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Purpose: To systematically review the reporting of clinically significant outcome measure (CSO) thresholds and methods for calculating thresholds following anterior cruciate ligament (ACL) reconstruction., Methods: A systematic review of PubMed, Embase, and Web of Science databases was conducted to identify articles that met inclusion criteria from January 1, 2015, to July 7, 2024. Inclusion criteria included studies reporting CSO thresholds including minimal clinically important difference (MCID), substantial clinical benefit (SCB), or patient acceptable symptomatic state (PASS) for patients following ACL reconstruction with minimum 12-month follow-up. The MINORS criteria was used to assess study quality. Study demographics, patient-reported outcome measures (PROMs), CSO thresholds, and method of CSO calculation were collected., Results: A total of 56 studies (n=52,292 patients) met the final inclusion criteria. Reported PROMs included International Knee Documentation Committee (IKDC) (n=35 studies), Knee Injury and Osteoarthritis Outcome score (KOOS) (n=33 studies), Tegner (n=20 studies) and Lysholm (n=19 studies) scores. The PASS was reported in 35 studies, MCID in 30, and SCB in 4. Among the studies that reported PASS, the most used threshold calculation was the ROC-Youden index (71.4%, n=25/35). In the studies reporting MCID, the most used threshold calculation was the 0.5 standard deviation (SD) of mean change method (36.7%, n=11/30). The most reported threshold calculation among the SCB studies was the ROC curve analysis (75%, n=3/4). In studies independently calculating CSOs, the most common methods were 0.5 standard deviations (SD) of mean change for MCID (50%, n=10/20), the ROC-Youden index for PASS (73.3%, n=11/15), and ROC curve analysis (75.0%, n=3/4) for SCB. Descriptions of anchor questions were reported in 22 studies (39.3%)., Conclusion: Substantial variability exists in the reporting and calculation of MCID, SCB, and PASS for various PROMs following ACL reconstruction., (Copyright © 2025. Published by Elsevier Inc.)

More than 70 million adults in the United States are impacted by osteoarthritis (OA). Symptomatic articular cartilage loss that progresses to debilitating OA is being diagnosed more frequently and earlier in life, such that a growing number of active patients are faced with life-altering health care decisions at increasingly younger ages. Joint replacement surgeries, in the form of various artificial arthroplasties, are reliable operations, especially for older (≥65 years), more sedentary patients with end-stage OA, but have major limitations for younger, more active patients. For younger adults and those who wish to remain highly active, artificial arthroplasties are associated with significantly higher levels of pain, complications, morbidity, dysfunction, and likelihood of revision. Unfortunately, non-surgical management strategies and surgical treatment options other than joint replacement are often not indicated and have not proven to be consistently successful for this large and growing population of patients. As such, these patients are often relegated to postpone surgery, take medications including opioids, profoundly alter their lifestyle, and live with pain and disability until artificial arthroplasty is more likely to meet their functional demands without high risk for early revision. As such, our research team set out to develop, test, and validate biologic joint restoration strategies that could provide consistently successful options for young and active patients with joint disorders who were not considered ideal candidates for artificial arthroplasty. In pursuit of this goal, we implemented a targeted bedside-to-bench-to-bedside translational approach to hypothesis-driven studies designed to address this major unmet need in orthopaedics by identifying and overcoming key clinical limitations and obstacles faced by health care teams and patients in realizing optimal outcomes after biologic joint restoration. The objective of this article is to condense more than two decades of rigorous patient-centered research aimed at optimizing osteochondral and meniscus allograft transplantation toward more consistently successful management of complex joint problems in young and active patients., Competing Interests: Authors report the following disclosures: C.B. has no conflicts to report. C.R.C. reports the following:Arthrex, Inc: IP royalties; Paid consultant Paid presenter or speaker; Research support; Collagen Matrix Inc: IP royalties; Paid consultant; Paid presenter or speaker; Research support; Musculoskeletal Transplant Foundation: IP royalties; Paid consultant; Paid presenter or speaker; Research support. C.C. has no conflicts to report. B.D.C. reports the following:AO Trauma North America: Board or committee member; Arthrex, Inc: Other financial or material support; Curvafix: Paid consultant; Paid presenter or speaker; DePuy, A Johnson & Johnson Company: Paid presenter or speaker; Fragility Fracture Network--USA: Board or committee member; Globus Medical: IP royalties; International Geriatric Fracture Society: Board or committee member; Journal of Hip Preservation: Editorial or governing board; Journal of Orthopaedic Trauma: Editorial or governing board; KCI: Paid consultant; Paid presenter or speaker; Orthopaedic Trauma Association: Board or committee member; Osteocentric: Unpaid consultant; RomTech: Stock or stock Options; SLACK Incorporated: Editorial or governing board; Synthes: Paid consultant; Research support; Urgo Medical: Unpaid consultant. S.D.F. reports the following:AO North America: Other Professional Activities; Stryker Corporation: Other Professional Activities. C.H. reports the following:Allosource (license): IP royalties; Journal of Orthopaedic Research: Editorial or governing board; Publishing royalties, financial or material support; Musculoskeletal Transplant Foundation: Research support; Orthopedic Research & Reviews: Editorial or governing board. *J.L.C. reports the following:AANA: Research support; AO Trauma: Research support; Advanced Research Projects Agency for Health: Research support; Arthrex, Inc: IP royalties; Paid consultant; Research support; Boehringer Ingelheim: Paid consultant; Collagen Matrix Inc: Paid consultant; Research support; GE Healthcare: Research support; Journal of Knee Surgery: Editorial or governing board; Midwest Transplant Network: Board or committee member; Musculoskeletal Transplant Foundation/MTF Biologics: Board or committee member; IP royalties; Research support; National Institutes of Health (NIAMS & NICHD): Research support; OREF: Research support; PCORI: Research support; Thieme: Publishing royalties, financial or material support; Trupanion: Paid consultant; U.S. Department of Defense: Research support. K.K. has no conflicts to report. M.J.S. reports the following:American Shoulder and Elbow Surgeons: Board or committee member; Current Orthopedic Practice: Editorial or governing board; DePuy, A Johnson & Johnson Company: IP royalties; Paid consultant; Paid presenter or speaker; Ignite Orthopedics: IP royalties; Stock or stock Options. C.N. reports the following:AAOS: Board or committee member; American Orthopaedic Society for Sports Medicine: Board or committee member; AO Foundation: Other financial or material support; Arthrex, Inc: Paid presenter or speaker; Arthroscopy: Editorial or governing board; Publishing royalties, financial or material support; Arthroscopy Association of North America: Board or committee member; Guidepoint Consulting: Paid consultant; Vericel, Inc.: Paid presenter or speaker. L.R. has no conflicts to report. K.R. reports the following:National Institutes of Health: Other Professional Activities; Advanced Research Projects Agency for Health: Other Professional Activities. K.S. reports the following:AAOS: Board or committee member; AO North America: Board or committee member Arthrex, Inc: Paid presenter or speaker; Research support; CarboFix: Stock or stock Options; Johnson & Johnson: Paid consultant; Paid presenter or speaker; ODi: IP royalties; Orthopaedic Trauma Association: Board or committee member. J.P.S. reports the following:Arthrex, Inc: Paid consultant; Research support, DePuy, A Johnson & Johnson Company: Paid consultant; Journal of Knee Surgery: Editorial or governing board; National Institutes of Health (NIAMS & NICHD): Research support; Orthopedic Designs North America: Paid consultant; Smith & Nephew: Paid consultant; Thieme: Publishing royalties, financial or material support; U.S. Department of Defense: Research support. A.M.S. reports the following:IP royalties from the Musculoskeletal Transplant Foundation. R.S. has no conflicts to report. *Note: Authors James L. Cook and Cristi R. Cook are husband and wife., (Thieme. All rights reserved.)

Based on recent evidence-based advances in meniscus allograft transplantation (MAT), fresh (viable) meniscus allografts have potential for mitigating key risk factors associated with MAT failure, and preclinical and clinical data have verified the safety of fresh meniscus allografts as well as possible efficacy advantages compared with fresh-frozen meniscus allografts. The objective of this study was to prospectively assess clinical outcomes for the initial cohort of patients undergoing MAT using fresh meniscus allografts at our center. Patients who were prospectively enrolled in a dedicated registry were included for analyses when they had undergone primary MAT using a fresh meniscus allograft for treatment of medial and/or lateral meniscus deficiency with at least 1-year follow-up data recorded. Forty-five patients with a mean final follow-up of 47.8 months (range = 12-90 months) were analyzed. The mean patient age was 30.7 years (range = 15-60 years), mean body mass index (BMI) was 29.7 kg/m 2 (range = 19-48 kg/m 2 ), and 14 patients (31%) were females. In total, 28 medial, 13 lateral, and 4 combined medial and lateral MATs with 23 concurrent ligament reconstructions and 2 concurrent osteotomies were included. No local or systemic adverse events or complications related to MAT were reported for any patient in the study. Treatment success rate for all patients combined was 91.1% with three patients requiring MAT revision and one patient requiring arthroplasty. Treatment failures occurred 8 to 34 months after MAT and all involved the medial meniscus. None of the variables assessed were significantly different between treatment success and treatment failure cohorts. Taken together, the data suggest that the use of fresh (viable) meniscus allografts can be considered a safe and effective option for medial and lateral MAT. When transplanted using double bone plug suspensory fixation with meniscotibial ligament reconstruction, fresh MATs were associated with a 91% success rate, absence of local or systemic adverse events or complications, and statistically significant and clinically meaningful improvements in patient-reported measures of pain and function at a mean of 4 years postoperatively., Competing Interests: The authors report the following conflicts:J.L.C. reports the following: AANA: Research support; AO Trauma: Research support; Advanced Research Projects Agency for Health: Research support; Arthrex, Inc: IP royalties; Paid consultant; Research support; Boehringer Ingelheim: Paid consultant; Collagen Matrix Inc: Paid consultant; Research support; GE Healthcare: Research support; Journal of Knee Surgery: Editorial or governing board; Midwest Transplant Network: Board or committee member; Musculoskeletal Transplant Foundation/MTF Biologics: Board or committee member; IP royalties; Research support; National Institutes of Health (NIAMS & NICHD): Research support; OREF: Research support; PCORI: Research support; Thieme: Publishing royalties, financial or material support; Trupanion: Paid consultant; U.S. Department of Defense: Research support.J.P.S. reports the following: Arthrex, Inc: Paid consultant; Research support, DePuy, A Johnson & Johnson Company: Paid consultant; Journal of Knee Surgery: Editorial or governing board; National Institutes of Health (NIAMS & NICHD): Research support; Orthopedic Designs North America: Paid consultant; Smith & Nephew: Paid consultant; Thieme: Publishing royalties, financial or material support; U.S. Department of Defense: Research support.K.R. has no conflicts to report.C.N. reports the following: AAOS: Board or committee member; American Orthopaedic Society for Sports Medicine: Board or committee member; AO Foundation: Other financial or material support; Arthrex, Inc: Paid presenter or speaker; Arthroscopy: Editorial or governing board; Publishing royalties, financial or material support; Arthroscopy Association of North America: Board or committee member; Guidepoint Consulting: Paid consultant; Vericel, Inc.: Paid presenter or speaker.C.C. has no conflicts to report.C.R.C. reports the following: Arthrex, Inc.: research support, consulting fees and royalties; Zimmer; nonconsulting fees from Arthrex, CONMED Linvatec, and Musculoskeletal Transplant Foundation; and royalties from CONMED Linvatec and Musculoskeletal Transplant Foundation.R.M. reports the following: AAOS: Board or committee member; American College of Sports Medicine: Board or committee member; American Orthopaedic Association: Board or committee member; American Orthopaedic Society for Sports Medicine: Board or committee member; Arthroscopy Association of North America: Board or committee member; Cartiheal: Research support.Johnson & Johnson: Paid consultant; Journal of Bone and Joint Surgery – American: Editorial or governing board; Moximed: Research support; Novocart: Research support; Rugby Research Injury Prevention Group: Board or committee member., (Thieme. All rights reserved.)

Emerging evidence suggests that patients' behavioral health may influence outcomes after osteochondral allograft transplantation (OCAT). A comprehensive behavioral health program (BHP) including preoperative screening and education, and postoperative counseling and support, led by a health behavior psychologist was implemented for patients considering OCAT. We hypothesized that patients undergoing knee OCAT and enrolled in the BHP would have a significantly higher 2-year graft survival rate than those not enrolled. Prospectively collected data for patients undergoing knee OCAT enrolled in the lifelong outcomes registry were analyzed. Based on the timing of implementation of a comprehensive BHP to provide preoperative screening and education followed by postoperative counseling and support, BHP and no-BHP cohorts were compared. Treatment failure was defined as the need for either OCAT revision surgery or knee arthroplasty. The Kaplan-Meier method using log-rank tests compared cumulative survival rates. Multivariable Cox regression analysis was used to determine the effects of confounding variables on the influence of BHP enrollment on graft survival. A total of 301 patients were analyzed (no-BHP = 220 and BHP = 81). At 2-year follow-up, a significantly lower cumulative graft survival rate was observed for patients not enrolled in the BHP (68.2 vs. 91.4%; p  = 0.00347). Adjusting for sex, age, body mass index, tobacco use, tibiofemoral bipolar OCAT type surgery, and nonadherence, patients not enrolled in the BHP were 2.8 times more likely to experience OCAT treatment failure by 2 years after primary OCAT compared with patients in the BHP (95% confidence interval, 1.02-4.98; p  = 0.01). A comprehensive BHP contributes to significant improvements in 2-year graft survival rates following OCAT in the knee. Preoperative mental and behavioral health screening and support for shared decision-making regarding treatment options, in conjunction with patient and caregiver education and assistance through integrated health care team engagement, are beneficial to patients pursuing complex joint preservation surgeries. Level of evidence is 2, prospective cohort study., Competing Interests: The author group reports the following interests:J.W. is an employee of Arthrex, Inc.K.R. has no conflicts to report.R.S. has no conflicts to report.J.P.S. reports the following:Arthrex, Inc: Paid consultant; Research support, DePuy, A Johnson & Johnson Company: Paid consultant; Journal of Knee Surgery: Editorial or governing board; National Institutes of Health (NIAMS & NICHD): Research support; Orthopedic Designs North America: Paid consultant; Smith & Nephew: Paid consultant; Thieme: Publishing royalties, financial or material support; U.S. Department of Defense: Research supportC.C. has no conflict to report.A.S. receives IP royalties from the Musculoskeletal Transplant Foundation.C.N. reports the following:AAOS: Board or committee member; American Orthopaedic Society for Sports Medicine: Board or committee member; AO Foundation: Other financial or material support; Arthrex, Inc: Paid presenter or speaker; Arthroscopy: Editorial or governing board; Publishing royalties, financial or material support; Arthroscopy Association of North America: Board or committee member; Guidepoint Consulting: Paid consultant; Vericel, Inc.: Paid presenter or speakerJ.L.C. reports the following:AANA: Research support; AO Trauma: Research support; Advanced Research Projects Agency for Health: Research support; Arthrex, Inc: IP royalties; Paid consultant; Research support; Boehringer Ingelheim: Paid consultant; Collagen Matrix Inc: Paid consultant; Research support; GE Healthcare: Research support; Journal of Knee Surgery: Editorial or governing board; Midwest Transplant Network: Board or committee member; Musculoskeletal Transplant Foundation/MTF Biologics: Board or committee member; IP royalties; Research support; National Institutes of Health (NIAMS & NICHD): Research support; OREF: Research support; PCORI: Research support; Thieme: Publishing royalties, financial or material support; Trupanion: Paid consultant; U.S. Department of Defense: Research support., (Thieme. All rights reserved.)

Background: Osteochondral allograft transplantation (OCAT) can be performed without the need for blood-type matching or anti-rejection medications. However, other donor-recipient mismatch variables could influence outcomes. Therefore, it is critical to examine the impacts of sex and age mismatching on functional OCA survival., Methods: Prospectively collected data for patients undergoing primary knee OCAT enrolled in a lifelong outcomes registry were analyzed for functional OCA survival based on sex- and age-matched and -mismatched cohorts. Treatment failure was defined as the need for OCAT revision surgery or knee arthroplasty., Results: 162 donor-recipient pairs were analyzed; 57 (35.2%) were sex-mismatched and 89 (54.9%) were age-mismatched. Sex-mismatched OCATs were not associated with a significantly different cumulative graft survival rate when compared to sex-matched OCATs (78.9% vs 75.2% p = 0.324). Age-mismatched OCATs were not associated with a significantly different cumulative graft survival rate when compared to age-matched OCATs (71.6% vs 81.5% p = 0.398). When adjusting for sex, BMI, concomitant procedures, and surgery type, age-mismatched and sex-mismatched OCATs were not significantly associated with higher likelihood for treatment failure., Conclusion: By analyzing functional graft survival rates for donor-recipient sex- or age-mismatched OCAs following primary OCAT, the results of the present study support current donor-recipient matching protocols for OCA transplantation in the knee. Based on current evidence, donor-recipient blood-type, sex-, and age-matching are not required for safe and effective primary OCAT in the knee. However, further studies are imperative for defining modifiable variables that further optimize safety and outcomes while maximizing donor tissue quality, availability, access, and use., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: James P Stannard is a paid consultant and receives research support from Arthrex, Inc; is a paid consultant for DePuy, A Johnson & Johnson Company; is on the editorial or governing board for the Journal of Knee Surgery; receives research support from National Institutes of Health (NIAMS & NICHD); is a paid consultant for Orthopedic Designs North America; is a paid consultant for Smith & Nephew; receives publishing royalties, financial or material support from Thieme; and receives research support from the U.S. Department of Defense. Aaron Stoker receives IP royalties from Musculoskeletal Transplant Foundation. Clayton William Nuelle is a board or committee member for AAOS; is a board or committee member for the American Orthopaedic Society for Sports Medicine; receives other financial or material support from AO Foundation; is a paid presenter or speaker for Arthrex, Inc; is on the editorial or governing board, receives publishing royalties, financial or material support from Arthroscopy; is a board or committee member for Arthroscopy Association of North America; is a paid consultant for Guidepoint Consulting; and is a paid presenter or speaker for Vericel, Inc. James L Cook receives research support from AANA; receives research support from AO Trauma; receives IP royalties, is a paid consultant and receives research support from Arthrex, Inc; is a paid consultant for Bioventus; is a paid consultant for Boehringer Ingelheim; is a paid consultant and receives research support from Collagen Matrix Inc; receives research support from GE Healthcare; is on the editorial or governing board for the Journal of Knee Surgery; is a board or committee member for Midwest Transplant Network; is a board or committee member, receives IP royalties and research support from Musculoskeletal Transplant Foundation; receives research support from the National Institutes of Health (NIAMS & NICHD); receives research support from OREF; receives research support from Orthopaedic Trauma Association; receives research support from PCORI; receives research support from Regenosine; receives research support from SITES Medical; receives publishing royalties, financial or material support from Thieme; is a paid consultant for Trupanion; and receives research support from U.S. Department of Defense., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Background: Arthroscopic rotator cuff repair has been shown to decrease pain and increase function of certain rotator cuff tears. One potential source of pain is the technique used for bone tunnel creation in the humerus prior to suture anchor placement. This study compared the standard metal punch method to a continuous drilling method for tunnel creation prior to subsequent suture anchor placement. Our hypothesis was that the use of a drill would result in less bony trauma and therefore superior resolution of postoperative pain following rotator cuff repair., Methods: Tunnels were created for 6 cadaveric (mean age: 50.83 ± 3.25; male n = 3; female n = 3) shoulder humeri using a 4-anchor construct to mimic transosseous equivalent rotator cuff repair. Following suture fixation, micro-computed tomography scans were performed for evaluation of peri-tunnel bone architecture. A tensile force was applied to the anchor through the suture material at a constant displacement rate of 1 mm/s until ultimate failure of the construct. All statistical analyses were performed using SPSS (version 25; IBM), and significance was set at P ≤.05. A total of 43 subjects between 18 and 80 years old were randomized into the study, with 22 in the drill group and 21 in the punch group. Following surgery, the first 5 patients in each cohort underwent magnetic resonance imaging at the 2-week postoperative visit. Pain and other patient-reported outcome measures (PROMs) were assessed at all standard of care postoperative visits. Patient demographics and PROMs were assessed for significance within the groups using repeated measures analysis of variance and unpaired t test. A P value of <.05 was set for significance., Results: Preclinical: there were no statistically significant differences (P > .05) between punched and drilled anchors with respect to peri-socket bone architecture and material properties., Clinical: there were no statistically significant differences (P > .05) between punch and drill cohorts for assessments of pain, function, or bone marrow lesion size. However, the punch cohort reported statistically significant and clinically meaningful reductions in pain scores at 2 weeks, 6 weeks, 3 months, and 6 months compared with preoperative scores (P < .02), whereas the drill cohort reported statistically significant and clinically meaningful reductions in pain scores at 6 weeks, 3 months, and 6 months after surgery (P < .05). Similarly, the punch cohort reported statistically significant reductions in Patient-Reported Outcomes Measurement Information System pain interference (PROMIS PI) scores, which were within 1 standard deviation of the healthy adult control population, at 2 weeks, 6 weeks, 3 months, and 6 months compared with preoperative scores (P < .05), whereas the drill cohort did not report statistically significant improvements in PROMIS PI scores until 3 months postoperatively and were not within 1 standard deviation of the healthy adult control population until 6 months after surgery., Conclusion: Preclinical and clinical data suggest that it is reasonable to use either a punch or drill socket-creation method for suture anchor placement in arthroscopic rotator cuff repair, while considering the potential for earlier pain relief associated with the punch method., (Copyright © 2024 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Osteochondral allograft transplantation (OCAT) has become a standard-of-care treatment option for patients with large symptomatic articular defects. Recent advances in allograft science and OCAT protocols have been reported to result in consistently robust outcomes after OCAT in the knee. However, only short-term comparisons have been reported, and analyses are lacking for treatment failure risk factors that account for confounding variables., Hypothesis: Midterm functional graft survival rate would exceed 80% for all OCATs combined, with consideration of risk factors for lower survivorship including older patient age, higher body mass index (BMI), tibiofemoral bipolar OCAT, and nonadherence to prescribed postoperative rehabilitation protocols., Study Design: Case series; Level of evidence, 4., Methods: Patients with outcome data available at ≥5 years after primary OCAT using high chondrocyte-viability (HCV) osteochondral allografts were analyzed according to 2 clinically relevant definitions: (1) initial treatment failure, defined by revision or arthroplasty surgery performed for the primary OCAT at any time point during the study period; and (2) functional graft failure, defined by documented conversion to arthroplasty after primary or revision OCAT at any time point during the study period. Analyses were used to assess outcomes for each definition, separately for age group, sex, obesity status, tobacco use, type of OCAT surgery, osteotomy status, concurrent ligament surgery status, and adherence to postoperative protocols. Kaplan-Meier analyses were used to assess differences in survival rates, and Cox proportional hazards models were used to assess risk factors and multivariable relationships with survival. Patient-reported outcome measures for pain, function, mobility, and satisfaction were also analyzed., Results: Analysis included 137 primary knee OCATs performed in 134 patients with a mean follow-up of 66 months (59 female, 75 male; mean age, 37.8 years; mean BMI, 28.5). The midterm (5- to 8-year) functional graft survival rate for patients undergoing primary OCAT in the knee using HCV grafts was 82% for all cases combined, ranging from 69% for tibiofemoral bipolar HCV OCATs to 89% for patellofemoral bipolar, 94% for multisurface unipolar, and 97% for single-surface unipolar. Initial treatment failure rates (revision or arthroplasty after primary OCAT) and OCAT nonsurvival rates (arthroplasty after primary or revision OCAT) were greater for older patient age, concurrent ligament reconstruction, tibiofemoral bipolar OCAT, and nonadherence to the prescribed postoperative rehabilitation protocols. When adjusted for patients' age, BMI, and tobacco use status, different surgery types did not demonstrate an increased risk for failure, while concurrent ligament reconstruction and nonadherence did. Patients who experienced functional graft survival after primary OCAT reported significantly greater improvements in PROMIS Physical Function and Mobility (Patient-Reported Outcomes Measurement Information System), International Knee Documentation Committee questionnaire, and Single Assessment Numeric Evaluation scores such that they were significantly higher at final follow-up as compared with patients who required arthroplasty. Patient-reported improvements in pain, function, and mobility exceeded minimal clinically important differences for ≥5 years after primary OCAT. When asked if they were satisfied with primary OCAT surgery, 76.2% of patients were very satisfied or satisfied with their results, while 8.5% were neutral and 15.4% were unsatisfied or very unsatisfied., Conclusion: With use of HCV osteochondral allografts, midterm (5- to 8-year) functional graft survival rates for patients undergoing primary OCAT in the knee were notably higher than previously reported midterm rates for traditional OCATs. When adjusted for patient characteristics, risk factors for nonsurvival included concurrent ligament reconstruction for knee instability and nonadherence to the prescribed postoperative rehabilitation protocols. Patients who experienced functional graft survival for ≥5 years after primary OCAT reported statistically significant and clinically meaningful improvements in pain, function, and mobility., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: J.L.C. has received intellectual property royalties, consulting fees, and research support from Arthrex; consulting fees from Bioventus, Boehringer Ingelheim, Collagen Matrix Inc, and Trupanion; research support from GE Healthcare, Collagen Matrix, Musculoskeletal Transplant Foundation, PCORI, Regenosine, and SITES Medical; and royalties from Musculoskeletal Transplant Foundation and Thieme. C.W.N. has received other financial or material support from AO Foundation; speaking fees from Arthrex, Synthes GmbH, and Vericel; consulting fees from Arthrex and Guidepoint Consulting; and support for education from Elite Orthopedics. J.P.S. had received consulting fees and research support from Arthrex; consulting fees from DePuy, Orthopedic Designs North America, Medical Device Business Services, and Smith & Nephew; speaking fees from Synthes GmbH; support for education from Elite Orthopedics; and publishing royalties from Thieme. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Background: Osteochondral allograft transplantation (OCAT) and meniscus allograft transplantation (MAT) have each become more commonly implemented for the treatment of young to middle-aged patients with complex knee pathology. Evidence regarding tibiofemoral OCAT in the setting of concurrent MAT is limited., Purpose/hypothesis: The purpose of this study was to characterize outcomes for femoral condyle OCAT with concurrent MAT (OCAT+MAT) in the ipsilateral compartment of patients after evidence-based shifts in practice. It was hypothesized that OCAT+MAT would be associated with successful outcomes characterized by statistically significant and clinically meaningful improvements in patient-reported outcome measures (PROMs) of knee pain and function in >80% of patients for at least 2 years after transplantation., Study Design: Case series; Level of evidence, 4., Methods: With institutional review board approval and documented informed consent, patients who underwent primary OCAT+MAT between 2016 and 2020 and enrolled in a lifelong registry for prospective collection of outcomes after OCAT were included. Patients with minimum 2-year follow-up data regarding complications, failures, adherence, and PROMs were analyzed. Patients who required OCAT and/or MAT revision or conversion to arthroplasty were defined as experiencing treatment failures., Results: A total of 23 consecutive patients (mean age, 37.1 years; mean body mass index, 28 kg/m 2 ; 14 men) met the inclusion criteria, with a mean follow-up of 51 months (range, 24-86 months). The initial treatment success rate was 78% based on 5 initial treatment failures, and the overall success rate was 83% based on a successful revision OCAT. All failures occurred in the medial compartment. Older patient age (42.2 vs 32.1 years; P = .046) and nonadherence to postoperative restriction and rehabilitation protocols ( P = .033; odds ratio, 14) were significant risk factors for treatment failure. All measured PROMs achieved significant improvements ( P < .001) and minimum clinically important differences at a minimum of 2 years postoperatively., Conclusion: OCAT+MAT was associated with successful short- to mid-term outcomes in 83% of cases. Evidence-based shifts in practice were implemented before the enrollment of this patient cohort. Older patients and those who were not adherent to postoperative restriction and rehabilitation protocols had a significantly higher risk for treatment failure and subsequent conversion to arthroplasty., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: J.P.S. has received research support from Arthrex, the United States Department of Defense, and Thieme; education payments from Elite Orthopedics; consulting fees from Medical Device Business Services, Arthrex, DePuy Synthes, Orthopedic Designs North America, and Smith+Nephew; nonconsulting fees from Synthes GmbH and Medical Devices Business Services; and royalties from Thieme. C.W.N. has received research support from AO Foundation and Arthroscopy; education payments from Arthrex, Elite Orthopedics, and Medinc of Texas; consulting fees from Arthrex and Guidepoint Consulting; nonconsulting fees from Arthrex, Vericel, and Synthes GmbH; royalties from Arthroscopy; and hospitality payments from Stryker. J.L.C. has received research support from AO Trauma, Arthrex, Collagen Matrix, DePuy Synthes, MTF Biologics, Orthopaedic Trauma Association, Purina, Regenosine, SITES Medical, Thieme, and the United States Department of Defense; consulting fees from Arthrex and Trupanion; and royalties from Arthrex, MTF Biologics, and Thieme. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© 2024 The Author(s).)

Anterior cruciate ligament (ACL) injuries and subsequent surgical reconstruction are exceedingly common orthopaedic procedures. Surgical technique and graft preparation techniques continue to evolve as surgeons seek to increase surgical outcomes and decrease recovery time. As such, there is significant interest in identifying tools and techniques that may enhance the surgical process for patients undergoing an ACL reconstruction. Recently, there has been significant interest in evaluating biologic scaffolds that may augment graft healing. This Technical Note describes our technique for the preparation of a bone-patellar tendon-bone ACL graft with a BioBrace biocomposite scaffold augmentation., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: C.W.N. received financial support from the 10.13039/501100001702AO Foundation, 10.13039/100007307Arthrex, Guidepoint Consulting, and Vericel and is a board member of the American Association of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America. S.F.D. received financial support from 10.13039/100001473AO North America, 10.13039/100007307Arthrex, and Springer and is a board member of the American Orthopaedic Society for Sports Medicine and Arthroscopy Association of North America. All other authors (P.B., L.O.O.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)

Purpose: To objectively assess the accuracy of socket measurements taken during cruciate ligament reconstruction using a retrograde reaming technique., Methods: Six complete knee sawbone specimens were used to ream anterior and posterior cruciate ligament sockets in the femur and tibia in a retrograde fashion using a standard retrograde reaming device. The longest and shortest sides of the sockets were measured using a ruler. One-sided Wilcoxon signed-rank sum tests were used to evaluate whether the actual measured socket length matched the estimated length set on the drill guide., Results: One fellowship-trained surgeon reamed 24 total sockets in sawbone specimens using guides. Statistical analysis revealed a significant difference between the estimated measurement and the actual shortest tunnel length in each of the sockets. The median short side socket lengths were shorter than their respective intended depths by 4 mm for the femoral anterior cruciate ligament socket, 6 mm for the femoral posterior cruciate ligament socket, 6 mm for the tibial anterior cruciate ligament socket, and 4.5 mm for the tibial posterior cruciate ligament socket. All differences were significant at α = 0.05., Conclusions: The estimated cruciate socket lengths reamed during ligament reconstruction using a retrograde reamer and standard intra-articular measuring instrumentation were greater than the actual measured socket lengths., Clinical Relevance: Successful cruciate ligament reconstruction relies on accurate socket measurements. This study examined the accuracy of commercially available cruciate ligament socket drill guides and the implications for clinical practice, to include graft-tunnel mismatch and surface area available for healing. Surgeons may consider reaming slightly longer than estimated sockets when performing all-inside cruciate ligament reconstructions to ensure appropriate socket depth for graft fixation., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: E.R.M. reports a relationship with the 10.13039/100008542Arthroscopy Association of North America that includes board/committee membership and a spouse who is employed by Arthex. C.W.N. reports a relationship with the 10.13039/100008542Arthroscopy Association of North America, 10.13039/100009885American Academy of Orthopaedic Surgeons, and 10.13039/100011549American Orthopaedic Society for Sports Medicine that includes board membership and a consulting or advisory role with 10.13039/100007307Arthrex and Vericel Corporation. B.C.B. reports a relationship with the Texas Orthopaedic Association that includes board membership and a consulting or advisory role with 10.13039/100008894Stryker Orthopaedics. The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of Defense or the U.S. government. The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The other author (M.P.) declares that he has no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Background: Socket-tunnel overlap during meniscal allograft transplantation (MAT) combined with anterior cruciate ligament reconstruction (ACLR) may compromise graft integrity and lead to impaired fixation and treatment failure., Purpose/hypothesis: The purpose of this study was to determine optimal socket-tunnel drilling parameters for medial and lateral MAT with concurrent ACLR using artificial tibias and computed tomography (CT) scans for 3-dimensional (3D) modeling. It was hypothesized that clinically relevant socket tunnels could be created to allow for concurrent medial or lateral MAT and ACLR without significant risk for overlap at varying tunnel guide angles., Study Design: Descriptive laboratory study., Methods: A total of 27 artificial right tibias (3 per subgroup) were allocated to 9 experimental groups based on the inclination of the socket tunnels (55°, 60°, and 65°) created for simulating medial and lateral MAT and ACLR. Five standardized socket tunnels were created for each tibia using arthroscopic guides: one for the ACL tibial insertion and one for each meniscus root insertion. CT scans were performed for all specimens and sequentially processed using computer software to produce 3D models for quantitative assessment of socket-tunnel overlap risk. Statistical analysis was performed with Kruskal-Wallis and Mann-Whitney U tests., Results: No subgroup consistently presented significantly safer distances than other subgroups for all distances measured. Three cases (11%) and 24 cases (~90%) of tunnel overlap occurred between the ACL tunnel and tunnels for medial and lateral MAT, respectively. Most socket-tunnel overlap (25 of 27; 92.6%) occurred between sockets at depths ranging between 6.3 and 10 mm from the articular surface. For ACLR and posterior root of the lateral meniscus setting, the guide set at 65° increased socket-tunnel distances., Conclusion: When combined ACLR and MAT using socket tunnels for graft fixation is performed, the highest risk for tibial socket-tunnel overlap involves the ACLR tibial socket and the lateral meniscus anterior root socket at a depth of 6 to 10 mm from the tibial articular surface., Clinical Relevance: Setting tibial guides at 65° to the tibial articular surface with the tunnel entry point anteromedial and socket aperture location within the designated anatomic "footprint" will minimize the risk for socket-tunnel overlap., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: S.D. has received research support from Arthrex; education payments from Arthrex, Encore Medical, Smith+Nephew, Medical Device Business Services, and Zimmer Biomet; nonconsulting fees from DJO and Synthes; honoraria from Encore Medical; and hospitality payments from Stryker. C.R.C. has received research support from Arthrex and Zimmer; consulting fees from Arthrex and CONMED Linvatec; nonconsulting fees from Arthrex, CONMED Linvatec, and Musculoskeletal Transplant Foundation; and royalties from Arthrex, CONMED Linvatec, and Musculoskeletal Transplant Foundation. C.W.N. has received education payments from Arthrex and Encore Orthopedics, consulting fees from Guidepoint Consulting and Arthrex, nonconsulting fees from Arthrex and Vericel, hospitality payments from Synthes GmbH, and other financial or material support from the AO Foundation. J.P.S. has received research support from Arthrex; education payments from Elite Orthopedics; consulting fees from Arthrex, DePuy Synthes/Medical Device Business Services, Orthopedic Designs North America, and Smith+Nephew; nonconsulting fees from Synthes and Medical Device Business Services; and royalties from Thieme. J.L.C. has received research support from AO Trauma, Arthrex, Collagen Matrix, DePuy Synthes, Musculoskeletal Transplant Foundation, Purina, Regenosine, and Sites Medical; consulting fees from Arthrex and Trupanion; royalties from Arthrex, Musculoskeletal Transplant Foundation, and Thieme; and was a board or committee member for the Musculoskeletal Transplant Foundation. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2024.)

The annual demand for knee arthroplasty has been steadily rising, particularly in younger patients. The primary objective of this systematic review was to determine the impact of knee arthroplasties on knee function and activity levels in young (≤55 years) patients. A PubMed search from inception (1977) to March 2022 to identify eligible studies produced 640 peer-reviewed studies for consideration. A total of 18 studies including 4,186 knee arthroplasties in 3,200 patients (mean patient age at the time of surgery: 47.4 years, range: 18-55 years) were ultimately included for analysis. Mean final follow-up (FFU) duration was 5.8 years (range: 2-25.1 years). Mean FFU improvement in Knee Society Clinical Score was 48.0 (1,625 knees, range: 20.9-69.0), Knee Society Function Score was 37.4 (1,284 knees, range: 20-65). Mean FFU for the Tegner and Lysholm activity scale was 2.8 (4 studies, 548 knees, range: 0.7-4.2); University of California Los Angeles Physical Activity Questionnaire score was 2.8 (3 studies, 387 knees, range: 1.2-5); lower extremity activity scale was 1.84 (529 knees). The available evidence suggest that young patients typically realize sustained improvements in knee function compared to preoperative levels; however, these improvements do not typically translate into a return to desired activity levels or quality of life, and this patient population should expect a higher and earlier risk for revision than their older counterparts. Further research, including robust registry data, is needed to establish evidence-based indications, expectations, and prognoses for outcomes after knee arthroplasty in young and active patients., Competing Interests: C. W. N. is a board or committee member for AAOS; is a board or committee member for American Orthopaedic Society for Sports Medicine; receives other financial or material support from AO Foundation; is a paid presenter or speaker for Arthrex, Inc; is on the editorial or governing board, receives publishing royalties, financial or material support from Arthroscopy; is a board or committee member for Arthroscopy Association of North America; is a paid consultant for Guidepoint Consulting; and is a paid presenter or speaker for Vericel, Inc.J. P. S. is a board or committee member for American Orthopaedic Association; is a board or committee member for AO Foundation; is a board or committee member for AO North America; is a paid consultant and receives research support from Arthrex, Inc; is a paid consultant for DePuy, A Johnson & Johnson Company; is on the editorial or governing board (Editor-in-Chief) for the Journal of Knee Surgery; is a board or committee member for Mid-America Orthopaedic Association; receives research support from National Institutes of Health (NIAMS & NICHD); is a paid consultant for Orthopedic Designs North America; is a paid consultant for Smith & Nephew; receives publishing royalties, financial or material support from Thieme; receives research support from U.S. Department of Defense.J. L C. receives research support from AO Trauma; receives IP royalties, is a paid consultant and receives research support from Arthrex, Inc; receives research support from Collagen Matrix Inc; receives research support from DePuy, A Johnson & Johnson Company; is on the editorial or governing board (Associate Editor) for the Journal of Knee Surgery; is a board or committee member for Midwest Transplant Network; is a board or committee member, receives IP royalties and research support from Musculoskeletal Transplant Foundation; receives research support from National Institutes of Health (NIAMS & NICHD); receives research support from Orthopaedic Trauma Association; receives research support from Purina; receives research support from Regenosine; receives research support from SITES Medical; receives publishing royalties, financial or material support from Thieme; is a paid consultant for Trupanion and receives research support from U.S. Department of Defense., (Thieme. All rights reserved.)

The irreparable posterosuperior rotator cuff tear describes a tear of the supraspinatus and/or infraspinatus tendon that is massive, contracted, and immobile in both the anterior-posterior and medial-lateral directions. Patients with an intact subscapularis and preserved forward elevation are challenging to treat because there is not a consensus treatment algorithm. For low-demand, elderly patients, several subacromial surgical options are available that can provide pain relief without the risks or burden of rehabilitation posed by reverse total shoulder arthroplasty or a complex soft-tissue reconstruction (e.g., superior capsular reconstruction, tendon transfer, bridging grafts). Debridement, more specifically the "smooth-and-move" procedure, offers a reliable outcome with documented improvements in pain and function at long-term follow-up. Similarly, the biodegradable subacromial balloon spacer (InSpace; Stryker, Kalamazoo, MI) has been shown to significantly improve pain and function in patients who are not responsive to nonoperative treatment. Disease progression with these options is possible, with a small percentage of patients progressing to rotator cuff arthropathy. Biologic tuberoplasty and bursal acromial reconstruction are conceptually similar to the balloon spacer but instead use biologic grafts to prevent bone-to-bone contact between the humeral head and the acromion. Although there is no single gold standard treatment, the variety of surgical techniques allows patients and surgeons to effectively manage these challenging situations., Competing Interests: Disclosures The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: C.W.N. reports a relationship with Arthrex that includes: consulting or advisory and speaking and lecture fees, a relationship with Vericel Corporation and Guidepoint Consulting that includes: consulting or advisory, a relationship with AO Foundation that includes: speaking and lecture fees and travel reimbursement, a relationship with Arthroscopy Association of North America that includes: board membership and travel reimbursement, and a relationship with American Academy of Orthopaedic Surgeons that includes: board membership. R.U.H. reports a relationship with Wolters Kluwer Lippincott Williams & Wilkins Pty Ltd that includes: publishing royalties, financial or material support, a relationship with Stryker that includes: consulting or advisory and speaking and lecture fees, a relationship with American Shoulder and Elbow Surgeons that includes: board membership, a relationship with Arthroscopy Association of North America that includes: board membership. All other authors (M.D.S.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: Osteochondral allograft transplantation (OCAT) allows the restoration of femoral condyle osteochondritis dissecans (OCD) lesions using an osteochondral unit. When OCD lesions are irreparable, or treatments have failed, OCAT is an appropriate approach for revision or salvage surgery. Based on its relative availability, cost-effectiveness, lack of donor site morbidity, and advances in preservation methods, OCAT is also an attractive option for primary surgical treatment for femoral condyle OCD., Hypothesis: OCAT for large femoral condyle OCD lesions would be highly successful (>90%) based on significant improvements in knee pain and function, with no significant differences between primary and salvage procedure outcomes., Study Design: Cohort study; Level of evidence, 3., Methods: Patients were enrolled into a registry for assessing outcomes after OCAT. Those patients who underwent OCAT for femoral condyle OCD and had a minimum of 2-year follow-up were included. Reoperations, treatment failures, and patient-reported outcomes were compared between primary and salvage OCAT cohorts., Results: A total of 22 consecutive patients were included for analysis, with none lost to the 2-year follow-up (mean, 40.3 months; range, 24-82 months). OCD lesions of the medial femoral condyle (n = 17), lateral femoral condyle (n = 4), or both condyles (n = 1) were analyzed. The mean patient age was 25.3 years (range, 12-50 years), and the mean body mass index was 25.2 kg/m 2 (range, 17-42 kg/m 2 ). No statistically significant differences were observed between the primary (n = 11) and salvage (n = 11) OCAT cohorts in patient and surgical characteristics. Also, 91% of patients had successful outcomes at a mean of >3 years after OCAT with 1 revision in the primary OCAT cohort and 1 conversion to total knee arthroplasty in the salvage OCAT cohort. For both primary and salvage OCATs, patient-reported measures of pain and function significantly improved at the 1-year and final follow-up, and >90% of patients reported that they were satisfied and would choose OCAT again for treatment., Conclusion: Based on the low treatment failure rates in conjunction with statistically significant and clinically meaningful improvements in patient-reported outcomes, OCAT can be considered an appropriate option for both primary and salvage surgical treatment in patients with irreparable OCD lesions of the femoral condyles., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: C.N. has received financial or material support from AO Foundation and Arthroscopy; education payments from Arthrex and Elite Orthopedics; consulting fees from Arthrex and Guidepoint Consulting; nonconsulting fees from Vericel, Arthrex, and Stryker; royalties from Arthroscopy; and hospitality payments from Synthes GmbH. J.P.S. has received research support from Arthrex; financial or material support from Thieme; education payments from Elite Orthopedics; consulting fees from Medical Device Business Services, DePuy, Orthopedic Designs North America, Smith & Nephew, and Arthrex; nonconsulting fees from Synthes GmbH and Medical Device Business Services; and royalties from Thieme. R.M. has received research support from Cartiheal, Moximed, and Novocart. M.K. has received education payments from Elite Orthopedics and Arthrex; nonconsulting fees from Synthes GmbH; and honoraria from Synthes GmbH. J.L.C. has received research support from AO Trauma, Arthrex, Collagen Matrix, DePuy, Orthopaedic Trauma Association, Purina, Regenosine, and SITES Medical; financial or material support from Thieme; consulting fees from Arthrex and Trupanion; royalties from Arthrex, MTF Biologics, and Thieme; and is a board or committee member for MTF Biologics. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2024.)

Osteochondral injuries of the knee can be a frequent source of debilitating pain and dysfunction. Significant chondral (>1.5-2 cm 2 ) lesions of the femoral condyles can be especially difficult to manage with nonsurgical measures. Fresh osteochondral allograft (OCA) transplantation has been shown to be a reliable surgical procedure to manage a wide array of high-grade focal chondral lesions, with or without subchondral bone involvement. OCA transplantation affords the transfer of a size-matched allograft of mature hyaline cartilage with its associated subchondral bony scaffold. Indications include primary or secondary management of large, high-grade chondral or osteochondral defects secondary to trauma, developmental malformation, osteonecrosis, or other focal degenerative disease. Contraindications include end-stage osteoarthritis, uncorrected malalignment, ligament or meniscus deficiency, and inflammatory joint disease. Improvements in surgical technique, allograft storage, and tissue availability have created more reproducible clinical results and increased chondrocyte viability. Long-term (>10 year) graft survival rates have been shown to be between 70% and 91%, and the procedure has been shown to be cost-effective based on cost per quality-adjusted life year. Finally, OCA transplantation has been shown to provide excellent return to play rate for athletes with medium-to-large cartilage lesions. OCA transplantation is therefore an important option in the treatment algorithm of articular cartilage injuries., (Copyright © 2023 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Purpose: To assess the risk of socket-tunnel overlap for posterior medial or lateral meniscal root repair combined with anterior cruciate ligament reconstruction (ACLR) using artificial tibias and computed tomography scans for 3-dimensional modeling., Methods: Artificial tibias (n = 27; n = 3/subgroup) were allocated to groups based on inclination of socket-tunnels (55°, 60°, 65°) created for posterior root of the medial meniscus (MMPR) and lateral meniscus posterior root (LMPR) repair, and ACLR. Three standardized socket-tunnels were created: one for the ACL and one for each posterior meniscal root insertion. Computed tomography scans were performed and sequentially processed using computer software to produce 3-dimensional models for assessment of socket-tunnel overlap. Statistical analysis was performed with Kruskal-Wallis and Mann-Whitney U tests. Significance was set at P < .05., Results: The present study found no significant risk of tunnel overlap when drilling for combined ACLR and MMPR repair, whereas 7 cases of tunnel overlap occurred between ACL tunnels and LMPR (25.9% of cases). No subgroup or specific pattern of angulation consistently presented significantly safer distances than other subgroups for all distances measured., Conclusions: This study demonstrated 25.9% rate of overlap for combined LMPR repair and ACLR, compared with 0% for MMPR repair with ACLR. Lower ACL drilling angle (55 or 60°) combined with greater lateral meniscus drilling angle (65°) produced no socket-tunnel overlap., Clinical Relevance: Socket-tunnel overlap during meniscal root repair combined with ACLR may compromise graft integrity and lead to impaired fixation and treatment failure of either the ACL, the meniscus, or both. Despite this, risk for socket-tunnel overlap has not been well characterized., Competing Interests: The authors report the following potential conflicts of interest or sources of funding: S.D. reports grants from Arthrex and board member/owner/officer/committee appointments from American Orthopaedic Society for Sports Medicine, Arthroscopy, and AANA. C.R.C. reports grants and royalties or licenses from, and payment or honoraria for lectures, presentations, speakers’ bureaus, manuscript writing, or educational events from Arthrex, Collagen Matrix, and the Musculoskeletal Transplant Foundation. C.W.N. reports royalties or licenses from Arthroscopy, consulting fees from Guidepoint Counseling, and payment or honoraria for lectures, presentations, speakers’ bureaus, manuscript writing, or educational events from Arthrex and Vericel, leadership or fiduciary role in other board, society, committee or advocacy group, paid or unpaid: American Academy of Orthopaedic Surgeons, AANA, American Orthopaedic Society for Sports Medicine, and Arthroscopy; and other financial or nonfinancial interests from the AO Foundation. J.P.S. reports grants or contracts from Arthrex, 10.13039/100000002National Institutes of Health (National Institute of Arthritis and Musculoskeletal and Skin Diseases and Eunice Kennedy Shriver 10.13039/100000071National Institute of Child Health and Human Development), and 10.13039/100000005U.S. Department of Defense; royalties or licenses from Thieme; consulting fees from 10.13039/100007307Arthrex, DePuy, A Johnson & Johnson Company, Orthopedic Designs North America, and Smith & Nephew; and leadership or fiduciary role in other board, society, committee or advocacy group, paid or unpaid: 10.13039/100005382American Orthopaedic Association, Journal of Knee Surgery, AO Foundation, Mid-America Orthopaedic Association, and AO North America. J.L.C. reports grants from AO Trauma, DePuy, A 10.13039/100004331Johnson & Johnson Company, Arthrex, the Musculoskeletal Transplant Foundation, Collagen Matrix, National Institutes of Health (National Institute of Arthritis and Musculoskeletal and Skin Diseases and Eunice Kennedy Shriver National Institute of Child Health and Human Development), Orthopaedic Trauma Association, SITES Medical, Purina, U.S. Department of Defense, and Regenosine; royalties or licenses from Arthrex, the Musculoskeletal Transplant Foundation, and Thieme; and consulting fees from Arthrex and Trupanion; leadership or fiduciary role in other board, society, committee or advocacy group, paid or unpaid: Midwest Transplant Network and Musculoskeletal Transplant Foundation. All other authors (J.B.d.A., W.B.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Full ICMJE author disclosure forms are available for this article online, as supplementary material., (© 2024 The Authors.)

Context: Interest in the relationship between psychology and the outcomes of anterior cruciate ligament (ACL) reconstruction (ACLR) continues to grow as variable rates of return to preinjury level of activity continue to be observed., Evidence Acquisition: Articles were collected from peer-reviewed sources available on PubMed using a combination of search terms, including psychology, resilience, mental health, recovery, and anterior cruciate ligament reconstruction. Further evaluation of the included bibliographies were used to expand the evidence., Study Design: Clinical review., Level of Evidence: Level 4., Results: General mental health and wellbeing, in addition to a host of unique psychological traits (self-efficacy, resilience, psychological readiness and distress, pain catastrophizing, locus of control, and kinesiophobia) have been demonstrated convincingly to affect treatment outcomes. Moreover, compelling evidence suggests that a number of these traits may be modifiable. Although the effect of resilience on outcomes of orthopaedic surgical procedures has been studied extensively, there is very limited information linking this unique psychological trait to the outcomes of ACLR. Similarly, the available information related to other parameters, such as pain catastrophizing, is limited with respect to the existence of adequately sized cohorts capable of accommodating more rigorous and compelling analyses. A better understanding of the specific mechanisms through which psychological traits influence outcomes can inform future interventions intended to improve rates of return to preinjury level of activity after ACLR., Conclusion: The impact of psychology on patients' responses to ACL injury and treatment represents a promising avenue for improving low rates of return to preinjury activity levels among certain cohorts. Future research into these areas should focus on specific effects of targeted interventions on known, modifiable risk factors that commonly contribute to suboptimal clinical outcomes., Strength-Of-Recommendation Taxonomy (sort): B., Competing Interests: The following authors declared potential conflicts of interest: A.J.S. has received stock or stock options from Springbok Analytics and consulting fees from Stryker. K.P.S. has received research support from DJ Orthopaedics and National Institutes of Health (NIAMS & NICHD), consulting fees from the NFL and Novopods, and royalties from Oberd. A.B. has received royalties and consulting fees from Arthrex and royalties from SLACK Incorporated and Springer. A.A. has received speaking fees from Arthrex. S.D. has received speaking fees from AO North America, research support from Arthrex, and royalties from Springer. J.J.E. has received consulting fees from Johnson & Johnson. S.J.F. has received speaking payments from Anika Therapeutics and consulting fees from Zimmer. C.W.N has received financial support from AO Foundation, speaking fees from Arthrex and Vericel, and consulting fees from Guidepoint Consulting.

Purpose: To determine whether low resilience is predictive of worse patient-reported outcomes (PROs) or diminished improvements in clinical outcomes after joint preserving and arthroscopic surgery., Methods: A comprehensive search of PubMed, Medline, Embase, and Science Direct was performed on September 28, 2022, for studies investigating the relationship between resilience and PROs after arthroscopic surgery in accordance with the Preferred Reported Items for Systematic Reviews and Meta-analyses guidelines., Results: Nine articles (level II-IV studies) were included in the final analysis. A total of 887 patients (54% male, average age 45 years) underwent arthroscopic surgery, including general knee (n = 3 studies), ACLR-only knee (n = 1 study), rotator cuff repair (n = 4 studies), and hip (n = 1 study). The Brief Resilience Scale was the most common instrument measuring resilience in 7 of 9 studies (78%). Five of 9 studies (56%) stratified patients based on high, normal, or low resilience cohorts, and these stratification threshold values differed between studies. Only 4 of 9 studies (44%) measured PROs both before and after surgery. Three of 9 studies (33%) reported rates of return to activity, with 2 studies (22%) noting high resilience to be associated with a higher likelihood of return to sport/duty, specifically after knee arthroscopy. However, significant associations between resilience and functional outcomes were not consistently observed, nor was resilience consistently observed to be predictive of subjects' capacity to return to a preinjury level of function., Conclusions: Patient resilience is inconsistently demonstrated to affect clinical outcomes associated with joint preserving and arthroscopic surgery. However, substantial limitations in the existing literature including underpowered sample sizes, lack of standardization in stratifying patients based on pretreatment resilience, and inconsistent collection of PROs throughout the continuum of care, diminish the strength of most conclusions that have been drawn., Level of Evidence: Level IV, systematic review of level II-IV studies.

Isolated posterior shoulder instability accounts for approximately 10% of shoulder instability cases. Patients may present after an acute trauma or with insidious onset and associated posterior shoulder pain. Knotless and all-suture anchor devices have become increasing popular and are often used in arthroscopic shoulder instability cases to avoid knot stacks and allow for the ability to re-tension the fixation. This technical note describes our technique for 2-portal posterior labral repair using knotless all-suture anchors with the patient in the lateral decubitus position., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: S.F.D. reports board membership with the American Orthopaedic Society for Sports Medicine and Arthroscopy Association of North America; receives speaking and lecture fees from AO North America; receives funding grants from 10.13039/100007307Arthrex; is on the editorial or governing board of Arthroscopy; and receives publishing royalties and financial or material support from Springer. C.W.N. reports board membership with the 10.13039/100009885American Academy of Orthopaedic Surgeons, 10.13039/100011549American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America; reports a relationship with AO Foundation; receives speaking and lecture fees from 10.13039/100007307Arthrex and Vericel; has a consulting or advisory relationship with Guidepoint Consulting; is on the editorial or governing board of Arthroscopy; and receives publishing royalties and financial or material support from Arthroscopy. All other authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)

Aims: The aim of this study was to establish consensus statements on the diagnosis, nonoperative management, and indications, if any, for medial patellofemoral complex (MPFC) repair in patients with patellar instability, using the modified Delphi approach., Methods: A total of 60 surgeons from 11 countries were invited to develop consensus statements based on their expertise in this area. They were assigned to one of seven working groups defined by subtopics of interest within patellar instability. Consensus was defined as achieving between 80% and 89% agreement, strong consensus was defined as between 90% and 99% agreement, and 100% agreement was considered to be unanimous., Results: Of 27 questions and statements on patellar instability, three achieved unanimous consensus, 14 achieved strong consensus, five achieved consensus, and five did not achieve consensus., Conclusion: The statements that reached unanimous consensus were that an assessment of physeal status is critical for paediatric patients with patellar instability. There was also unanimous consensus on early mobilization and resistance training following nonoperative management once there is no apprehension. The statements that did not achieve consensus were on the importance of immobilization of the knee, the use of orthobiologics in nonoperative management, the indications for MPFC repair, and whether a vastus medialis oblique advancement should be performed., Competing Interests: D. Dejour reports royalties or licenses from Corin, Arthrex, and SBM and consulting fees from Smith & Nephew, all unrelated to this study. M. K. Mulcahey reports consulting fees from Arthrex, unrelated to this study. J. R. Wittstein reports consulting fees from Geistlich, payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Arthrex and Vericel, stock or stock options from ViewFi Health, all unrelated to this study. L. M. Jazwari reports grants or contracts from Arthrex, Mitek, Smith & Nephew, and Wolters Kluwer Health, both related and unrelated to this study, royalties or licenses and payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Wolters Kluwer Health, and stock or stock options from Lazurite, all unrelated to this study., (© 2023 The British Editorial Society of Bone & Joint Surgery.)

Aims: The aim of this study was to establish consensus statements on medial patellofemoral ligament (MPFL) reconstruction, anteromedialization tibial tubercle osteotomy, trochleoplasty, and rehabilitation and return to sporting activity in patients with patellar instability, using the modified Delphi process., Methods: This was the second part of a study dealing with these aspects of management in these patients. As in part I, a total of 60 surgeons from 11 countries contributed to the development of consensus statements based on their expertise in this area. They were assigned to one of seven working groups defined by subtopics of interest. Consensus was defined as achieving between 80% and 89% agreement, strong consensus was defined as between 90% and 99% agreement, and 100% agreement was considered unanimous., Results: Of 41 questions and statements on patellar instability, none achieved unanimous consensus, 19 achieved strong consensus, 15 achieved consensus, and seven did not achieve consensus., Conclusion: Most statements reached some degree of consensus, without any achieving unanimous consensus. There was no consensus on the use of anchors in MPFL reconstruction, and the order of fixation of the graft (patella first versus femur first). There was also no consensus on the indications for trochleoplasty or its effect on the viability of the cartilage after elevation of the osteochondral flap. There was also no consensus on postoperative immobilization or weightbearing, or whether paediatric patients should avoid an early return to sport., Competing Interests: S. L. Sherman reports royalties or licenses from CONMED Linvatec, consulting fees from Arthrex, BioVentus, JRF Ortho, Kinamed, Smith & Nephew, Vericel, CONMED Linvatec, payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Arthex, Joint Restoration Foundation, Kinamed, Smith & Nephew, and Vericel, and stock or stock options from Epic Bio, Reparel, Sarcio, and Vivorte, all of which are unrelated to this study. J. Chahla reports consulting fees from Arthrex, CONMED Linvatec, Ossur, and Smith & Nephew, and payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Smith & Nephew, all of which are unrelated to this study. M. J. Alaia reports consulting fees from BodyCad, JRF Ortho, and Mitek, institutional grants from Orcosa, and royalties from Springer, all of which are unrelated to this study. M. J. Tanaka reports grants or contracts from FujiFilm, royalties or licenses from Verywell, and consulting fees from Depuy Synthes, all of which are unrelated to this study. J. L. Pace reports consulting fees from Arthrex and JRF Ortho, payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Arthrex, and stock or stock options from OutcomeMD, all of which are unrelated to this study. L. M. Jazwari reports grants or contracts from Arthrex, Mitek, Smith & Nephew, and Wolters Kluwer Health, payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Wolters Kluwer Health, and stock or stock options from Lazurite, all of which are unrelated to this study., (© 2023 The British Editorial Society of Bone & Joint Surgery.)

Purpose: To compare the semitendinosus and gracilis tendon lengths and diameters to the palmaris longus, plantaris, flexor digitorum profundus, and flexor pollicis longus (FPL) tendons in a cadaveric model to evaluate the feasibility of hamstring autograft use for staged flexor tendon reconstruction., Methods: Fifteen fresh cadavers were evaluated for surgical incisions about the knee, forearm, and hand. All flexor digitorum profundus (FDP), FPL, palmaris longus, plantaris, semitendinosus, and gracilis tendons were harvested from each specimen. Diameter and length were recorded and means with SDs were calculated. The mean diameters of the gracilis and semitendinosus were compared to the mean diameters of the FDP and FPL tendons. The hamstring tendon lengths were then compared in terms of percentage of the palmaris longus and plantaris tendon lengths., Results: The gracilis (18.0 cm) and semitendinosus (19.9 cm) means were notably longer than the palmaris longus (16.0 cm) and shorter than the plantaris (30.0 cm). The average gracilis tendon diameter (3.8 mm) was smaller than the flexor tendon diameters except for the little finger FDP (3.8 mm). The semitendinosus tendon diameter (4.8 mm) was larger than all flexor tendons with the exception of the middle finger FDP (4.6 mm). Average gracilis and semitendinosus tendon diameters were 3.7 mm and 4.5 mm in males, and 3.8 mm and 4.8 mm in females., Conclusions: This study showed the gracilis tendon to have adequate length and diameter for potential autograft use in staged flexor tendon reconstruction in all digits but the little finger. The semitendinosus is larger in diameter than the native flexor tendons, making it a poor autograft option in cases with an intact pulley system., Clinical Relevance: Common tendon autograft options for flexor tendon reconstruction are variably present, and the use of gracilis and semitendinosus autograft present potential graft options., (Copyright © 2023. Published by Elsevier Inc.)

Meniscus allograft transplantation can be successful for treatment of meniscal deficiency using a number of transplant techniques. In this Technical Note, we describe a double bone plug medial meniscus allograft transplantation technique that uses knotless all-suture anchors with cortical-button suspensory fixation. This technique maintains the reported advantages for bone-plug fixation while mitigating the risk for meniscal root damage, facilitating easier bone plug insertion and seating, expanding tensioning capabilities, and preventing soft-tissue irritation from suture knot stacks., (© 2023 The Authors.)

Treatment of osteochondritis dissecans (OCD) lesions poses a significant challenge for orthopaedic surgeons and can cause debilitating limitations on the activity of patients. Timing of intervention, surgical technique, and selection of graft when needed are all key elements of treatment that need to be considered carefully and discussed with patients. Primary fixation of an OCD fragment with intact subchondral bone has been shown to be beneficial in some cases. There is limited literature, however, on how to approach large chondral lesions in young patients without a large subchondral base attached to the fragment. Treatment of large OCD lesions of the knee with an all-arthroscopic approach provides several benefits, including limited dissection for exposure, improved ability to assess the stability of the OCD lesion during articulation after fixation, and an expedited recovery compared to an open approach. The purpose of this technical note is to detail a technique of performing an all-arthroscopic bone grafting and primary fixation of a medial femoral condyle OCD lesion., (© 2023 The Authors.)

Meniscal root pathology has garnered increased attention over the past decade. Meniscal root tears are considered to essentially represent a meniscus-deficient state, which has led to a rise in the surgical fixation of this pathology. Meniscus root tears are classified as either radial tears within 1 cm of the root insertion, or a direct avulsion of meniscal root. These injuries are important to recognize because they contribute to impaired joint mechanics and rapid articular cartilage degeneration. Given this, there remains significant interest in identifying novel surgical techniques that may facilitate better surgical repair and enhance patient outcomes. The purpose of this technical note is to describe a surgical technique for a medial meniscus root ripstop repair with cannulated drilling. This technique is simple and reproducible, while also allowing for the augmentation of potentially poor tissue quality., (© 2023 The Authors.)

Tibial spine avulsion fractures, or tibial eminence fractures, are intra-articular knee injuries that affect the bony attachment of the anterior cruciate ligament (ACL). It is commonly seen in children and adolescents aged 8 to 15 years old and can be caused by noncontact pivot shift injuries or by traumatic hyperextension knee injuries, as seen in adult ACL patients. A thorough history and physical exam is important in these patients alongside proper imaging that will confirm the diagnosis of a tibial spine avulsion. Proper imaging may also demonstrate other associated conditions or injuries to the cartilage, meniscus, or ligamentous structures. Following diagnosis, treatment can be both nonoperative versus operative, depending upon the degree of displacement and reducibility of the fragment, as well as other concomitant injuries. For nondisplaced or minimally displaced, and reducible injuries, the patient can be immobilized in full extension for several weeks. For displaced fragments that are unable to be reduced by closed methods, open reduction internal fixation or arthroscopic fixation is recommended. In this Technical Note, we describe an arthroscopy-assisted reduction and internal fixation with suture tape through 2 transtibial tunnels with a cortical suture button fixation technique., (© 2023 The Authors.)

Purpose: The purpose of this study was to assess patellar tendon (PT) and quadriceps tendon (QT) thickness on preoperative magnetic resonance imaging (MRI), in both the sagittal and axial planes, at multiple points along each tendon, and to correlate these findings to anthropometric patient data before anterior cruciate ligament (ACL) surgery., Methods: Patients who underwent PT or QT autograft ACL reconstruction between 2020 and 2022 and who had preoperative MRIs with adequate visualization of the proximal QT and distal PT were retrospectively identified . Patient demographics were recorded (age, height, weight, sex, injury side). Preoperative MRI measurements were performed by 3 independent examiners using standardized protocol. Preoperative MRI measurements were the QT anterior-posterior (AP) thickness at 1, 2, and 4 cm from the proximal patella on axial and sagittal MRI images at the central aspect of the tendon, as well as PT AP thickness at 1, 2, and 4 cm from the distal patella on axial and sagittal MRI images at the central aspect of the tendon., Results: Forty-one patients (21 females, 20 males) were evaluated, with a mean age of 33.4 years. The quadriceps tendon was significantly thicker than the patellar tendon at all measured locations ( P < .0001) with average QT versus PT thickness (in mm) at each level sagittal 1 cm (7.13 vs 4.35), sagittal 2 cm (7.41 vs 4.44), sagittal 4 cm (7.26 vs 4.81), axial 1 cm (7.35 vs 4.50), axial 2 cm (7.63 vs 4.47), axial 4 cm (7.46 vs 4.62), respectively. There were no significant correlations between tendon size and patient body mass index., Conclusions: The quadriceps tendon is significantly thicker than the patellar tendon at 1, 2, and 4 cm from the patella in both males and females based on preoperative MRI before ACL surgery., Clinical Relevance: Investigating the thickness of the tendons available for autograft harvest before surgery will give us a better understanding of tendon anatomy in the setting of ACL reconstruction., (© 2023 The Authors.)

Common injuries, such as anterior cruciate ligament (ACL) tears, can result in both anterior and rotational instability of the knee. An arthroscopic anterior cruciate ligament reconstruction (ACLR) method has been shown to be effective in restoring anterior translational stability, but this could be followed by persistent rotational instability by means of residual pivot shifts or repeat instability episodes. Alternative techniques, such as a lateral extraarticular tenodesis (LET), has been proposed as a technique for preventing persistent rotational instability following ACLR. This article presents a case of a LET using an autologous central slip of iliotibial (IT) band with fixation to the femur using a 1.8-mm knotless all-suture anchor., (© 2023 The Authors.)

Symptomatic myofascial herniations of the extremities occur infrequently; however, they can contribute to significant pain, weakness, and neuropathy with activity. Muscle herniation typically occurs through either a traumatic or congenital focal defect in the deep overlying fascia. Patients may present with an intermittently palpable subcutaneous mass and may have neuropathic symptoms, depending on the degree of nerve involvement. Patients are initially treated with conservative modalities, whereas surgery is reserved for patients who demonstrate persistent functional limitations and neurologic symptoms. Here, we demonstrate a technique for primary repair of a symptomatic lower-leg fascial defect., (© 2022 The Authors.)

Anterior cruciate ligament (ACL) reconstruction is one of the most commonly performed knee operations. An "all-inside" technique creates bone sockets for ACL graft passage, as opposed to more traditional full bone tunnels, and typically incorporates suspensory fixation instead of screw fixation to secure the graft. This technique may be indicated for any ACL reconstruction surgery, where adequate bone stock exists to drill sockets and to use cortical fixation. The technique may be used with all soft tissue, as well as bone plug ACL grafts and autograft hamstring or quadriceps tendon; most allograft tendon options may be performed with an all-inside technique. Advantages include anatomic tunnel/socket placement, decreased postoperative pain and swelling, minimal hardware, appropriate graft tensioning and retensioning, and circumferential graft to bone healing. Tips for successful all-inside surgery include matching graft diameter to socket diameter, drilling appropriate length sockets based on individual graft length, so as not to "bottom out" the graft and confirming cortical button fixation intraoperatively. Potential complications include graft-socket mismatch, full-tunnel reaming, and loss of cortical fixation. Multiple studies have shown the all-inside technique to have similar or superior biomechanical properties and clinical outcomes compared to the more traditional full-tunnel ACL reconstruction techniques., (Copyright © 2022 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Arthroscopic posterior cruciate ligament (PCL) reconstruction is a technically demanding procedure, particularly with respect to tibial footprint debridement and tibial tunnel placement, where iatrogenic damage to anatomic structures is a well reported complication and incorrect tunnel placement can have functional implications. Preparation of the tibial component often involves switching between 30° and 70° arthroscopes and frequent portal swapping and reorientation, which can be inefficient and time-consuming. As the technology and picture resolution of needle arthroscopy has improved, its clinical application has widened. This manuscript describes the use of needle arthroscopy-assisted arthroscopic PCL reconstruction for optimal visualization of the PCL tibial footprint using an accessory posterolateral portal, while obviating the need of both 30° and 70° arthroscopes., (© 2022 The Authors.)

Patellofemoral instability is a common cause of knee pain that can lead to long-standing pain, chondral injury, recurrent dislocations, and degenerative changes if not treated appropriately. Tibial tubercle osteotomy is indicated when there is anatomy predisposing to patellar maltracking and instability, namely abnormal patellar height or tibial tubercle location. In this Technical Note, we describe a technique for tibial tubercle anteriorization and distalization as part of the overall treatment algorithm for patellar instability with associated patella alta. This method of tibial tubercle osteotomy reliably produces anterior and distal translation of the patella to correct patellar height and decrease contact pressure across the patellofemoral joint., (© 2022 The Authors.)

Patellofemoral disorders are common causes of knee pain that result in frequent visitations to musculoskeletal care clinics. Patellar tendinopathy, patellar instability and patellar maltracking, and pain are some of the most common pathologies resulting in patellofemoral dysfunction. For each of these diagnoses, there are unique orthoses and braces available, some of which are uniquely designed to address the pathology involved. While the spectrum of patellofemoral disorders is wide ranging and can often be challenging to treat, bracing frequently plays a large role in the overall treatment algorithm. In this article, we summarized the current literature and treatment recommendations related to the most common types of patellar braces. We performed a thorough review of randomized controlled trials and up to date literature to reach well-informed conclusions on current best practice regarding the uses of patellar braces for patellofemoral disorders., Competing Interests: None declared., (Thieme. All rights reserved.)

Anterior cruciate ligament (ACL) and medial collateral ligament (MCL) injuries are common knee injuries, which can result from contact and noncontact during sports, recreation, or work-related activities. Prophylactic knee braces (PKBs) have been designed to protect the knee and decrease risk of recurrence of these injuries. Despite their success, PKBs have not been proven to be consistently effective and cost of the device must be evaluated to optimize its use in sports, particularly American football. Biomechanical studies have suggested that increased hip and knee flexion angles may reduce frontal plane loading with bracing which can protect the knee joint. This is essential with knee loading and rotational moments because they are associated with jumping, landing, and pivoting movements. The clinical efficacy of wearing PKBs can have an impact on athletic performance with respect to speed, power, motion, and agility, and these limitations are evident in athletes who are unaccustomed to wearing a PKB. Despite these concerns, use of PKBs increases in patients who have sustained an MCL injury or recovering from an ACL reconstruction surgery. As the evidence continues to evolve in sports medicine, there is limited definitive data to determine their beneficial or detrimental effects on overall injury risk of athletes, therefore leading those recommendations and decisions for their usage in the hands of the athletic trainers and team physicians' experience to determine the specific brace design, brand, fit, and situations for use., Competing Interests: J.P.S. reports other from American Orthopaedic Association, other from AO Foundation, other from AO North America, grants and personal fees from Arthrex, Inc, grants from Coulter Foundation, personal fees from DePuy, A Johnson & Johnson Company, other from Journal of Knee Surgery, other from Mid-America Orthopaedic Association, grants from National Institutes of Health (NIAMS & NICHD), personal fees from Orthopedic Designs North America, personal fees from Smith & Nephew, personal fees from Thieme, grants from U.S. Department of Defense, outside the submitted work.R.M. reports other from American Orthopaedic Association, other from American Orthopaedic Society for Sports Medicine, grants from Cartiheal, other from Journal of Bone and Joint Surgery - American, grants from Moximed, other from Orthopaedic Research Society, other from Rugby Research Injury Prevention Group, outside the submitted work.C.W.N. reports other from AAOS, other from American Orthopaedic Society for Sports Medicine, personal fees from Arthrex, Inc, personal fees from Arthroscopy, other from Arthroscopy Association of North America, personal fees from Guidepoint Consulting, personal fees from Vericel, Inc, outside the submitted work.P.A.S. reports other from American Orthopaedic Society for Sports Medicine, grants and personal fees from Arthrex, Inc, other from Journal of Knee Surgery, other from Spinal Simplicity, outside the submitted work., (Thieme. All rights reserved.)

The purpose of this study is to determine factors associated with the need for revision anterior cruciate ligament reconstruction (ACLR) after multiligament knee injury (MLKI) and to report outcomes for patients undergoing revision ACLR after MLKI. This involves a retrospective review of 231 MLKIs in 225 patients treated over a 12-year period, with institutional review board approval. Patients with two or more injured knee ligaments requiring surgical reconstruction, including the ACL, were included for analyses. Overall, 231 knees with MLKIs underwent ACLR, with 10% ( n  = 24) requiring revision ACLR. There were no significant differences in age, sex, tobacco use, diabetes, or body mass index between cohorts requiring or not requiring revision ACLR. However, patients requiring revision ACLR had significantly longer follow-up duration (55.1 vs. 37.4 months, p  = 0.004), more ligament reconstructions/repairs (mean 3.0 vs. 1.7, p  < 0.001), more nonligament surgeries (mean 2.2 vs. 0.7, p  = 0.002), more total surgeries (mean 5.3 vs. 2.4, p  < 0.001), and more graft reconstructions (mean 4.7 vs. 2.7, p  < 0.001). Patients in both groups had similar return to work ( p  = 0.12) and activity ( p  = 0.91) levels at final follow-up. Patients who had revision ACLR took significantly longer to return to work at their highest level (18 vs. 12 months, p  = 0.036), but similar time to return to their highest level of activity ( p  = 0.33). Range of motion (134 vs. 127 degrees, p  = 0.14), pain severity (2.2 vs. 1.7, p  = 0.24), and Lysholm's scores (86.3 vs. 90.0, p  = 0.24) at final follow-up were similar between groups. Patients requiring revision ACLR in the setting of a MLKI had more overall concurrent surgeries and other ligament reconstructions, but had similar final outcome scores to those who did not require revision surgery. Revision ligament surgery can be associated with increased pain, stiffness, and decrease patient outcomes. Revision surgery is often necessary after multiligament knee reconstructions, but patients requiring ACLR in the setting of a MLKI have good overall outcomes, with patients requiring revision ACLR at a rate of 10%., Competing Interests: J.P.S. reports grants and personal fees from Arthrex, Inc., grants from DePuy Synthes, other from Journal of Knee Surgery, grants from National Institutes of Health (NIAMS and NICHD), personal fees and other from Thieme, grants from U.S. Department of Defense, other from AO Foundation, other from American Orthopedic Association, other from AO North America, grants from Coulter Foundation, other from Mid-America Orthopedic Association, personal fees from Orthopedic Designs North America, personal fees from Smith and Nephew outside the submitted work.J.L.C. reports grants and personal fees from Arthrex, Inc., personal fees from AthleteIQ, grants from ConforMIS, personal fees from CONMED Linvatec, grants from Coulter Foundation, grants from DePuy Synthes, grants and personal fees from Eli Lilly, other from Journal of Knee Surgery, grants from Merial, other from Midwest Transplant Network, grants, personal fees and other from Musculoskeletal Transplant Foundation, grants from National Institutes of Health (NIAMS & NICHD), grants from Purina, grants from Sites Medical, personal fees and other from Thieme, grants from TissueGen Inc, personal fees from Trupanion, grants from U.S. Department of Defense, grants from Zimmer-Biomet, outside the submitted work.C.W.N. reports other from Arthroscopy, other from Arthroscopy Association of North America outside the submitted work., (Thieme. All rights reserved.)

Osteochondral injuries commonly occur after lateral patellar instability events. Recognition and early intervention of displaced fragments is key to maintaining the viability of the fragment and congruency of the articular surface. Multiple fixation techniques exist for achieving stable fixation of displaced osteochondral lesions, including metal or bioabsorbable screws and all suture techniques. In this Technical Note, we describe a technique for internal fixation of a displaced osteochondral fragment of the lateral femoral condyle using knotless suture anchors. This technique affords minimally invasive restoration of the native anatomy with excellent stability of the fracture fragment, allowing early range of motion and ambulation., (© 2021 Published by Elsevier Inc. on behalf of the Arthroscopy Association of North America.)

Posterior cruciate ligament (PCL) injuries are often encountered in the setting of other knee pathology and sometimes in isolation. A thorough understanding of the native PCL anatomy is crucial in the successful treatment of these injuries. The PCL consists of two independent bundles that function in a codominant relationship to perform the primary role of resisting posterior tibial translation relative to the femur. A secondary role of the PCL is to provide rotatory stability. The anterolateral (AL) bundle has a more vertical orientation when compared with the posteromedial (PM) bundle. The AL bundle has a more anterior origin than the PM bundle on the lateral wall of the medial femoral condyle. The tibial insertion of AL bundle on the PCL facet is medial and anterior to the PM bundle. The AL and PM bundles are 12-mm apart at the center of the femoral origins, while the tibial insertions are more tightly grouped. The different spatial orientation of the two bundles and large distance between the femoral centers is responsible for the codominance of the PCL bundles. The AL bundle is the dominant restraint to posterior tibial translation throughout midrange flexion, while the PM bundle is the primary restraint in extension and deep flexion. Biomechanical testing has shown independent reconstruction of the two bundles that better reproduces native knee biomechanics, while significant differences in clinical outcomes remain to be seen. Stress X-rays may play an important role in clinical decision-making process for operative versus nonoperative management of isolated PCL injuries. Strong understanding of PCL anatomy and biomechanics can aid surgical management., Competing Interests: J.C. has reported consulting fees from Arthrex, Smith and Nephew, CONMED, Depuy, and Ossur. C.W.N. reports other from Arthrex, Arthroscopy Journal, other from AANA, outside submitted work., (Thieme. All rights reserved.)

Proximal humerus fractures are common fractures that may occur after ground level falls or other traumatic events resulting in a direct injury to the shoulder. Depending on the fracture morphology and the age of the patient, anatomic reduction can vastly improve outcomes, especially in fracture patterns that involve the greater tuberosity. In this case example, we performed a minimally invasive, arthroscopic reduction and fixation of a proximal humerus fracture that involved significant displacement of the greater tuberosity. The technique employed is reproducible and avoids the morbidity of a large open incision while simultaneously providing compression of the fracture fragment for excellent healing potential., (© 2020 Published by Elsevier on behalf of the Arthroscopy Association of North America.)

Subpectoral biceps tenodesis of the shoulder may be a useful tool that can address a wide range of disorders in the setting of pathology of the long head of the biceps tendon. Primary indications include (1) zone 2 or zone 3 tendon pathology and (2) failed previous proximal tendon tenodesis. Secondary indications include (1) an overhead athlete or thrower, (2) chronic tendinopathy, and (3) surgeon preference. A subpectoral technique allows tendon fixation directly posterior (deep) to the pectoralis tendon high in the bicipital fossa or in the mid fossa or fixation low in the fossa inferior to the pectoralis tendon (infrapectoral). Fixation technique options include an onlay suture anchor, onlay unicortical button, inlay bicortical button, or inlay interference screw. Potential surgical complications include humeral fracture, loss of fixation, tendon pullout or rupture, and neurovascular injury. Regardless of the specific location or technique used, subpectoral tenodesis is a valuable tool for the treatment of proximal biceps tendon pathology., (Copyright © 2020 Arthroscopy Association of North America. All rights reserved.)

Increased laxity within the graft construct system can lead to graft failure after anterior cruciate ligament (ACL) reconstruction. Suboptimal cortical device positioning could lead to increased laxity within the system, which could influence the mechanics and function of the graft reconstruction. This study evaluates the benefit of intraoperative fluoroscopy to confirm device position on the femur during ACL reconstruction using cortical suspensory fixation. One hundred consecutive patients who underwent soft tissue ACL reconstruction using a suspensory cortical device for femoral fixation were retrospectively evaluated. Patients were split into two groups: Group A utilized anteromedial portal visualization and had intraoperative fluoroscopic imaging performed at the time of ACL graft fixation to confirm femoral device placement on the lateral femoral metaphyseal cortex. Group B utilized anteromedial portal visualization alone. Both groups had radiographic X-rays performed at the first postoperative visit to evaluate device location and all images were independently evaluated by three fellowship trained orthopaedic surgeons. Device position was classified as optimal if there was complete apposition of the entire device against the femoral cortex and suboptimal if it was > 2 mm off the cortex. Fisher's exact test, analysis of variance, and 95% confidence intervals were calculated to compare the groups for statistical significance. The results showed 0/60 (0%) patients in group A had suboptimal device position at postoperative follow-up, while 4/40 (10%) patients in group B had suboptimal device position ( p  = 0.013). There were no graft failures in group A and one graft failure in group B. There was a significant difference in cortical device position in patients who had intraoperative fluoroscopic imaging versus patients who had no intraoperative imaging. The use of confirmatory intraoperative imaging may be beneficial to confirm appropriate device location when using a femoral cortical suspensory fixation technique for ACL reconstruction., Competing Interests: None declared., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Osteochondral injuries of the patella occur often in the setting of traumatic patellar dislocations. Early fixation of the displaced fragment(s) is paramount to maintaining the viability of the articular cartilage and the congruency of the patella. Multiple fixation techniques have been described to ensure stable fixation, including wires, screws, and all-suture techniques with both absorbable and nonabsorbable materials. We performed an open reduction and internal fixation of a large traumatic patellar osteochondral lesion using 3 bioabsorbable compression screws. The technique is straightforward and provides compression across the fragments, affording excellent stability, which allows early range of motion and ambulation., (© 2019 by the Arthroscopy Association of North America. Published by Elsevier.)

The purpose of this study was to determine incidence of concurrent peroneal nerve injury and to compare outcomes in patients with and without peroneal nerve injury after surgical treatment for multiligament knee injuries (MLKIs). A retrospective study of 357 MLKIs was conducted. Patients with two or more knee ligaments requiring surgical reconstruction were included. Mean follow-up was 35 months (0-117). Incidence of concurrent peroneal nerve injury was noted and patients with and without nerve injury were evaluated for outcomes. Concurrent peroneal nerve injury occurred in 68 patients (19%). In patients with nerve injury, 45 (73%) returned to full duty at work; 193 (81%) patients without nerve injury returned to full duty ( p  = 0.06). In patients with nerve injury, 37 (60%) returned to their previous level of activity; 148 (62%) patients without nerve injury returned to their previous level of activity ( p  = 0.41). At final follow-up, there were no significant differences in level of pain (mean visual analog scale 1.6 vs. 2; p  = 0.17), Lysholm score (mean 88.6 vs. 88.8; p  = 0.94), or International Knee Documentation Committee score (mean 46.2 vs. 47.8; p  = 0.67) for patients with or without peroneal nerve injury, respectively. Postoperative range of motion (ROM) (mean 121 degrees) was significantly lower ( p  = 0.02) for patients with nerve injury compared with patients without nerve injury (mean 127 degrees). Concurrent peroneal nerve injury occurred in 19% of patients in this large cohort suffering MLKIs. After knee reconstruction surgery, patients with concurrent peroneal nerve injuries had significantly lower knee ROM and trended toward a lower rate of return to work. However, outcomes with respect to activity level, pain, and function were not significantly different between the two groups. This study contributes to our understanding of patient outcomes in patients with concurrent MLKI and peroneal nerve injury, with a focus on the patient's ability to return to work and sporting activity., Competing Interests: None declared., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Purpose: To correlate preoperative magnetic resonance imaging (MRI) and intraoperative anatomic findings within the proximal long head biceps tendon to histologic evaluation of 3 separate zones of the tendon in patients with chronic biceps tendinopathy., Methods: Sixteen patients with chronic biceps tendinopathy were treated with open subpectoral biceps tenodesis. Preoperative MRI tendon grading was as follows: normal tendon, increased signal, tendon splitting, incomplete/complete tear. The removed portion of the biceps tendon was split into 3 segments: zone 1, 0-3.5 cm from the labral insertion; zone 2, 3.5-6.5 cm; and zone 3, 6.5-9 cm, and was histologically evaluated using the Bonar score. Tenosynovium adjacent to the tendon was assessed histologically using the Osteoarthritis Research Society International score. CD31, CD3, and CD79a immunohistochemistries were conducted to determine vascularization, T-cell infiltrates, and B-cell infiltrates, respectively. Analysis of variance and Pearson correlations were performed for statistical analysis., Results: Preoperative MRI showed no significant differences in tendon appearance between zones 1-3. Intraoperative findings included nonspecific degenerative SLAP tears or mild/moderate biceps tenosynovitis in all cases. Significantly (P < .001) higher Bonar scores were noted for tendon in zones 1 (7.9 ± 1.8) and 2 (7.3 ± 1.5) compared with zone 3 (5.0 ± 1.1). Cell morphology scores in zone 1 (1.9 ± 0.4) and zone 2 (1.5 ± 0.6) were significantly higher than that in zone 3 (0.8 ± 0.3) (P < .05). Inflammatory tenosynovium showed weak correlation with tendon changes in zone 1 (r = 0.08), zone 2 (r = 0.03), or zone 3 (r = 0.1)., Conclusions: In patients with chronic long head biceps tendinopathy who underwent open subpectoral tenodesis, MRI and intraoperative assessment did not show significant structural abnormalities within the tendon despite significant histopathologic changes. Severity of tendon histopathology was more pronounced in the proximal and mid-portions of the tendon., Clinical Relevance: Proximal versus distal biceps tenodesis is a subject of frequent debate. This study contributes to the ongoing evaluation of the characteristics of the proximal biceps in this type of pathologic condition., (Copyright © 2018 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Osteochondritis dissecans (OCD) lesions of the patellofemoral joint can be difficult to identify and treat. Asymptomatic or stable lesions in skeletally immature patients may be treated nonoperatively, but symptomatic lesions often require surgical intervention. Evidence of instability should be carefully evaluated with preoperative magnetic resonance imaging or computed tomography arthrogram. Careful preoperative planning is necessary to ensure the appropriate surgical approach and implants are selected for surgical management. Multiple techniques have been described, but internal fixation of both "classic" and cartilage-only OCD lesions has been shown to have strong outcomes in managing these difficult cases., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Background: This study was conducted to evaluate the effects of commonly used injection medication combinations on supraspinatus tenocyte cell viability and tissue metabolism., Methods: Twenty adult dogs underwent ultrasound guided injection of the canine equivalent of the subacromial space, based on random assignment to one of four treatment groups (n=5/group): normal saline, 1.0% lidocaine/methylprednisolone, 1.0% lidocaine/triamcinolone or 0.0625% bupivacaine/triamcinolone. Full-thickness sections of supraspinatus tendon were harvested under aseptic conditions and evaluated on days 1 and 7 post-harvest for cell viability and tissue metabolism. Data were analyzed for significant differences among groups., Results: Tendons exposed to 1% lidocaine/ methylprednisolone had significantly lower cell viability at day 1 as compared to all other groups and control. All local anesthetic/ corticosteroid combination groups had decreased cell viability at day 7 when compared to the control group., Conclusions: This study demonstrated significant in vivo supraspinatus tenotoxicity following a single injection of combination local anesthetic/ corticosteroid when compared to saline controls., Level of Evidence: Level II.