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To identify risk factors for patient election to proceed with cartilage transplant after staging chondroplasty.This study retrospective reviewed patients prospectively enrolled at the time of staging chondroplasty, with early election defined as patient decision to proceed to cartilage transplantation within 6 months of chondroplasty. Cox proportional hazards analysis was used to determine univariate predictors of conversion, and a predictive calculator, the Cartilage Early Return for Transplant score, was formulated using stepwise regression employing the Akaike information criterion. Receiver operator curves and the area under the curve were used to evaluate the predictive ability of the final model on the studied patient population.Sixty-five knees (63 patients) were evaluated, with an overall transplant election rate of 27.7% within 6 months after chondroplasty. Based on multivariate results, the final Akaike information criterion-driven Cartilage Early Return for Transplant score employed preoperative Knee Injury and Osteoarthritis Outcome Score Pain Score, Veterans Rand 12-Item Health Survey Physical Score, condylar involvement, and AMADEUS (Area Measurement And DEpth Underlying Structure) score to generate a 0- to 7-point risk-stratification system with a 3% early election to proceed to transplant risk in the 0- to 2-point score group, 33% risk in the 3- to 4-point group, and 79% risk in the 5+-point group (Risk of early patient election to pursue cartilage transplantation after chondroplasty is closely and additively associated with preoperative AMADEUS grade, condylar involvement, Knee Injury and Osteoarthritis Outcome Score Pain Score, and Veterans Rand 12-Item Health Survey Physical Score.Understanding risk factors for conversion to cartilage transplantation may improve preoperative planning and counseling prior to staging chondroplasty.

Background: Tibial tubercle–trochlear groove (TT-TG) distance is a risk factor for recurrent patellar dislocation and is often included in algorithmic treatment of instability. The underlying factors that determine TT-TG have yet to be clearly described in orthopaedic literature. Purpose/Hypothesis: The purpose of our study was to determine the underlying anatomic factors contributing to TT-TG distance. We hypothesized that degree of tubercle lateralization and knee rotation angle may substantially predict TT-TG. Study Design: Cross-sectional study; Level of evidence, 3. Methods: All patients evaluated for patellar instability at a single institution between 2013 and 2021 were included. Patients with previous knee osseous procedures were excluded. TT-TG and its anatomic relationship to patellofemoral measures, including dysplasia, femoral anteversion, tibial tubercle lateralization, knee rotation angle, and tibial torsion, were measured and subsequently quantified using univariate and multivariable analysis. Results: In total, 76 patients met the inclusion criteria (46 female, 30 male; mean ± SD age, 20.6 ± 8.6 years) and were evaluated. Mean TT-TG was 16.2 ± 5.4 mm. On univariate analysis, increasing knee rotation angle ( P < .01), tibial tubercle lateralization ( P = .02), and tibial torsion ( P = .01) were associated with increased TT-TG. In dysplastic cases, patients without medial hypoplasia (Dejour A or B) demonstrated significantly increased TT-TG (18.1 ± 5.4 mm) as compared with those with medial hypoplasia (Dejour C or D; TT-TG: 14.9 ± 5.2 mm; P = .02). Multivariable analysis revealed that increased knee rotation angle (+0.43-mm TT-TG per degree; P < .01) and tubercle lateralization (+0.19-mm TT-TG per percentage lateralization; P < .01) were statistically significant determinants of increased TT-TG distance. Upon accounting for these factors, tibial torsion, trochlear width, and medial hypoplasia were no longer significant components in predicting TT-TG ( P≥ .54). Of note, all patients with TT-TG ≥20 mm had tibial tubercle lateralization ≥68%, a knee rotation angle ≥5.8°, or both factors concurrently. Conclusion: TT-TG distance is most influenced by knee rotation angle and tibial tubercle lateralization.

To (1) determine the effect of severe patella alta on lateral patellar displacement after medial patellofemoral ligament (MPFL) reconstruction and medial quadriceps tendon-femoral ligament (MQTFL) reconstruction and (2) determine whether lateral displacement significantly differs between MPFL and MQTFL reconstructions in the setting of severe patella alta (Caton-Deschamps Index [CDI] of 1.6).Eight cadaveric specimens were included. High-tensile strength suture was used to create a model of adjustable patellar height. Patellar height was set using fluoroscopy to CDI ratios of 1.0 (normal) and 1.6 (alta). Specimens underwent testing (1) with MPFL reconstruction, (2) with MQTFL reconstruction, and (3) in a medial patellofemoral complex (MPFC)-deficient control state, in randomized order, at both CDI settings: 1.0 and 1.6. Lateral patellar translation was measured at 0°, 10°, 20°, 30°, 45°, 60°, and 90° of knee flexion with 10 N of laterally directed load.At a CDI of 1.6, MPFL reconstruction showed significantly lower lateral displacement than MQTFL reconstruction at 0° and 20°. When compared with MPFC-deficient controls at a CDI of 1.6, MPFL reconstruction showed significantly lower displacement at 0° and 20° whereas MQTFL reconstruction was not significantly different at any degree of flexion.In the setting of severe patella alta (CDI of 1.6), MPFL reconstruction results in less lateral patellar displacement than MQTFL reconstruction at 0° and 20° of knee flexion. At higher flexion angles (≥30°), there is no difference between the 2 reconstruction techniques and the CDI no longer has an effect. At a CDI of 1.0, MPFL reconstruction shows lower displacement than MQTFL reconstruction in full extension only. Surgeons performing MPFC reconstruction should evaluate patients for patella alta and consider patellar height when deciding on the reconstruction technique.This study suggests that MQTFL reconstruction may be less stable than MPFL reconstruction in the setting of patella alta, without other known pathoanatomic factors, at early knee flexion angles. Patellar height should be considered when choosing the appropriate reconstruction technique in the absence of a distalization procedure.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used for multimodal pain control after surgery. These medications work by selective or nonselective inhibition of cyclooxygenase, which has downstream effects on thromboxanes, prostaglandins, and prostacyclins. Clinical studies have shown beneficial effects for alleviating pain and reducing opioid consumption after surgery. Within hip arthroscopy, there is evidence that postoperative NSAIDs can also reduce the risk of symptomatic heterotopic bone formation. However, preclinical and animal studies have raised concern over the effect of NSAIDs on bone and soft-tissue healing. In addition, selective and nonselective cyclooxygenase 2 inhibitors may have different safety profiles regarding postoperative soft-tissue healing. The purpose of this review was to outline the mechanisms of action, efficacy, and effect on soft-tissue healing of postoperative NSAIDs and to provide evidence-based recommendations for appropriate use.

PURPOSE OF REVIEW: Patellofemoral instability involves complex, three-dimensional pathological anatomy. However, current clinical evaluation and diagnosis relies on attempting to capture the pathology through numerous two-dimensional measurements. This current review focuses on recent advancements in patellofemoral imaging and three-dimensional modeling. RECENT FINDINGS: Several studies have demonstrated the utility of dynamic imaging modalities. Specifically, radiographic patellar tracking correlates with symptomatic instability, and quadriceps activation and weightbearing alter patellar kinematics. Further advancements include the study of three-dimensional models. Automation of commonly utilized measurements such as tibial tubercle–trochlear groove (TT-TG) distance has the potential to resolve issues with inter-rater reliability and fluctuation with knee flexion or tibial rotation. Future directions include development of robust computational models (e.g., finite element analysis) capable of incorporating patient-specific data for surgical planning purposes. SUMMARY: While several studies have utilized novel dynamic imaging and modeling techniques to enhance our understanding of patellofemoral joint mechanics, these methods have yet to find a definitive clinical utility. Further investigation is required to develop practical implementation into clinical workflow.

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

The lateral patellofemoral complex is an important stabilizer to medial and lateral displacement of the patella. Soft tissue abnormalities can range from pathologic tightness to laxity, presenting with symptoms related to patellar instability, anterior knee pain, or arthritis. Clinical evaluation should be performed to confirm patellar dislocation, assess the integrity of the lateral and medial soft tissues, and explore other pathoanatomic factors that may need to be addressed. Lateral retinacular lengthening is recommended over lateral release owing to the potential of iatrogenic medial instability with release, and a lateral patellofemoral ligament reconstruction can be performed to effectively treat medial instability.

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

Patellar instability is a complex disorder with multiple etiologies, and treatment must be individualized to the unique pathoanatomy of each patient. Medial patellofemoral ligament reconstruction is one of the most commonly performed procedures for the treatment of patellar instability. Patients with a symptomatic supratrochlear spur, defined by the presence of a “jumping” J sign on examination, also may benefit from an adjunctive proximal trochlear resection. Here, we describe a technique for an arthroscopic proximal trochlear resection, or “bumpectomy,” involving resection of the supratrochlear spur. In appropriately indicated patients, we have found this procedure to be a useful adjunct to medial patellofemoral ligament reconstruction without the need for concurrent trochlear sulcus deepening., Technique Video Video 1 This is a presentation of an arthroscopic technique for proximal trochlear resection to treat patients with patellar instability. Our disclosures are listed here as well as online. This is a 17-year-old male patient who has a 10-year history of patellar instability with subluxation and occasional complete dislocation events laterally and failed conservative management. He has no effusion on examination, he has 2 quadrants of lateral and medial translation, and has a jumping J-sign that is 2 quadrants when going from extension to flexion. When we look at his lateral radiograph as well as 3-dimensional MRI data, we see that he has a 9.9-mm supratrochlear spur that is even greater than this when we add cartilage into the equation. We also see that this extension of the trochlea is proximal to the proximal aspect of the posterior condyles, which means that this is taller than the normal trochlear height and likely can be resected as opposed to a formal trochleoplasty being performed. The patient has a Caton–Deschamps ratio of 1.25, and a Dejour classification of B. We elected to treat the primary issues, which were the proximal bump as well as the ligamentous instability by performing a proximal trochlear resection and MPFL reconstruction with hamstring allograft. During the examination under anesthesia, we see a giant jumping J-sign as he gets to approximately 70° of flexion or slightly more. We then can evaluate lateral translation, where we see that he's fully dislocatable on extension and once he is fully dislocated, he has a difficult time engaging due to this area of abrupt transition as he gets into high flexion. If we move the knee into flexion and try to dislocate laterally at 90° this is not possible, but the kneecap does come out at about 70°, demonstrating his significant dysplasia. Arthroscopic examination, starting at the notch moving proximal, demonstrates the trochlear dysplasia as well as the supratrochlear spur that is present at the most proximal aspect of the trochlea. We now spinal needle localize a superior lateral patellar portal, which can help with diagnostic arthroscopy as well as visualization of this spur. Here we can see the superior lateral trochlear damage, as well as the patella tracking and the distal medial patellar chondral wear. We then obtain a perfect lateral radiograph, where here we can see on live fluoroscopy the prominence of this bump proximally. We then find the associated area in the arthroscopic view that correlates with the fluoroscopic view so that we know where to perform our resection. This bump is typically proximal to the posterior condyle line that we draw perpendicular to the femur, as discussed in the preoperative planning. We then postage stamp using fluoroscopy to demonstrate where this should be located so we know where to start our resection. We then use a combination of direct arthroscopic visualization as well as fluoroscopic visualization to use a curette to remove the proximal bump or spur. Once we are through the cartilage, we then move to a bone-cutting shaver, or a Burr, to resect this to the level of the anterior femur. The goal of the surgery is to create a smooth transition similar to a cam resection for hip arthroscopy which would allow for less contact pressure on the patella. Here we see spinal needle localization of the direct lateral portal; we can use this for easier access to resect the remaining component of the spur perpendicular to where the spur is located. It's important to carry this resection from all the way lateral to medial. We can then move our camera to the superior lateral portal and have our shaver through the direct lateral portal so that we can visualize the resection from another viewpoint to make sure that it is adequate. Using different portals for viewing as well as the fluoroscopic guidance helps make sure that the resection is being performed in a 3-dimensional way that is correct and allows for a smooth transition for the patella after this is complete. Resection of the bump is typically not adequate in itself, but the resection should be done in a way that the ramp that is created is relatively shallow and so that there is not a vertical wall that is created from the resection of the bump. Here we can see that smooth transition both in arthroscopy and now the final result on fluoroscopy here where it has been resected and there’s a normal transition into the groove. After surgery the patient’s allowed full weight-bearing in a brace locked in extension until they have active quad extension without a lag. We then unlock the brace, we work on full range of motion without restriction, and hope to achieve this by 6 to 8 weeks after surgery and allowing return to full activity 4 to 6 months after surgery. (MPFL, medial patellofemoral ligament reconstruction; MRI, magnetic resonance imaging.)

PURPOSE OF REVIEW: Reverse total shoulder arthroplasty (rTSA) has emerged as an effective treatment option for patients with rotator cuff arthropathy resulting from irreparable rotator cuff tears. However, patients with combined loss of abduction and external rotation may still experience functional deficits after rTSA. One option to address this has been the latissimus dorsi tendon transfer (LDTT), or modified L’Episcopo procedure. The purpose of this review is to describe the role of LDTT with rTSA and to critically evaluate the evidence on whether a supplemental LDTT ultimately improves patient function. RECENT FINDINGS: Patients with an intact rotator cuff demonstrated a significant increase in active external rotation following rTSA compared to those with a deficient rotator cuff following rTSA. Compared to their pre-operative baseline assessments, patients who undergo rTSA with LDTT report significant improvements in active external rotation. However, a randomized trial comparing rTSA patients with and without LDTT failed to demonstrate a significant difference in active external rotation or patient-reported outcomes between groups. SUMMARY: Observational studies have shown that patients experience significant improvements in active range of motion and various patient-reported outcome measures following rTSA with latissimus dorsi tendon transfer. When directly comparing rTSA with LDTT to rTSA alone, the current literature fails to demonstrate a statistically significant difference in active external rotation or patient-reported outcomes at short-term follow-up. Further randomized controlled trials are required to fully understand the potential benefits of added tendon transfer in the rTSA patient population.

The goal of this study was to evaluate the stiffness and resistance to elongation of an internal bracing (IB) construct in posterior cruciate ligament reconstruction (PCLR). The authors hypothesized that augmentation with an internal brace would increase construct stiffness and decrease posterior tibial translation during cyclic loading in a fresh frozen cadaveric model. Ten cadaver knees underwent PCL reconstruction with (PCLR+IB) and without (PCLR) augmentation with an internal brace and were compared with an intact PCL state. Knees were subjected to cyclic posterior drawer loading at 45 N, 90 N, and 134 N. The PCLR+IB showed significantly less tibial translation with posterior drawer loading compared with the PCLR. Posterior tibial translation measured 8.83 mm for the PCLR vs 6.59 mm for the PCLR+IB ( P =.05) at 45 N posterior load. This difference remained significant at higher loads, with posterior translation of 10.84 mm and 8.44 mm for PCLR and PCLR+IB, respectively, at 90 N ( P =.035) and posterior translation of 12.80 mm and 10.23 mm for PCLR and PCLR+IB, respectively, at 134 N ( P =.023). No significant differences were found in overall construct stiffness between groups. These data suggest a checkrein mechanism of action for the internal brace in this construct, rather than a load-sharing mechanism. Importantly, the PCLR+IB technique did not constrain posterior translation more than the intact, physiologic state. Clinical studies are warranted to determine whether these ex vivo biomechanical benefits will translate to improved outcomes. [ Orthopedics . 2021;44(4):235–240.]

Background: Articular step-off between the donor and recipient in osteochondral allograft transplant has been shown to alter contact pressures. Currently, commercial allograft donor selection is primarily based on simple anatomic parameters such as trochlear length, trochlear width, and tibial width. Purpose: To identify anatomic factors associated with optimal graft matching by using a 3-dimensional simulation model. Study Design: Descriptive laboratory study. Methods: Computed tomography images of 10 cadaveric trochlear specimens were obtained to generate 3-dimensional models. Circular defects were created virtually in the recipient trochleae at both superolateral (18.0 mm and 22.5 mm) and central (18.0 mm, 22.5 mm, 30.0 mm) locations. The donor models were virtually projected onto the defect models, and the most optimal graft from any location of the donor specimen was selected. Cartilage incongruity, subchondral bone incongruity, and peripheral articular step-off were calculated for each graft-defect combination. Linear regression models were generated to identify predictors of incongruity, step-off, and the effect of sulcus and sagittal angle mismatch. Akaike information criterion–driven stepwise regression models were generated to identify multivariate predictors. Results: Ideal matches were found for 100% of superolateral defects but for only 15% to 53% of central defects, depending on the defect size. Multivariate stepwise regression identified laterality (odds ratio [OR], 0.54; P = .081), sulcus angle (OR, 0.79; P < .001), sagittal angle (OR, 0.83; P = .001), lateral radius of curvature (OR, 0.81; P < .001), and medial facet width (OR, 0.86; P = .155) as predictors of ideal graft matching. In central defects with proud grafts, increasing sagittal angle and sulcus angle resulted in significantly ( P < .001) increased articular step-off, which became sequentially larger with defect size. Conclusion: Sagittal angle, sulcus angle, and lateral radius of curvature mismatch should be used to determine optimal donor allografts, especially in the setting of large (30-mm) central defects. Increasing sulcus angle and sagittal angle mismatch correlated with increasing step-off in proud grafts, whereas sulcus angle and sagittal angle inconsistently correlated with step-off in recessed grafts. Clinical Relevance: Additional descriptive trochlear measurements should be incorporated into the algorithm for donor selection. These findings can be used to identify acceptable mismatch parameters.

Proximal humerus fractures are common, particularly in elderly patients and those with osteopenia or osteoporosis. Although nonsurgical management results in satisfactory outcomes for most patients, surgical treatment is indicated in select cases. Despite an increasing trend toward arthroplasty, open reduction and internal fixation of proximal humerus fractures can still provide excellent clinical outcomes. Proper technique for internal fixation of the proximal humerus requires an understanding of osseous and neurovascular anatomy. In particular, understanding reliable regions of biomechanically superior bone can help prevent failure of fixation. Biomechanical studies have shown that locked plating of proximal humerus fractures provides stable fixation. Cadaveric and finite element models underscore the importance of screw placement in the posteromedial metaphysis. When medial column support is challenging to obtain, or when bone quality is poor, augmentation with bone autograft, allograft, and/or synthetic composites can improve the biomechanics of internal fixation constructs. The purpose of this review is to outline the anatomic, biologic, and biomechanical principles of plate fixation for proximal humerus fractures to provide evidence-based recommendations for optimizing fixation and preventing fixation failure.

Anterior cruciate ligament (ACL) injuries remain common among athletes; these injuries require reconstruction to restore stability and enable successful return to sport.The role of postoperative dynamic knee bracing following ACL reconstruction in protecting graft integrity and promoting return to sport remains largely unknown.Limited biomechanical studies on functional bracing have reported decreased strain across the ACL with increasing anterior shear loading.Investigations evaluating functional brace use in clinical studies have not yet demonstrated consistent improvement in clinical outcomes, reduced graft retear rates, or improved return-to-sport rates in sports other than skiing.Additional investigation examining athletes of various ages participating in different sporting activities is necessary to better understand the role of functional bracing following ACL reconstruction.

Rotator cuff repairs (RCR) frequently fail to heal, particularly those with advanced fatty infiltration, supraspinatus and infraspinatus atrophy, narrowed acromiohumeral distance, and large-to-massive tear size. Unfortunately, the longer the follow up, the more sobering the statistics, with some reported retear rates ranging up to 94%. Importantly, recent long-term radiographic assessments after primary RCR reveal direct correlations between failure and patient-reported outcomes, functional deterioration, and ultimately, progression of glenohumeral arthritis and/or frank cuff tear arthropathy. As shoulder surgeons, we must continue to seek out novel approaches to improve tendon to bone healing and recapitulate the native rotator cuff enthesis. In doing so, we hope to engender more sustained subjective and objective results for our patients over time. Investigations are ongoing into several biomechanical and biological or structural adjuncts, from platelet-rich plasma and bone marrow aspirate concentrate to autograft or allograft structural augments. We must continue to push the envelope and refuse to settle for the current reality and alarmingly high failure rates following RCR.

To provide an updated review of the literature on the use of orthobiologics as a potential treatment option to alleviate symptoms associated with osteoarthritis (OA), slow the progression of the disease, and aid in cartilage regeneration. A comprehensive review of the literature was performed to identify basic science and clinical studies examining the role of orthobiologics in the diagnosis and management of osteoarthritis. Certain molecules (such as interleukin-6 (IL-6), interleukin-8 (IL-8), matrix metalloproteinase (MMPs), cartilage oligomeric matrix protein (COMP), and tumor necrosis factor (TNF), microRNAs, growth differentiation factor 11 (GDF-11)) have been recognized as biomarkers that are implicated in the pathogenesis and progression of degenerative joint disease (DJD). These biomarkers have been used to develop newer diagnostic applications and targeted biologic therapies for DJD. Local injection therapy with biologic agents such as platelet-rich plasma or stem cell–based preparations has been associated with significant improvement in joint pain and function in patients with OA and has increased in popularity during the last decade. The combination of PRP with kartogenin or TGF-b3 may also enhance its biologic effect. The mesenchymal stem cell secretome has been recognized as a potential target for the development of OA therapies due to its role in mediating the chondroprotective effects of these cells. Recent experiments have also suggested the modification of gut microbiome as a newer method to prevent OA or alter the progression of the disease. The application of orthobiologics for the diagnosis and treatment of DJD is a rapidly evolving field that will continue to expand. The identification of OA-specific and joint-specific biomarker molecules for early diagnosis of OA would be extremely useful for the development of preventive and therapeutic protocols. Local injection therapies with HA, PRP, BMAC, and other stem cell–based preparations are currently being used to improve pain and function in patients with early OA or those with progressed disease who are not surgical candidates. Although the clinical outcomes of these therapies seem to be promising in clinical studies, future research will determine the true role of orthobiologic applications in the field of DJS.

Objectives To determine whether methamphetamine (MA) users are at an increased risk for complications compared to matched controls in the setting of orthopaedic trauma. Design Retrospective cohort study. Setting Academic Level-1 Trauma Center. Patients MA users and matched controls. Intervention MA use. Main outcome measurements Infection, Deep Vein Thrombosis (DVT), and nonunion. Results Five hundred sixty-seven patients were included in our study (189 MA users, 378 matched controls). On univariate analysis, MA users had a higher incidence of DVT (3.2% vs. 0.5%), but no statistically significant difference in infection or nonunion rates. MA users also had a higher incidence of intensive care unit admission (36.0% vs. 27.8%), leaving the hospital against medical advice (9.0% vs. 2.1%), nonadherence to weightbearing precautions (18.8% vs. 7.3%), and a higher incidence of loss of follow-up (47.1% vs. 30.4%). However, MA users had a lower incidence of surgical treatment for orthopaedic injuries (51.9% vs. 65.9%). When surgical treatment was pursued, more trips to the operating room were required for orthopaedic injuries in the MA group (2.6 vs. 1.5 trips). On multivariate analysis, MA users continued to demonstrate a higher incidence of DVT and a lower incidence of operative management, but more trips to the operating room when surgical management was pursued, a higher admission rate to the intensive care unit, and a greater incidence of loss of follow-up. Conclusions MA use is associated with increased inpatient and outpatient complications. Level of evidence Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Purpose To determine the risk of postoperative humeral fracture following tenotomy, open tenodesis and arthroscopic tenodesis of the long head of the biceps brachii. Methods A retrospective review of deidentified patient data from the Medicare Standard Analytic File using the PearlDiver software was conducted to identify procedures performed between 2005 and 2014. Groups were matched by age, gender, region, and medical comorbidities. Results We evaluated 157,163 patients who had undergone arthroscopic or open tenodesis or tenotomy of the long head of the biceps brachii over a 10-year period (2005-2014), and we identified 2,196 postoperative humeral fractures (1.4%). Matched subgroup analysis consisting of 44,292 patients demonstrated a statistically significant increase in humeral fracture risk in open (280; 1.26%) compared to arthroscopic tenodesis (232; 1.04%) with a P value of 0.03 and an odds ratio of 1.21. The majority of fractures were sustained by patients 65-74 years of age. Conclusion In this study, an increased risk of postoperative humeral fracture was associated with open tenodesis of the LHB. Level of Evidence III, Retrospective Comparative Trial.

We sought to characterize the prevalence of methamphetamine (MA) abuse and associated orthopaedic injury patterns at our level 1 trauma center.We conducted a retrospective review of all orthopaedic consults for the year 2016. Patients were classified as MA users based on urine toxicology results and social history.The prevalence of MA use was 10.0%. MA users were more likely to present with hand lacerations and other infections (P0.05 for all). Regarding the mechanism of injury, MA users were more likely to be involved in automobile versus pedestrian, automobile versus bicycle, ballistic, knife, closed fist, other assault/altercation, and animal bite injuries (P0.05 for all).MA use is prevalent at our level 1 trauma center. The prevalence and injury patterns of MA abuse warrant deeper study into the effects of this drug on orthopaedic outcomes.Level III.

To describe the morphology of the adductor tubercle (AT), medial epicondyle (ME), and gastrocnemius tubercle (GT); to quantify their relationships to the medial patellofemoral ligament (MPFL) footprint location; and to classify the reliability of each landmark based on measurement variability.Eight cadaveric specimens were dissected to expose the following landmarks on the femur: MPFL footprint, AT, ME, and GT. Using the MicroScribe 3D digitizer, each landmark was projected into a 3-dimensional coordinate system and reconstructed into a complex, closed polygon. For each specimen tubercle, the base surface area, volume, height, base:height ratio, sulcus point, and distance from the MPFL footprint center were calculated. Levene's test was performed to evaluate differences in variance of the morphologic parameters between the three osseous structures.The ME had significantly greater variance in volume than the GT (The 3 major osseous landmarks of the medial femur have significantly different variances in volume and base:height ratio. Specifically, the variability and elongated morphology of the ME differentiated this landmark from the AT and GT, which demonstrated the most consistent morphology.The results of this study may be useful to accurately locate landmarks for femoral tunnel placement and determine the isometric MPFL point during reconstruction.

The purpose of this study was to compare failure rates and patient-reported outcomes between transosseus (TO) suture and suture anchor (SA) quadriceps tendon repairs.Following institutional review board approval, patients who underwent primary repair for quadriceps tendon rupture with TO or SA techniques between January 2009 and August 2018 were identified from an institutional database and retrospectively reviewed. Patients were contacted for satisfaction (1-10 scale), current function (0-100 scale), failure (retear), and revision surgeries; International Knee Documentation Committee (IKDC) score and Knee Injury and Osteoarthritis Outcomes Score (KOOS) were also collected to achieve a minimum of 2-year follow-up.Sixty-four patients (34 SA, 30 TO) were available by phone or e-mail at a mean of 4.81 ± 2.60 years postoperatively. There were 10 failures, for an overall failure rate of 15.6%. Failure incidence did not significantly differ between treatment groups (P = .83). Twenty-seven patients (47% of nonfailed patients) had completed patient-reported outcomes. The SA group reported higher subjective function (SA: 90 [85-100] vs TO: 85 [60-93], 95% CI of difference: -19.9 to -2.1 × 10There is no significant difference in failure rate between transosseus and suture anchor repairs for quadriceps tendon ruptures (P = .83). Most failures occur secondary to a traumatic reinjury within the first year postoperatively. Despite the lack of difference in failure rates, at final follow-up, patients who undergo suture anchor repair may report significantly greater subjective function and final IKDC, KOOS Pain, Quality of Life, and Sport scores.III, retrospective cohort study.

To compare social media attention and citation rates between technique articles and matched original research articles (ORAs) regarding surgical procedures.All technique articles published from August 2019 through July 2020 in the free, electronic versions ofA total of 285 matched research articles (n = 57, 20.0%) and technique articles (n = 228, 80.0%) were included. The mean AAS among all technique articles was 3.63 ± 10.08 (range, 0-96) whereas the mean AAS among all ORAs was 1.30 ± 3.98 (range, 0-25), representing a statistically significant difference (Technique articles resulted in significantly greater AASs and social media attention in comparison with open-access ORAs on similar topics. Publications that described technical procedures in a technique journal and studies from North America were positively associated with greater AASs and greater numbers of citations received by articles.An improved understanding of how much attention is given to technique articles versus matched ORAs by social media may influence the methods authors and journals use for distributing content. The present study suggests that one option to increase the amount of social media attention received for a particular study may be to utilize an accompanying surgical technique video or illustrations as these are easily shareable on social media and offer rapid dissemination of knowledge, similar to that of an infographic. However, physicians who view multimedia within technique articles should be encouraged to review the accompanying articles and the supporting original research as a primary source before making changes in their clinical practice.

Background: Data on outcomes in patients with borderline hip dysplasia (BHD) who undergo hip arthroscopy remain limited, particularly in regard to return to sport (RTS). Purpose: To evaluate outcomes in patients with BHD and their ability to RTS after hip arthroscopy for treatment of femoroacetabular impingement syndrome (FAIS). Study Design: Case series; Level of evidence, 4. Methods: Consecutive patients with self-reported athletic activity and radiographic evidence of BHD, characterized by a lateral femoral center-edge angle (LCEA) between 18° and 25° and a Tönnis angle >10°, who underwent hip arthroscopy for FAIS between November 2014 and March 2017 were identified. Patient characteristics and clinical outcomes including the Hip Outcome Score–Activities of Daily Living (HOS-ADL), Hip Outcome Score–Sports Subscale (HOS-SS), modified Harris Hip Score (mHHS), international Hip Outcome Tool (iHOT-12), and visual analog scale (VAS) for pain and satisfaction were analyzed at minimum 2-year follow-up. In addition, all patients completed an RTS survey. Results: A total of 41 patients with a mean age and body mass index (BMI) of 29.6 ± 13.4 years and 25.3 ± 5.6, respectively, were included. Mean LCEA and Tönnis angle for the study population were 22.7°± 1.8° and 13.3°± 2.9°, respectively. A total of 31 (75.6%) patients were able to RTS after hip arthroscopy at a mean of 8.3 ± 3.2 months. A total of 14 patients (45.2%) were able to RTS at the same level of activity, 16 patients (51.6%) returned to a lower level of activity, and only 1 (3.2%) patient returned to a higher level of activity. Of the 11 high school and collegiate athletes, 10 (90.9%) were able to RTS. All patients demonstrated significant improvements in all patient-reported outcome measures (PROMs) as well as in pain scores at a mean of 26.1 ± 5.4 months after surgery. Patients who were able to RTS had a lower preoperative BMI than patients who did not RTS. Analysis of minimum 2-year PROMs demonstrated better HOS-ADL, HOS-SS, mHHS, iHOT-12, and VAS outcomes for pain in patients able to RTS versus those who did not RTS ( P < .05). Conclusion: Of the patients with BHD studied here, 75.6% of patients successfully returned to sport at a mean of 8.3 ± 3.2 months after hip arthroscopy for FAIS. Of the patients who successfully returned to sport, 45.2% returned at the same level, and 3.2% returned at a higher activity level.

The lateral patellofemoral complex is an important stabilizer to medial and lateral displacement of the patella. Soft tissue abnormalities can range from pathologic tightness to laxity, presenting with symptoms related to patellar instability, anterior knee pain, or arthritis. Clinical evaluation should be performed to confirm patellar dislocation, assess the integrity of the lateral and medial soft tissues, and explore other pathoanatomic factors that may need to be addressed. Lateral retinacular lengthening is recommended over lateral release owing to the potential of iatrogenic medial instability with release, and a lateral patellofemoral ligament reconstruction can be performed to effectively treat medial instability.

To compare joint distraction measured on ultrasound (US) with joint space width (JSW) measured on fluoroscopy in hip arthroscopy and to determine whether ultrasound guidance is as safe and effective as fluoroscopy, the current gold standard, for establishing arthroscopic portals.Cadaveric whole-body specimens were positioned supine and subjected to 60 lbs. of unilateral axial traction using a distal femoral Steinman pin. Joint distraction was measured via JSW on fluoroscopic and ultrasound images. A single, fellowship-trained orthopaedic surgeon established anterolateral arthroscopy portals via ultrasound or fluoroscopic guidance in a randomized sequence. Total procedure time, number of times the spinal needle pierced the capsule, and iatrogenic chondral or labral injury were recorded.Twelve full-body specimens (20 hips) underwent distraction, and 17 hips underwent portal placement with fluoroscopic (n = 8) or ultrasound (n = 9) guidance. JSW measured on ultrasound was significantly less laterally (13.0 vs 9.2 mm,Joint distraction measured on ultrasound can be used to subjectively determine if the joint is adequately distracted in hip arthroscopy. Ultrasound-guided portal placement was associated with more needle insertion attempts, iatrogenic injury of the labrum, and overall procedure time in comparison to fluoroscopic guidance.Fluoroscopy is the gold standard to confirm adequate joint distraction, aid in establishing arthroscopy portals, and evaluate resection of the femoral head during hip arthroscopy but exposes the patient to ionizing radiation, requires additional operators in the operating room, and involves the need for a heavy lead shield. Alternatives to fluoroscopy are needed, but ultrasound has not proven superior in our cadaveric model.

Background: There is a paucity of information on rate and time to return to play (RTP) in elite-level soccer players who have sustained foot fractures. Purpose: To (1) determine the rate and timing of RTP after foot fracture (eg, tarsal, metatarsal, or phalangeal), (2) investigate foot fracture reinjury incidence after RTP, and (3) evaluate performance after foot fracture as compared with matched, uninjured controls. Study Design: Descriptive epidemiology study. Methods: Athletes sustaining foot fractures were identified across the 5 major European soccer leagues (English Premier League, Bundesliga, La Liga, Ligue 1, and Serie A) between 2000 and 2016. Injured athletes were matched to controls (1:1) using demographic characteristics and performance metrics from 1 season before injury. The authors recorded RTP rate, reinjury incidence, player characteristics associated with RTP within 2 seasons of injury, player availability, field time, and performance metrics during the 4 seasons after injury. Results: A total of 192 elite soccer players sustaining a foot fracture were identified; 40 players (20.8%) underwent operative treatment. Athletes missed an average of 69.41 ± 59.43 days and 5.15 ± 23.28 games. In the 4 seasons after injury, 80% of players returned to play, with 72% returning to play within 1 season of injury. Nine players (5%) sustained a subsequent foot fracture. Athletes with a foot fracture demonstrated significantly longer league retention compared with uninjured controls ( P < .001). Elite soccer players older than 30 years of age were less likely to RTP (odds ratio, 0.67; P = .002), whereas career experience, field position, and baseline performance showed no significant association with RTP rates. Injured athletes demonstrated similar performance to controls during the 4 years after injury, and there were no position-dependent differences on subgroup analysis. The players who underwent operative treatment had more assists per 90 minutes and more team points per game during the first season after injury compared with athletes treated nonoperatively. Conclusion: Foot fractures in elite soccer players resulted in moderate loss of play time (69.41 days). RTP rates were high at 80%, although players older than 30 years of age were less likely to RTP. On RTP, athletes who sustained a foot fracture maintained performance similar to preinjury levels and to uninjured controls.

Background: Failure rates after arthroscopic shoulder stabilization are highly variable in the current orthopaedic literature. Predictive factors for risk of failure have been studied to improve patient selection, refine surgical techniques, and define the role of bony procedures. However, significant heterogeneity in the analysis and controlling of risk factors makes evidence-based management decisions challenging. Purpose: The goals of this systematic review were (1) to critically assess the consistency of reported risk factors for recurrent instability after arthroscopic Bankart repair, (2) to identify the existing studies with the most comprehensive inclusion of confounding factors in their analyses, and (3) to give recommendations for which factors should be reported consistently in future clinical studies. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review of the literature was performed in accordance with the PRISMA guidelines. An initial search yielded 1754 titles, from which 56 full-text articles were screened for inclusion. A total of 29 full-text articles met the following inclusion criteria: (1) clinical studies regarding recurrent anterior shoulder instability; (2) surgical procedures performed including arthroscopic anterior labral repair; (3) reported clinical outcome data including failure rate; and (4) assessment of risk factors for surgical failure. Further subanalyses were performed for 15 studies that included a multivariate analysis, 17 studies that included glenoid bone loss, and 8 studies that analyzed the Instability Severity Index Score. Results: After full-text review, 12 of the most commonly studied risk factors were identified and included in this review. The risk factors that were most consistently significant in multivariate analyses were off-track lesions (100%), glenoid bone loss (78%), Instability Severity Index Score (75%), level of sports participation (67%), number of anchors (67%), and younger age (63%). In studies of bone loss, statistical significance was more likely to be found using advanced imaging, with critical bone loss thresholds of 10% to 15%. Several studies found predictive thresholds of 2 to 4 for Instability Severity Index Score by receiver operating characteristic or multivariate analysis. Conclusion: Studies reporting risk factors for failure of arthroscopic Bankart repair often fail to control for known confounding variables. The factors with the most common statistical significance among 15 multivariate analyses are off-track lesions, glenoid bone loss, Instability Severity Index Score, level of sports participation, number of anchors, and younger age. Studies found significance more commonly with advanced imaging measurements or arthroscopic assessment of glenoid bone loss and with lower thresholds for the Instability Severity Index Score (2-4). Future studies should attempt to control for all relevant factors, use advanced imaging for glenoid bone loss measurements, and consider a lower predictive threshold for the Instability Severity Index Score.

» Injuries to the proximal rectus femoris remain rare, occurring primarily in soccer and American football athletes during kicking and sprinting because of its unique biarthrodial nature. » The appropriate diagnosis is dependent on careful physical examination and imaging interpretation. » While no universal treatment algorithm has been adopted for high-level athletes, recent investigations support operative repair using suture anchors to restore strength and function in order to allow an effective return to competition while minimizing the risk of injury recurrence. » Complications following surgical management include injury to the lateral femoral cutaneous nerve and hematoma formation, and there are reports of residual pain and weakness with chronic injuries that fail the initial nonoperative treatment. » Current investigations examining outcomes following treatment remain limited, warranting additional studies that examine patient-reported results, return-to-play rates, and the role of orthobiologics and accelerated rehabilitation protocols following injury to further improve athlete health and safety.

The stability of a total hip arthroplasty relies on proper positioning of the acetabular cup. Recent research has shown that this cup position is more dynamic than previously thought. The 3-dimensional orientation of the acetabular cup changes when the pelvis tilts anteriorly or posteriorly. These changes in pelvic tilt are directly related to the biomechanics of the lumbosacral junction. In normal physiology, the lumbar spine straightens with sitting and becomes more lordotic with standing. This directly translates to posterior or anterior pelvic tilt due to the rigid sacroiliac attachments. During sitting, increased posterior pelvic tilt opens the acetabulum to accommodate flexion and internal rotation of the hip. This helps prevent anterior impingement and posterior hip dislocation. During standing, anterior pelvic tilt increases superior coverage of the acetabulum. This helps prevent posterior impingement and anterior hip dislocations. When lumbosacral motion becomes pathologic, spinopelvic motion changes and acetabular cup orientation is affected. In cases of decreased lumbosacral motion, patients rely on greater hip motion to reach standing or sitting positions. This can cause pathologic impingement. In addition, traditional safe zones for cup position may not apply in the presence of pathologic spinopelvic motion. This article discusses the normal physiology of spinopelvic motion, the patterns of pathologic change, and the clinical implications therein.

The multiple ligament injured knee is a complex biomechanical environment. When primary stabilizers fail, secondary stabilizers have an increased role. In addition, loss of primary restraints puts undue stress on the remaining intact structures of the knee. Treatment of these injuries requires accurate diagnosis of all injured structures, and careful consideration of repairs and reconstructions that restore the synergistic stability of all ligaments in the knee.

Background: Knee injection using either bone marrow aspirate concentrate (BMAC) or stromal vascular fraction (SVF) from adipose tissue has been shown to result in symptomatic improvement in patients with knee osteoarthritis (OA). It is still unclear whether one of these therapies is superior over the other. Purpose: To systematically report the clinical studies evaluating BMAC and SVF in the treatment of knee OA and to compare the clinical efficacy of these 2 injection therapies. Study Design: Meta-analysis; Level of evidence, 4. Methods: This meta-analysis was performed per the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines. Studies were included if they reported the clinical outcomes after a single BMAC or SVF injection in the knee joint of patients with OA. Studies evaluating preparations of culture-expanded stem cells were excluded. A random effects model was used; the clinical efficacy of BMAC or SVF injection was assessed using the standardized mean difference (SMD) and compared. Visual analog scale (VAS) scores for pain and Western Ontario and McMaster Universities Osteoarthritis (WOMAC) knee index were the primary outcomes. The level of statistical significance was set at P < .05. Results: Ten studies and 472 patients with knee OA who received either BMAC (233 patients) or SVF (239 patients) were included. Patients who received an injection had improved VAS outcomes (mean ± SD): from 5.8 ± 1.3 to 2.6 ± 17 for BMAC and from 6.4 ± 1.4 to 3.4 ± 0.5 for SVF. They also experienced significantly reduced pain (SMD [VAS], 2.6 for BMAC and 3.4 for SVF) and improved function (SMD [WOMAC], 1.4 for BMAC and 1.2 for SVF). However, the SVF injection had a significantly greater effect on pain reduction than did the BMAC injection ( P < .0001). Based on WOMAC, the clinical effect of BMAC versus SVF knee injection in patients with knee OA was equivalent ( P = .626). Results were limited by the presence of publication bias as well as variability in the preparation methods utilized in the BMAC and SVF injection protocols. Complications were reported in 50% of the BMAC studies (knee stiffness, persistent knee swelling) and 67% of the SVF studies (knee swelling, knee pain, positive SVF cultures without symptoms of infection, and bleeding at the abdominal harvest site). Conclusion: A single BMAC or SVF injection into the knee joint of patients with OA resulted in symptomatic improvement at short-term follow-up. However, SVF seemed to be more effective than did BMAC in the reduction of knee pain. There was significant variation in the BMAC and SVF injection preparation techniques used across the studies and a lack of stratification of outcomes based on the radiologic classification of OA. Therefore, these results should be taken with caution.

There are numerous described techniques for surgical management of high-grade acromioclavicular (AC) joint injuries, and the associated clinical outcomes can be quite variable. Contemporary techniques are typically directed at anatomic reconstruction of the coracoclavicular (CC) ligaments through either an arthroscopy-assisted or an open approach. Most patients treated with acute surgery improve, whereas in chronic cases, the majority improve, but a significant number have persistent recurrent deformity due to loss of anatomic reduction. In addition, whether acute or chronic, over one quarter of patients do not have a PASS (patient acceptable symptomatic state). Of interest, PASS may not primarily be related to the final deformity in terms of coracoclavicular distance, and investigation is still required in terms of the effect of anteroposterior or rotational instability of the AC joint after injury and surgery. Finally, PASS values for AC separation are not well established, resulting in a current limitation of the strength of applying threshold values to this pathology.

Background: There are few large database studies on national trends in regional anesthesia for various arthroscopic shoulder procedures and the effect of nerve blocks on the postoperative rate of opioid prescription filling. Hypothesis: The use of regional nerve block will decrease the rate of opioid prescription filling after various shoulder arthroscopic procedures. Also, the postoperative pattern of opioid prescription filling will be affected by the preoperative opioid prescription-filling history. Study Design: Cohort study; Level of evidence, 3. Methods: Patient data from Humana, a large national private insurer, were queried via PearlDiver software, and a retrospective review was conducted from 2007 through 2015. Patients undergoing arthroscopic shoulder procedures were identified through Current Procedural Terminology codes. Nerve blocks were identified by relevant codes for single-shot and indwelling catheter blocks. The blocked and unblocked cases were age and sex matched to compare the pain medication prescription-filling pattern. Postoperative opioid trends (up to 6 months) were compared by regression analysis. Results: We identified 82,561 cases, of which 54,578 (66.1%) included a peripheral nerve block. Of the patients who received a block, 508 underwent diagnostic shoulder arthroscopy; 2449 had labral repair; 4746 had subacromial decompression procedure; and 12,616 underwent rotator cuff repair. The percentage of patients undergoing a nerve block increased linearly over the 9-year study period ( R 2 = 0.77; P = .002). After matching across the 2 cohorts, there was an identical trend in opioid prescription filling between blocked and unblocked cases ( P = .95). When subdivided by procedure, there was no difference in the trends between blocked and unblocked cases ( P = .52 for diagnostic arthroscopies; P = .24 for labral procedures; P = .71 for subacromial decompressions; P = .34 for rotator cuff repairs). However, when preoperative opioid users were isolated, postoperative opioid prescription filling was found to be less common in the first 2 weeks after surgery when a nerve block was given versus not given ( P < .001). Conclusion: An increasing percentage of shoulder arthroscopies are being performed with regional nerve blocks. However, there was no difference in patterns of filled postoperative opioid prescriptions between blocked and unblocked cases, except for the subgroup of patients who had filled an opioid prescription within 1 to 3 months prior to shoulder arthroscopy. Future research should focus on recording the amount of prescribed opioids consumed in national databases to reinforce our strategy against the opioid epidemic.