome, return to sport and complications/failures have been more variable. The purpose of this study is to report patient reported outcomes (PROs), clinical correlations, and predictors of failure in patients who have received an open Latarjet surgery. Methods: Patients who received an open Latarjet with by two fellowship–trained surgeons between August 2006 - November 2018 were included. Prospectively collected data was reviewed, and PROs included ASES, SF–12 PCS, SANE, QuickDASH, and satisfaction. Age, sex, sports participation, pain, primary vs. revision (prior failed arthroscopic/open Bankart) surgery, dislocation number, glenoid bone loss (GBL), glenoid track concept, and projected glenoid track were evaluated. Projected track was calculated using the axial diameter of the corcoid as part of the glenoid track concept. Postoperative ASES Results: 126 shoulders (125 patients) met inclusion criteria with mean age of 28.1 years (range 15–57). 7/126 (5.5%) had revision surgery prior to final follow-up and were excluded from outcomes analyses. Mean follow-up 3.7 years (range 2–9.3 years) was attained in 86.6% (103/119) of patients. All PROs significantly improved from preoperative baseline (ASES: 69.7→90.2; SANE: 55.8→85.9; QuickDASH: 28.4→10.5). PROs did not differ with sex, sport participation type, dislocation with/without sports, primary/revision, and preoperative dislocation number. No correlations existed between PROs and age, GBL, or number of previous surgeries. On-track (50/105, 47.6%) and projected on-track (90/105, 85.7%) lesions correlated with better patient satisfaction, but not PROs. A total of 97% (86/89) returned to sport, with 74% (66/89) at the same/slightly below pre-injury level. Failures included 13/126 (10.3%) postoperative dislocations and 6/126 (4.7%) with ASES scores Conclusions: The open Latarjet procedure lead to significant improvements in all PROs, and overall 97% of patients returned to sport. On-track and projected on-track measurements correlated with better patient satisfaction, but not improved PROs. No other factors were predictive of outcomes, nor clinically correlated with failure.

Objectives: To retrospectively evaluate the impact of early(6months) return to play(RTP) on the rate of failure, volume of play, and career longevity following ACL reconstruction in a cohort of professional European soccer players. It was hypothesized that athletes returning to professional competition earlier than 6 month after ACL reconstruction would not have an increased risk of failure, volume of play, and a shorter professional career. Methods: Professional soccer players treated for anterior cruciate ligament tear by a single surgeon were included in this retrospective study. The study was approved by the institutional review board. The inclusion criteria were that the patient was a (1) male, (2) professional soccer player with an (3) injury of the anterior cruciate ligament. Exclusion criteria were revision ACL, extra-articular ligamentous reconstruction, and previous contralateral ACL reconstruction. A total of 178 players who were all in the first or second division of their league met criteria for the study over a ten year period. Time from intervention to return to the first official game was recorded in days. Information if the patient was able to return to the same season was recorded, as well as the number of games and total and average minutes played in the return season. Number of seasons played after injury and if the player was active at the time of data collection (September 2019) was also recorded. If the player was still active, the player’s current club was recorded. Results: 90-early RTP and 88 standard RTP players were identified. Players in the early RTP group returned to professional level soccer at a mean of 4.76 months, which was significantly sooner than players in the standard RTP group who returned at a mean of 9.21 months (p < 0.01) following ACLR. A significantly greater number of players in the early RTP group returned during the same season of intervention (n = 56/92, 60.9%) than in the standard RTP group (n = 18/88, 20.5%) (p < 0.01). Players in the early RTP group competed in an average of 11.5 games during their return season while those in the standard RTP group competed in an average of 12.9 games (p > 0.05). The early RTP group played, on average, a total of 759.2 minutes and 56.5 minutes/game in their return season, while the standard RTP group played an average of 812.8 total minutes and 50.0 minutes/game in their return season (p > 0.05). Players in the early RTP group had significantly longer careers following ACLR, averaging 5.62 seasons, compared to those in the standard RTP group who competed in an average of 4.75 seasons after surgical intervention (p < 0.01). The early RTP group had 4 failures while the late RTP group had 1 failure failure. Conclusions: Professional European soccer players who return to play earlier than 6 months after ACL reconstruction returned more frequently during the same season, played the same number of games and minutes during their return season, had longer careers, but had more ACL graft failures when compared with those who returned greater than 6 months after surgery. Professional European soccer players who returned early after ACL reconstruction (

Objectives: Anterior cruciate ligament reconstruction (ACLR) remains one of the most readiness-impairing surgical conditions treated in the US Military. Greater time from the index injury to surgical management (ACLR) unnecessarily prolongs the total time of limited duty. Additionally, prolonged wait times from the index injury to ACLR may increase the patient’s likelihood of sustaining concomitant or secondary intraarticular pathologies (e.g., cartilage and meniscus damage). The optimal timing for surgical reconstruction following ACL injury is debated. The purpose of this study was to determine the impact of prolonged time from injury to surgery on medical separation within five years of primary ACLR. We hypothesized that longer durations from injury to primary ACLR would be associated with greater medical separation risk within five years following surgery. Methods: We conducted a retrospective database review using data from the Military Health System Data Repository (MDR) of primary ACLR without and with concomitant procedures (meniscus [M] and/or cartilage [C]) performed within Military Treatment Facilities (MTF) from fiscal year 2009 to and/or cartilage [C]) performed within Military Treatment Facilities (MTF) from fiscal year 2009 to 2011. At the time of the ACLR, ADSMs had to be continuously enrolled for two years prior to the surgery with no history of knee surgeries in direct care (i.e., MTFs) or purchased care to ensure a higher likelihood of the index event being a primary ACLR and not an ACLR revision. A total 2,809 active duty service members were included with primary ACLR. The MDR was queried for baseline demographic, military service, and surgical information at the time of ACLR. Duty status at the time of the ACLR and cause of separation up to five years after primary ACLR were abstracted. The time from the index injury diagnosis to the primary ACLR was calculated and grouped as follows: Acute = 0-42 days, Subacute = 43-91 days, Delayed = 92-179 days, Chronic ≥ 180 days. Kaplan-Meier survivability curves were estimated and evaluated with Log-rank. Cox Proportional Hazard Models calculated Hazard Ratios (HR) with 95% confidence intervals (95% CI) to identify time from injury to surgery, demographic, and military status factors that influenced medical separation risk for patients with primary ACLR (ACLR, ACLR+M, ACLR+C, ACLR+M+C). Results: The index surgical events were categorized by isolated ACLR (48%), ACLR+M (42%), ACLR+C (5%), and ACLR+M+C (4%). Overall, the time from diagnosis to ACLR was approximately equivalent across all time categories: Acute (19%), Subacute (31%), Delayed (23%), and Chronic (25%). The probability of medical separation 5 years following primary ACLR (ACLR, ACLR+M, ACLR+C, ACLR+M+C) was highest for the delayed [92-179 days] group (17%) and lowest for the acute [0-42 days] group (12%). Patients in the delayed group were over 51% more likely to medically separate in the 5 years following the primary ACLR than those who were treated within 42 days from injury (acute group). The difference between the acute group and subacute or chronic was not statistically significant. Those in infantry and combat support related military occupation classifications were 27% more likely to medically separate. Service members in the Army were more than 4.5 times more likely to medically separate compared to those in the Air Force. Smoking and BMI over 29 also increased the risk of medical separation within 5 years by 42% and 91%, respectively. The type of injury at the index event (ACLR, ACLR+M, ACLR+C, ACLR+M+C) did not significantly influence the likelihood of medical separation risk. Conclusion: Delay in treatment from injury to primary ACLR increases the number of limited duty days, effects medical readiness of ADSM, and military retention rates post ACLR. Specifically, when primary ACLR is delayed 3 to 6 months from injury, ADSM have a 51% increased likelihood of military medical separation risk in the 5 years following the ACLR than if they would have been treated within 41 days of injury. Early recognition of ACL tears as well as availability of surgeons and Operative Rooms (ORs) should be evaluated to determine their contribution to the delay in ACLR in the MHS.

Arthroscopic shoulder stabilization offers several potential advantages compared with open surgery, including the opportunity to more accurately evaluate the glenohumeral joint at the time of diagnostic assessment; comprehensively address multiple pathologic lesions that may be identified; and avoid potential complications unique to open stabilization, such as postoperative subscapularis failure. A thorough understanding of normal shoulder anatomy and biomechanics, along with the pathoanatomy responsible for anterior, posterior, and multidirectional shoulder instability patterns, is very important in the management of patients who have shoulder instability. The treating physician also must be familiar with diagnostic imaging and physical examination maneuvers that are required to accurately diagnose shoulder instability.

A successful surgical outcome for patients with shoulder instability requires a complete preoperative evaluation, a thorough diagnostic arthroscopy to evaluate for concomitant co-pathology, and an effective postoperative therapy program tailored to the repair strategy. In addition to the Bankart lesion, the surgeon must be aware of other co-pathologies such as the HAGL lesion, the ALPSA lesion and SLAP tears, all of which may occur in concert with capsular pathology and which present as potential barriers to a successful outcome. We have previously described the use of a posterolateral arthroscopic portal, 4 cm lateral to the posterolateral corner of the acromion. This portal simplifies and improves anchor placement, trajectory, and anatomic capsulolabral repair of the inferior glenoid. In this case, we perform a hybrid repair using the posterolateral portal to place the first suture anchor at the 6 o’clock position on the glenoid and the mid-glenoid portal to place two labral tape knotless anchors.

Osteochondritis dissecans (OCD) of the knee has multiple possible etiologies. Among these are repetitive microtrauma, disruption of normal endochondral ossification, as well genetic factors. The male to female ratio is approximately 4:1 in the United States and has been found to have the highest incidence in the African American population. Diagnosis is usually made by physical examination in association with radiographs (flexion notch view) and magnetic resonance imaging. Lesions are usually found on the lateral aspect of the medial femoral condyle. Arthroscopy continues to be the gold standard for assessing the stability of OCD lesions. Many unstable lesions may be treated with stabilization, and cartilage restoration may provide benefit; however long term data is still limited.

As arthroscopic and minimally invasive procedures have become increasingly more common over the past decade, a versatile understanding of several arthroscopic knot tying techniques is essential for reproducible and reliable repairs. While there are numerous descriptions of unique arthroscopic knots, selection and correct implementation is critical for adequate soft tissue fixation and successful patient outcomes. Specifically, the Roeder knot, a type of locking sliding knot, with 3 alternating half hitches, has been described to provide the loop and knot security among other sliding knot techniques. Therefore, the Roeder knot has emerged as a preferred knot tying technique amongst orthopedic surgeons, especially in the setting of arthroscopic shoulder stabilization procedures. In this case, we describe the basic fundamentals of performing a Roeder knot with 3 alternating half hitches to anchor the labrum to the glenoid in the setting of an arthroscopic Bankart repair.

Optimal portal placement for arthroscopic shoulder stabilization procedures can significantly aid a surgeon’s visualization during the repair as well as suture anchor placement. A percutaneous knotless anchor insertion kit used through a mid-glenoid portal allows the surgeon to access positions on the glenoid rim that are commonly difficult to reach. Moreover, the knotless kit has the ability to save valuable time during arthroscopic stabilization procedures and also eliminates the risk of postoperative knot impingement. The mid-glenoid portal should be made approximately 1 cm lateral from the joint line of the humeral head and 2 to 3 cm inferior and 1 to 2 cm medial from the posterolateral acromial angle. This portal placement avoids injury to the labrum and should be determined after assessing both the thickness of the local soft tissues and the size of the relevant bony architecture. A hole for the knotless anchor should be drilled approximately 1-2 mm onto the face of the glenoid, and the labral tape is then passed a short distance through the eyelet of the knotless fixation device before the construct is inserted into the glenoid. A hemostat is used to hold the tape as it is placed into the drill hole, and a mallet is used to drive the interference portion of the plastic implant to a marked depth. Finally, once the suture anchor is securely affixed, the insertion device is unloaded and pulled out of the portal with 6 counter-clockwise turns.