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The primary purpose of this study was to compare 2-year anatomic total shoulder arthroplasty (TSA) functional and radiographic outcomes between Walch type A and B glenoids treated with an all-polyethylene glenoid designed for hybrid fixation with peripheral cement and central osseous integration. The secondary purpose was to evaluate outcomes based on central peg technique. The hypotheses were that there would be no difference in short-term radiographic or functional outcome scores based on preoperative glenoid morphology or central peg technique.We performed a multicenter retrospective review of patients who underwent TSA with the same hybrid all-polyethylene glenoid and had minimum 2-year follow-up. Patient-reported outcomes and radiographic outcomes were analyzed based on preoperative Walch morphology and central peg technique. Radiographic analysis included preoperative glenoid morphology; preoperative and postoperative glenoid version, glenoid inclination, and posterior humeral head subluxation; and postoperative glenoid radiolucencies according to the Wirth and Lazarus classifications.A total of 266 patients with a mean age of 64.9 ± 8.2 years were evaluated at a mean of 28 months postoperatively. Postoperatively, there were significant improvements in all functional outcome measures (P .001), range-of-motion measures (forward elevation, external rotation at 0°, external rotation at 90°, internal rotation by spinal level, and internal rotation at 90°; P .001), and strength measures (Constant, external rotation, and modified belly press; P .001). There were no clinically meaningful differences in functional outcomes or statistically significant differences in radiographic appearance between Walch type A and B glenoids. Subgroup analysis revealed that glenoids with a cemented central peg had the worst radiographic outcomes based on Lazarus scoring.Patients undergoing TSA with a hybrid in-line pegged glenoid have excellent clinical outcomes at short-term follow-up regardless of preoperative glenoid morphology. Different central peg techniques do not appear to play a significant role in the risk of glenoid component lucencies at 2 years postoperatively.

To develop a standardized opioid prescribing schedule (SOPS) following anterior cruciate ligament reconstruction (ACLR) and rotator cuff repair (RCR) and evaluate postoperative opioid consumption alongside Patient-Reported Outcome Measurement Information System (PROMIS) pain interference scores.A prospective observational study was performed on all patients undergoing primary ACLR and RCR from March 2019 to October 2021. Patients taking opioids preoperatively and revision ACLR and RCR were excluded. PROMIS 6B questionnaires were administered before and after implantation of the SOPS initiated on December 15, 2019. Opioid consumption was determined by email surveys. Hypothesis testing was performed with Mann-WhitneyA total of 599 patients met inclusion criteria with 188 patients (71 ACLR and 117 RCR) completing surveys. Before the initiation of SOPS, the average number of oxycodone 5-mg tablets prescribed for ACLR was 44.6 (95% confidence interval [CI] 42.4-46.9) and for RCR was 44.7 (95% CI 42.7-46.8). The average usage was 23.1 (95% CI 16.9-29.2) and 22.1 (95% CI 16.2-28.0), respectively. Following SOPS of 30 tablets of oxycodone 5 mg for ACLR and 40 tablets for RCR, the average number of tablets prescribed significantly decreased for both procedures (The results of the present study demonstrate that the implementation of a SOPS reduced postoperative opioid prescribing amounts and consumption without significant impacting PROMIS pain interference scores for ACLR and RCR, supporting the possibility to decrease and standardize opioid prescribing following common sports medicine procedures.III: Retrospective, comparative, therapeutic study.

Background: Patients with anterior cruciate ligament (ACL) revision report lower outcome scores on validated knee questionnaires postoperatively compared to cohorts with primary ACL reconstruction. In a previously active population, it is unclear if patient-reported outcomes (PROs) are associated with a return to activity (RTA) or vary by sports participation level (higher level vs. recreational athletes). Hypotheses: Individual RTA would be associated with improved outcomes (ie, decreased knee symptoms, pain, function) as measured using validated PROs. Recreational participants would report lower PROs compared with higher level athletes and be less likely to RTA. Study Design: Cohort study; Level of evidence, 2. Methods: There were 862 patients who underwent a revision ACL reconstruction (rACLR) and self-reported physical activity at any level preoperatively. Those who did not RTA reported no activity 2 years after revision. Baseline data included patient characteristics, surgical history and characteristics, and PROs: International Knee Documentation Committee questionnaire, Marx Activity Rating Scale, Knee injury and Osteoarthritis Outcome Score, and the Western Ontario and McMaster Universities Osteoarthritis Index. A binary indicator was used to identify patients with same/better PROs versus worse outcomes compared with baseline, quantifying the magnitude of change in each direction, respectively. Multivariable regression models were used to evaluate risk factors for not returning to activity, the association of 2-year PROs after rACLR surgery by RTA status, and whether each PRO and RTA status differed by participation level. Results: At 2 years postoperatively, approximately 15% did not RTA, with current smokers (adjusted odds ratio [aOR] = 3.3; P = .001), female patients (aOR = 2.9; P < .001), recreational participants (aOR = 2.0; P = .016), and those with a previous medial meniscal excision (aOR = 1.9; P = .013) having higher odds of not returning. In multivariate models, not returning to activity was significantly associated with having worse PROs at 2 years; however, no clinically meaningful differences in PROs at 2 years were seen between participation levels. Conclusion: Recreational-level participants were twice as likely to not RTA compared with those participating at higher levels. Within a previously active cohort, no RTA was a significant predictor of lower PROs after rACLR. However, among patients who did RTA after rACLR, approximately 20% reported lower outcome scores. Most patients with rACLR who were active at baseline improved over time; however, patients who reported worse outcomes at 2 years had a clinically meaningful decline across all PROs.

Background Cadaveric studies have demonstrated adverse biomechanical consequences to small changes in the center of rotation (COR) from ideal in anatomic total shoulder arthroplasty (TSA). The aim of the present study was to determine if there is any association between humeral COR shift from ideal in anatomic TSA and patient-reported outcomes or range of motion (ROM). Methods A multicenter retrospective study was conducted of TSAs with minimum 2-year follow-up. Offset of the COR from ideal was measured on postoperative radiographs using a best-fit circle technique. The primary outcome was the final ASES score. A receiver operator characteristic curve was constructed to determine a significant threshold of COR change. Patient-reported outcomes and ROM for patients above and below the calculated threshold were assessed. The number of patients achieving a patient acceptable symptomatic state was also investigated. Results Eighty-seven patients aged 65.6 ± 8.3 years, 59% male, with mean 3.2-year follow-up were included. In 64% of cases, the COR was >2 mm from ideal and in 18% of cases it was >4 mm. A significant threshold COR change of 2.7 mm was determined, which was a significant predictor of below-average ASES scores following TSA (sensitivity: 79%, specificity: 72%, P 2.7, P= .009) and change in active forward flexion (41° for COR 2.7, P = .047) for patients with COR closer to ideal. Conclusions Accurate restoration of ideal humeral COR during anatomic TSA is challenging and significant shifts are common. A prosthetic COR greater than 2.7 mm from ideal is associated with worse patient-reported outcomes and ROM following anatomic TSA Level of evidence Level III

Background: Although graft choice may be limited in the revision setting based on previously used grafts, most surgeons believe that graft choice for anterior cruciate ligament (ACL) reconstruction is an important factor related to outcome. Hypothesis: In the ACL revision setting, there would be no difference between autograft and allograft in rerupture rate and patient-reported outcomes (PROs) at 6-year follow-up. Study Design: Cohort study; Level of evidence, 2. Methods: Patients who had revision surgery were identified and prospectively enrolled in this cohort study by 83 surgeons over 52 sites. Data collected included baseline characteristics, surgical technique and pathology, and a series of validated PRO measures. Patients were followed up at 6 years and asked to complete the identical set of PRO instruments. Incidence of additional surgery and reoperation because of graft failure were also recorded. Multivariable regression models were used to determine the predictors (risk factors) of PROs, graft rerupture, and reoperation at 6 years after revision surgery. Results: A total of 1234 patients including 716 (58%) men were enrolled. A total of 325 (26%) underwent revision using a bone-patellar tendon-bone (BTB) autograft; 251 (20%), soft tissue autograft; 289 (23%), BTB allograft; 302 (25%), soft tissue allograft; and 67 (5%), other graft. Questionnaires and telephone follow-up for subsequent surgery information were obtained for 809 (66%) patients, while telephone follow-up was only obtained for an additional 128 patients for the total follow-up on 949 (77%) patients. Graft choice was a significant predictor of 6-year Marx Activity Rating Scale scores ( P = .024). Specifically, patients who received a BTB autograft for revision reconstruction had higher activity levels than did patients who received a BTB allograft (odds ratio [OR], 1.92; 95% CI, 1.25-2.94). Graft rerupture was reported in 5.8% (55/949) of patients by their 6-year follow-up: 3.5% (16/455) of patients with autografts and 8.4% (37/441) of patients with allografts. Use of a BTB autograft for revision resulted in patients being 4.2 times less likely to sustain a subsequent graft rupture than if a BTB allograft were utilized ( P = .011; 95% CI, 1.56-11.27). No significant differences were found in graft rerupture rates between BTB autograft and soft tissue autografts ( P = .87) or between BTB autografts and soft tissue allografts ( P = .36). Use of an autograft was found to be a significant predictor of having fewer reoperations within 6 years compared with using an allograft ( P = .010; OR, 0.56; 95% CI, 0.36-0.87). Conclusion: BTB and soft tissue autografts had a decreased risk in graft rerupture compared with BTB allografts. BTB autografts were associated with higher activity level than were BTB allografts at 6 years after revision reconstruction. Surgeons and patients should consider this information when choosing a graft for revision ACL reconstruction.

Background: Lytic or malpositioned tunnels may require bone grafting during revision anterior cruciate ligament reconstruction (rACLR) surgery. Patient characteristics and effects of grafting on outcomes after rACLR are not well described. Purpose: To describe preoperative characteristics, intraoperative findings, and 2-year outcomes for patients with rACLR undergoing bone grafting procedures compared with patients with rACLR without grafting. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 1234 patients who underwent rACLR were prospectively enrolled between 2006 and 2011. Baseline revision and 2-year characteristics, surgical technique, pathology, treatment, and patient-reported outcome instruments (International Knee Documentation Committee [IKDC], Knee injury and Osteoarthritis Outcome Score [KOOS], Western Ontario and McMaster Universities Osteoarthritis Index, and Marx Activity Rating Scale [Marx]) were collected, as well as subsequent surgery information, if applicable. The chi-square and analysis of variance tests were used to compare group characteristics. Results: A total of 159 patients (13%) underwent tunnel grafting—64 (5%) patients underwent 1-stage and 95 (8%) underwent 2-stage grafting. Grafting was isolated to the femur in 31 (2.5%) patients, the tibia in 40 (3%) patients, and combined in 88 patients (7%). Baseline KOOS Quality of Life (QoL) and Marx activity scores were significantly lower in the 2-stage group compared with the no bone grafting group ( P≤ .001). Patients who required 2-stage grafting had more previous ACLRs ( P < .001) and were less likely to have received a bone–patellar tendon–bone or a soft tissue autograft at primary ACLR procedure ( P≤ .021) compared with the no bone grafting group. For current rACLR, patients undergoing either 1-stage or 2-stage bone grafting were more likely to receive a bone–patellar tendon–bone allograft ( P≤ .008) and less likely to receive a soft tissue autograft ( P≤ .003) compared with the no bone grafting group. At 2-year follow-up of 1052 (85%) patients, we found inferior outcomes in the 2-stage bone grafting group (IKDC score = 68; KOOS QoL score = 44; KOOS Sport/Recreation score = 65; and Marx activity score = 3) compared with the no bone grafting group (IKDC score = 77; KOOS QoL score = 63; KOOS Sport/Recreation score = 75; and Marx activity score = 7) ( P≤ .01). The 1-stage bone graft group did not significantly differ compared with the no bone grafting group. Conclusion: Tunnel bone grafting was performed in 13% of our rACLR cohort, with 8% undergoing 2-stage surgery. Patients treated with 2-stage grafting had inferior baseline and 2-year patient-reported outcomes and activity levels compared with patients not undergoing bone grafting. Patients treated with 1-stage grafting had similar baseline and 2-year patient-reported outcomes and activity levels compared with patients not undergoing bone grafting.

Context Quadriceps weakness is associated with disability and aberrant gait biomechanics after anterior cruciate ligament reconstruction (ACLR). Strength-sufficiency cutoff scores, which normalize quadriceps strength to the mass of an individual, can predict who will report better function after ACLR. However, whether gait biomechanics differ between individuals who meet a strength-sufficiency cutoff (strong) and those who do not (weak) remains unknown. Objective To determine whether vertical ground reaction force, knee-flexion angle, and internal knee-extension moment differ throughout the stance phase of walking between individuals with strong and those with weak quadriceps after ACLR. Design Case-control study. Setting Laboratory. Patients or Other Participants Individuals who underwent unilateral ACLR >12 months before testing were dichotomized into strong (n = 31) and weak (n = 116) groups. Main Outcome Measures Maximal isometric quadriceps strength was measured at 90° of knee flexion using an isokinetic dynamometer and normalized to body mass. Individuals who demonstrated maximal isometric quadriceps strength ≥3.0 N·m·kg−1 were considered strong. Three-dimensional gait biomechanics were collected at a self-selected walking speed. Biomechanical data were time normalized to 100% of stance phase. Vertical ground reaction force was normalized to body weight (BW), and knee-extension moment was normalized to BW × height. Pairwise comparison functions were calculated for each outcome to identify between-groups differences for each percentile of stance. Results Vertical ground reaction force was greater in the weak group for the first 22% of stance (peak mean difference [MD] = 6.2% BW) and less in the weak group between 36% and 43% of stance (MD = 1.4% BW). Knee-flexion angle was greater (ie, more flexion) in the strong group between 6% and 52% of stance (MD = 2.3°) and smaller (ie, less flexion) between 68% and 79% of stance (MD = 1.0°). Knee-extension moment was greater in the strong group between 7% and 62% of stance (MD = 0.007 BW × height). Conclusions Individuals with ACLR who generated knee-extension torque ≥3.0 N·m·kg−1 exhibited different biomechanical gait profiles than those who could not. More strength may allow for better energy attenuation after ACLR.

Background: Postoperative stiffness is a known complication after rotator cuff repair (RCR). Glenohumeral hydrodistension (GH) has been a treatment modality for shoulder pathology but has not been used to treat postoperative stiffness after RCR. Purpose/Hypothesis: The purpose of this study was to identify the risk factors for postoperative stiffness after RCR and review outcomes after treatment with GH. Our hypotheses were that stiffness would be associated with diabetes and hyperlipidemia and correlated with the tendons involved and that patients with stiffness who underwent GH would have significant improvement in range of motion (ROM). Study Design: Case series; Level of evidence, 4. Methods: Included were 388 shoulders of patients who underwent primary RCR by a single surgeon between 2015 and 2019. Shoulders with revision RCRs were excluded. Patient characteristics, medical comorbidities, and perioperative details were collected. A total of 40 shoulders with postoperative stiffness (10.3%) received GH injectate of a 21-mL mixture (15 mL of sterile water, 5 mL of 0.5% ropivacaine, and 1 mL of triamcinolone [10 mg/mL]). The primary outcome measure was ROM in forward flexion, internal rotation, external rotation, and abduction. Statistical tests were performed using analysis of variance. Results: Patients with diabetes had significantly decreased internal rotation at final follow-up after RCR as compared with patients without diabetes. GH to treat stiffness was performed most commonly between 1 and 4 months after RCR (60%), and patients who received GH saw statistically significant improvements in forward flexion, external rotation, and abduction after the procedure. Patients with hyperlipidemia had the most benefit after GH. Among those undergoing concomitant procedures, significantly more patients who had open subpectoral biceps tenodesis underwent GH. Patients who underwent subscapularis repair or concomitant subacromial decompression had significant improvement in ROM after GH. Only 1 patient who received GH underwent secondary surgery for resistant postoperative stiffness. Conclusion: Patients with diabetes had increased stiffness. Patients with a history of hyperlipidemia or concomitant open subpectoral biceps tenodesis were more likely to undergo GH for postoperative stiffness. Patients who underwent subscapularis repair demonstrated the most improvement in ROM after GH. After primary RCR, GH can increase ROM and is a useful adjunct for patients with stiffness to limit secondary surgery.

Background: Meniscal preservation has been demonstrated to contribute to long-term knee health. This has been a successful intervention in patients with isolated tears and tears associated with anterior cruciate ligament (ACL) reconstruction. However, the results of meniscal repair in the setting of revision ACL reconstruction have not been documented. Purpose: To examine the prevalence and 2-year operative success rate of meniscal repairs in the revision ACL setting. Study Design: Case-control study; Level of evidence, 3. Methods: All cases of revision ACL reconstruction with concomitant meniscal repair from a multicenter group between 2006 and 2011 were selected. Two-year follow-up was obtained by phone and email to determine whether any subsequent surgery had occurred to either knee since the initial revision ACL reconstruction. If so, operative reports were obtained, whenever possible, to verify the pathologic condition and subsequent treatment. Results: In total, 218 patients (18%) from 1205 revision ACL reconstructions underwent concurrent meniscal repairs. There were 235 repairs performed: 153 medial, 48 lateral, and 17 medial and lateral. The majority of these repairs (n = 178; 76%) were performed with all-inside techniques. Two-year surgical follow-up was obtained on 90% (197/218) of the cohort. Overall, the meniscal repair failure rate was 8.6% (17/197) at 2 years. Of the 17 failures, 15 were medial (13 all-inside, 2 inside-out) and 2 were lateral (both all-inside). Four medial failures were treated in conjunction with a subsequent repeat revision ACL reconstruction. Conclusion: Meniscal repair in the revision ACL reconstruction setting does not have a high failure rate at 2-year follow-up. Failure rates for medial and lateral repairs were both

The influence of the humeral inclination in reverse total shoulder arthroplasty (RTSA) is not well understood. The purpose of this study was to determine outcomes and complications after RTSA with an inclination of 135° or 155° in a modular prosthesis. American Shoulder and Elbow Surgeons (ASES), visual analog scale (VAS), Single Assessment Numeric Evaluation (SANE), and Simple Shoulder Test (SST) scores, as well as forward elevation (FE), abduction (ABD), and external rotation (ER), were assessed after a minimum 2-year follow-up. Scapular notching and radiolucency were assessed according to Sirveaux and Lévigne. A total of 121 patients with a mean age of 69.7±7.3 years were evaluated after a mean of 36.5±8 months. The inclination was set to 135° in 80.2% and to 155° in 19.8% of patients. There was no significant difference between the groups for ASES, VAS, SANE, and SST scores. The FE ( P =.022) and ABD ( P =.002) were significantly higher for the 155° inclination group. Complication rates were not significantly different between the groups. Scapular notching was significantly more common with a 155° inclination ( P =.01), whereas humeral radiolucency was not correlated. All outcome scores improved significantly from pre- to postoperative ( P ≤.001). Reverse total shoulder arthroplasty leads to significant improvements in pain, range of motion, and outcome scores after mid-term follow-up. Overall, the inclination angle does not significantly affect clinical outcomes or the complication rate after RTSA at mid-term follow-up. However, an inclination of 155° shows significantly greater FE and ABD, although it results in a significantly higher rate of scapular notching. Cases with scapular notching are associated with significantly reduced mean ASES scores and ER as well as significantly higher VAS scores. [ Orthopedics . 2021;44(4):e527–e533.]

The purpose of this study was to determine the inter-rater reliability of arthroscopic video quality, determine correlation between surgeon rating and computational image metrics, and facilitate a quantitative methodology for assessing video quality.Five orthopaedic surgeons reviewed 60 clips from deidentified arthroscopic shoulder videos and rated each on a four-point Likert scale from poor to excellent view. The videos were randomized, and the process was completed a total of three times. Each user rating was averaged to provide a user rating per clip. Each video frame was processed to calculate brightness, local contrast, redness (used to represent bleeding), and image entropy. Each metric was then averaged over each frame per video clip, providing four image quality metrics per clip.Inter-rater reliability for grading video quality had an intraclass correlation of .974. Improved image quality rating was positively correlated with increased entropy (.8142;Our study demonstrates strong inter-rater reliability between surgeons when describing image quality and strong correlations between image quality and the computed image metrics. A model based on these metrics enables automatic quantification of image quality.Video quality during arthroscopic cases can impact the ease and duration of the case which could contribute to swelling and complication risk. This pilot study provides a quantitative method to assess video quality. Future works can objectively determine factors that affect visualization during arthroscopy and identify options for improvement.

Revision anterior cruciate ligament (ACL) reconstruction has been documented to have worse outcomes than primary ACL reconstruction. The reasons remain varied and not completely understood. METHODS: Patients undergoing revision ACL reconstruction were prospectively enrolled. Data collected included baseline demographics, surgical technique and pathological condition, prescribed rehabilitation instructions, and a series of validated patient-reported outcome instruments. Patients were followed for 2 years and asked to complete a set of outcome instruments identical to those completed at baseline. Subsequent surgical procedures on the ipsilateral knee were recorded. Regression analysis was used to control for age, sex, activity level, baseline outcome scores, and the above-mentioned rehabilitation-related variables in order to assess the factors affecting clinical outcomes 2 years after revision ACL reconstruction. RESULTS: A total of 843 patients met the inclusion criteria and were successfully enrolled, and 82% (695) were followed for 2 years. Two rehabilitation-related factors were found to influence outcome. First, patients who were prescribed an ACL brace for their return to sports had a significantly better Knee injury and Osteoarthritis Outcome Score (KOOS) for sports and recreational activities at 2 years (odds ratio [OR] =1.50, 95% confidence interval [CI] = 1.07 to 2.11; p = 0.019). Second, patients prescribed an ACL brace for the postoperative rehabilitation period were 2.3 times more likely to have subsequent surgery by 2 years (OR = 2.26, 95% CI = 1.11 to 4.60; p = 0.024). The odds of a graft rerupture were not affected by any type of brace wear. CONCLUSIONS: Rehabilitation-related factors that the physician can control at the time of an ACL reconstruction have the ability to influence clinical outcomes at 2 years. Weight-bearing and motion can be initiated immediately postoperatively. Bracing during the early postoperative period is not helpful. Use of a functional brace early in the postoperative period was associated with an increased risk of a reoperation. Use of a functional brace for a return to sports improved the KOOS on the sports/recreation subscale. LEVEL OF EVIDENCE: Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Context Hypertrophy of the infrapatellar fat pad (IFP) in idiopathic knee osteoarthritis has been linked to deleterious synovial changes and joint pain related to mechanical tissue impingement. Yet little is known regarding the IFP's volumetric changes after anterior cruciate ligament reconstruction (ACLR). Objectives To examine changes in IFP volume between 6 and 12 months after ACLR and determine associations between patient-reported outcomes and IFP volume at each time point as well as the volume change over time. In a subset of individuals, we examined interlimb IFP volume differences 12 months post-ACLR. Study Design Prospective cohort study. Setting Laboratory. Patients or Other Participants We studied 26 participants (13 women, 13 men, age = 21.88 ± 3.58 years, body mass index = 23.82 ± 2.21 kg/m2) for our primary aims and 13 of those participants (8 women, 5 men, age = 21.15 ± 3.85 years, body mass index = 23.01 ± 2.01 kg/m2) for our exploratory aim. Main Outcome Measure(s) Using magnetic resonance imaging, we evaluated the IFP volume change between 6 and 12 months post-ACLR in the ACLR limb and between-limbs differences at 12 months in a subset of participants. International Knee Documentation Committee subjective knee evaluation (IKDC) scores were collected at 6-month and 12-month follow-ups, and associations between IFP volume and patient-reported outcomes were determined. Results The IFP volume in the ACLR limb increased from 6 months (19.67 ± 6.30 cm3) to 12 months (21.26 ± 6.91 cm3) post-ACLR. Greater increases of IFP volume between 6 and 12 months were significantly associated with better 6-month IKDC scores (r = .44, P = .03). The IFP volume was greater in the uninjured limb (22.71 ± 7.87 cm3) than in the ACLR limb (20.75 ± 9.03 cm3) 12 months post-ACLR. Conclusions The IFP volume increased between 6 and 12 months post-ACLR; however, the IFP volume of the ACLR limb remained smaller than that of the uninjured limb at 12 months. In addition, those with better knee function 6 months post-ACLR demonstrated greater increases in IFP volume between 6 and 12 months post-ACLR. This suggests that greater IFP volumes may play a role in long-term joint health after ACLR.

Previous attempts to measure lateralization, distalization or inclination after reverse total shoulder arthroplasty (rTSA) and to correlate them with clinical outcomes have been made in the past years. However, this is considered to be too demanding and challenging for daily clinical practice. Additionally, the reported findings were obtained from heterogeneous rTSA cohorts using 145° and 155° designs and are limited in external validity. The purpose of this study was to investigate the prognostic preoperative and postoperative radiographic factors affecting clinical outcomes in patients following rTSA using a 135° prosthesis design. In a multi-center design, patients undergoing primary rTSA using a 135° design were included. Radiographic analysis included center of rotation (COR), acromiohumeral distance (AHD), lateral humeral offset (LHO), distalization shoulder angle (DSA), lateralization shoulder angle (LSA), critical shoulder angle (CSA), and glenoid and baseplate inclination. Radiographic measurements were correlated to clinical and functional outcomes, including the American Shoulder and Elbow Surgeons (ASES), Simple Shoulder Test (STT), Single Assessment Numeric Evaluation (SANE), and Visual Analogue Scale (VAS) score, active forward elevation (AFE), external rotation (AER), and abduction (AABD), at a minimum 2-year follow-up. There was a significant correlation between both DSA (r = 0.299, p = 0.020) and LSA (r = −0.276, p = 0.033) and the degree of AFE at final follow-up. However, no correlation between DSA (r = 0.133, p = 0.317) and LSA (r = −0.096, p = 0.471) and AER was observed. Postoperative AHD demonstrated a significant correlation with final AFE (r = 0.398, p = 0.002) and SST (r = 0.293, p = 0.025). Further, postoperative LHO showed a significant correlation with ASES (r = −0.281, p = 0.030) and LSA showed a significant correlation with ASES (r = −0.327, p = 0.011), SANE (r = −0.308, p = 0.012), SST (r = −0.410, p = 0.001), and VAS (r = 0.272, p = 0.034) at terminal follow-up. All other correlations were found to be non-significant (p &gt, 0.05, respectively). Negligible correlations between pre- and postoperative radiographic measurements and clinical outcomes following primary rTSA using a 135° prosthesis design were demonstrated, however, these observations are of limited predictive value for outcomes following rTSA. Subsequently, there remains a debate regarding the ideal placement of the components during rTSA to most sufficiently restore active ROM while minimizing complications such as component loosening and scapular notching. Additionally, as the data from this study show, there is still a considerable lack of data in assessing radiographic prosthesis positioning in correlation to clinical outcomes. As such, the importance of radiographic measurements and their correlation with clinical and functional outcomes following rTSA may be limited.

Objectives: Individuals with an anterior cruciate ligament (ACL) injury are at high risk of developing posttraumatic osteoarthritis (PTOA). A comprehensive study is needed to determine the time course of joint tissue metabolic changes occurring following ACL injury and reconstruction (ACLR). The purpose of this longitudinal nested comparison-control study was to simultaneously evaluate serum biomarkers of inflammation and cartilage matrix damage in ACL injured patients prior to ACLR and 6 and 12 months post-ACLR, as well as in matched uninjured controls. Methods: Serum was collected from 34 ACL injured individuals (53% female, 20.7±2.4 years old, 24.2±4.1 body mass index [BMI]) within 14 days of primary ACL injury (baseline), as well as at 6 and 12 months following bone-patellar-tendon-bone autograft ACLR. Serum was also collected from 34 uninjured matched controls (53% Female, 20.5±2.4 years old, 24.1±3.5 BMI) at a single timepoint. Blood was collected from the antecubital fossa, centrifuged and stored at -80°C prior to batch analysis. Commercial enzyme-linked immunosorbent assays were used to evaluate concentrations of: 1) a pro-inflammatory cytokine [Monocyte Chemoattractant Protein; MCP-1]; 2) a matrix degrading enzyme [matrix metalloproteinase-3; MMP-3]; 3) a cartilage breakdown biomarker [cartilage oligomeric matrix protein; COMP]; and type-II collagen turnover [type-II collagen cleavage: synthesis; C2C:CPII]. Separate Bonferroni-corrected independent t-tests were used to determine differences between the ACL injured group at each timepoint and uninjured controls for each biomarker (P ≤ 0.015). Similarly, separate Bonferroni-corrected dependent t-tests were used to determine differences in biomarker concentrations over time for the ACLR group. Results: Serum concentrations of MCP-1 and COMP were greater in the ACL injured individuals at all timepoints compared to the controls (P ≤ 0.015, Table 1), yet no differences were found over time in the ACL injured group. MMP-3 concentrations increased between baseline and 6 months post-ACLR (P ≤ 0.015, see Table), yet no differences were found between 6 and 12 months post-ACLR, between baseline and 12 months, or between ACLR and controls at any of the time points. C2C:CPII was not different between ACL injured individuals and controls at baseline or 6 months post-ACLR. C2C:CPII was significantly increased between 6 and 12 months-post ACLR, and was found to be greater than baseline and greater than controls at 12 months post-ACLR (P ≤ 0.015, see Table). Conclusion: Our study is critical in demonstrating the time course of multiple joint tissue metabolic changes following ACL injury and ACLR. Elevated serum MCP-1 and COMP concentrations, linked to early deleterious metabolic processes associated with PTOA development, are evident soon after ACL injury and persist at 12 months post-ACLR. Serum MMP-3 concentrations were elevated 6 months post-ACLR compared to the baseline measurements, suggesting factors occurring after ACLR initiate upregulation of matrix degrading enzymes. Furthermore, elevated C2C:CPII occurs within the first 12 months post ACLR but not until after the 6-month post-ACLR timepoint. Further studies are needed to determine how long these joint tissue metabolic changes persist after ACL injury and ACLR, as well as how joint tissue metabolism is affected by the type and timing of different surgical and nonsurgical treatments.

Background:Articular cartilage health is an important issue following anterior cruciate ligament (ACL) injury and primary ACL reconstruction. Factors present at the time of primary ACL reconstruction may influence the subsequent progression of articular cartilage damage.Hypothesis:Larger meniscus resection at primary ACL reconstruction, increased patient age, and increased body mass index (BMI) are associated with increased odds of worsened articular cartilage damage at the time of revision ACL reconstruction.Study Design:Case-control study; Level of evidence, 3.Methods:Subjects who had primary and revision data in the databases of the Multicenter Orthopaedics Outcomes Network (MOON) and Multicenter ACL Revision Study (MARS) were included. Reviewed data included chondral surface status at the time of primary and revision surgery, meniscus status at the time of primary reconstruction, primary reconstruction graft type, time from primary to revision ACL surgery, as well as demographics and Marx activity score at the time of revision. Significant progression of articular cartilage damage was defined in each compartment according to progression on the modified Outerbridge scale (increase ≥1 grade) or >25% enlargement in any area of damage. Logistic regression identified predictors of significant chondral surface change in each compartment from primary to revision surgery.Results:A total of 134 patients were included, with a median age of 19.5 years at revision surgery. Progression of articular cartilage damage was noted in 34 patients (25.4%) in the lateral compartment, 32 (23.9%) in the medial compartment, and 31 (23.1%) in the patellofemoral compartment. For the lateral compartment, patients who had >33% of the lateral meniscus excised at primary reconstruction had 16.9-times greater odds of progression of articular cartilage injury than those with an intact lateral meniscus ( P < .001). For the medial compartment, patients who had Conclusion:Excision of the medial and lateral meniscus at primary ACL reconstruction increases the odds of articular cartilage damage in the corresponding compartment at the time of revision ACL reconstruction. Increased age is a risk factor for deterioration of articular cartilage in both tibiofemoral compartments, while increased BMI and the use of allograft for primary ACL reconstruction are associated with an increased risk of progression in the patellofemoral compartment.

To identify and quantify patient- and procedure-related risk factors for post-arthroscopic knee infections using a large dataset.An administrative health care database including 8 years of records from 2 large commercial insurers and Medicare (a 5% random sample) was queried to identify all knee arthroscopies performed on patients aged at least 15 years using Current Procedural Terminology (CPT) codes. Each CPT code was designated as a high- or low-complexity procedure, with the former typically requiring accessory incisions or increased operative time. Deep infections were identified by a CPT code for incision and drainage within 90 days of surgery. Superficial infections were identified by International Classification of Diseases, Ninth Revision infection codes without any record of incision and drainage. Patients were compared based on age, sex, body mass index, tobacco use, presence of diabetes, and Charlson Comorbidity Index.A total of 526,537 patients underwent 595,083 arthroscopic knee procedures. Deep postoperative infections occurred at a rate of 0.22%. Superficial infections occurred at a rate of 0.29%. Tobacco use and morbid obesity were the largest risk factors for deep and superficial infections, respectively (P.001; relative risk of 1.90 and 2.19, respectively). There were also higher infection rates among patients undergoing relatively high-complexity arthroscopies, men, obese patients, diabetic patients, and younger patients (in order of decreasing relative risk). Increased Charlson Comorbidity Index was associated with superficial and total infections (P.001).Post-arthroscopic knee infections were more frequent among morbidly obese patients, tobacco users, patients undergoing relatively complex procedures, men, obese patients, diabetic patients, relatively young patients, and patients with increased comorbidity burdens in this study population. This knowledge may allow more informed preoperative counseling, aid surgeons in patient selection, and facilitate infection prevention by targeting individuals with higher inherent risk.Level IV, cross-sectional study.

Rotator cuff tears have a lifetime incidence between 25% and 40% in the United States, but optimum treatment strategies and protocol have not yet been widely accepted. This study evaluated the proportions of patients treated with nonoperative and operative modalities and how this proportion has changed during an 8-year period (2005-2012) among patients with Medicare.Using the PearlDiver patient record database, we identified Medicare patients having been diagnosed with a rotator cuff tear. These patients were then stratified on the basis of treatment with physical therapy, subacromial/glenohumeral injection, or rotator cuff repair. We analyzed the data in regard to standard demographic information, comorbidities, and the Charlson Comorbidity Index.During the study period, 878,049 patients were identified and 397,116 patients had rotator cuff repair. The proportion of patients treated initially with physical therapy dropped from 30.0% in 2005 to 13.2% in 2012, and the subacromial/glenohumeral injection proportion decreased from 6.00% to 4.19% (P .001). The proportion of patients who had rotator cuff repair increased from 33.8% to 40.4% from 2005 to 2012 (P .001). Charlson Comorbidity Indexes were significantly lower in operative patients compared with each nonoperative treatment examined.This analysis demonstrates a significant decrease in the initial trial of nonoperative treatment and an increase in the rate of surgery. Patients undergoing rotator cuff repair had fewer comorbidities than those undergoing nonoperative treatments. It also demonstrates that patients who had a trial of injection had a higher incidence of eventual rotator cuff repair compared with the patients with an initial trial of physical therapy.

Supplemental material, DS_10.1177_0363546519856348 for Relationship Between Sports Participation After Revision Anterior Cruciate Ligament Reconstruction and 2-Year Patient-Reported Outcome Measures in The American Journal of Sports Medicine

Background:Revision anterior cruciate ligament (ACL) reconstruction has been documented to have worse outcomes compared with primary ACL reconstructions.Purpose/Hypothesis:The purpose of this study was to determine if the prevalence, location, and/or degree of meniscal and chondral damage noted at the time of revision ACL reconstruction predicts activity level, sports function, and osteoarthritis symptoms at 2-year follow-up. The hypothesis was that meniscal loss and high-grade chondral damage noted at the time of revision ACL reconstruction will result in lower activity levels, decreased sports participation, more pain, more stiffness, and more functional limitation at 2 years after revision surgery.Study Design:Cohort study; Level of evidence, 2.Methods:Between 2006 and 2011, a total of 1205 patients who underwent revision ACL reconstruction by 83 surgeons at 52 hospitals were accumulated for study of the relationship of meniscal and articular cartilage damage to outcome. Baseline demographic and intraoperative data, including the International Knee Documentation Committee (IKDC) subjective knee evaluation, Knee injury and Osteoarthritis Outcome Score (KOOS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Marx activity score, were collected initially and at 2-year follow-up to test the hypothesis. Regression analysis was used to control for age, sex, body mass index, smoking status, activity level, baseline outcome scores, revision number, time since last ACL reconstruction, incidence of having a previous ACL reconstruction on the contralateral knee, previous and current meniscal and articular cartilage injury, graft choice, and surgeon years of experience to assess the meniscal and articular cartilage risk factors for clinical outcomes 2 years after revision ACL reconstruction.Results:At 2-year follow-up, 82% (989/1205) of the patients returned their questionnaires. It was found that previous meniscal injury and current articular cartilage damage were associated with the poorest outcomes, with prior lateral meniscectomy and current grade 3 to 4 trochlear articular cartilage changes having the worst outcome scores. Activity levels at 2 years were not affected by meniscal or articular cartilage pathologic changes.Conclusion:Prior lateral meniscectomy and current grade 3 to 4 changes of the trochlea were associated with worse outcomes in terms of decreased sports participation, more pain, more stiffness, and more functional limitation at 2 years after revision surgery, but they had no effect on activity levels.Registration:NCT00625885

The use of arthroscopy for purely diagnostic purposes has been largely supplanted by noninvasive technologies, such as magnetic resonance imaging (MRI). The mi-eye+TM (Trice Medical) technology is a small-bore needle unit for in-office arthroscopy. We conducted a pilot study comparing the mi-eye⁺™ unit with MRI, using surgical arthroscopy as a gold-standard reference. We hypothesized that the mi-eye⁺™ needle arthroscope, which can be used in an office setting, would be equivalent to MRI for the diagnosis of intra-articular pathology of the knee. This prospective, multicenter, observational study was approved by the Institutional Review Board. There were 106 patients (53 males, 53 females) in the study. MRIs were interpreted by musculoskeletally trained radiologists. The study was conducted in the operating room using the mi-eye⁺™ device. The mi-eye⁺™ device findings were compared with the MRI findings within individual pathologies, and a "per-patient" analysis was performed to compare the arthroscopic findings with those of the mi-eye⁺™ and the MRI. Additionally, we identified all mi-eye⁺™ findings and MRI findings that exactly matched the surgical arthroscopy findings. The mi-eye⁺™ demonstrated complete accuracy of all pathologies for 97 (91.5%) of the 106 patients included in the study, whereas MRI demonstrated complete accuracy for 65 patients (61.3%) (P < .0001). All discrepancies between mi-eye⁺TM and arthroscopy were false-negative mi-eye⁺™ results, as the mi-eye⁺TM did not reveal some aspect of the knee's pathology for 9 patients. The mi-eye⁺™ was more sensitive than MRI in identifying meniscal tears (92.6% vs 77.8%; P = .0035) and more specific in diagnosing these tears (100% vs 41.7%; P < .0001). The mi-eye⁺™ device proved to be more sensitive and specific than MRI for intra-articular findings at time of knee arthroscopy. Certainly there are contraindications to using the mi-eye⁺™, and our results do not obviate the need for MRI, but our study did demonstrate that the mi-eye⁺™ needle arthroscope can safely provide excellent visualization of intra-articular knee pathology.

Background: Revision anterior cruciate ligament (ACL) reconstruction has been documented to have worse outcomes compared with primary ACL reconstruction. Hypothesis: Certain factors under the control of the surgeon at the time of revision surgery can both negatively and positively affect outcomes. Study Design: Case-control study; Level of evidence, 3. Methods: Patients undergoing revision ACL reconstruction were identified and prospectively enrolled between 2006 and 2011. Data collected included baseline demographics, intraoperative surgical technique and joint disorders, and a series of validated patient-reported outcome instruments (International Knee Documentation Committee [IKDC] subjective form, Knee Injury and Osteoarthritis Outcome Score [KOOS], Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC], and Marx activity rating scale) completed before surgery. Patients were followed up for 2 years and asked to complete an identical set of outcome instruments. Regression analysis was used to control for age, sex, body mass index (BMI), activity level, baseline outcome scores, revision number, time since last ACL reconstruction, and a variety of previous and current surgical variables to assess the surgical risk factors for clinical outcomes 2 years after revision ACL reconstruction. Results: A total of 1205 patients (697 male [58%]) met the inclusion criteria and were successfully enrolled. The median age was 26 years, and the median time since their last ACL reconstruction was 3.4 years. Two-year follow-up was obtained on 82% (989/1205). Both previous and current surgical factors were found to be significant contributors toward poorer clinical outcomes at 2 years. Having undergone previous arthrotomy (nonarthroscopic open approach) for ACL reconstruction compared with the 1-incision technique resulted in significantly poorer outcomes for the 2-year IKDC ( P = .037; odds ratio [OR], 2.43; 95% CI, 1.05-5.88) and KOOS pain, sports/recreation, and quality of life (QOL) subscales ( P ≤ .05; OR range, 2.38-4.35; 95% CI, 1.03-10.00). The use of a metal interference screw for current femoral fixation resulted in significantly better outcomes for the 2-year KOOS symptoms, pain, and QOL subscales ( P ≤ .05; OR range, 1.70-1.96; 95% CI, 1.00-3.33) as well as WOMAC stiffness subscale ( P = .041; OR, 1.75; 95% CI, 1.02-3.03). Not performing notchplasty at revision significantly improved 2-year outcomes for the IKDC ( P = .013; OR, 1.47; 95% CI, 1.08-1.99), KOOS activities of daily living (ADL) and QOL subscales ( P ≤ .04; OR range, 1.40-1.41; 95% CI, 1.03-1.93), and WOMAC stiffness and ADL subscales ( P ≤ .04; OR range, 1.41-1.49; 95% CI, 1.03-2.05). Factors before revision ACL reconstruction that increased the risk of poorer clinical outcomes at 2 years included lower baseline outcome scores, a lower Marx activity score at the time of revision, a higher BMI, female sex, and a shorter time since the patient’s last ACL reconstruction. Prior femoral fixation, prior femoral tunnel aperture position, and knee flexion angle at the time of revision graft fixation were not found to affect 2-year outcomes in this revision cohort. Conclusion: There are certain surgical variables that the physician can control at the time of revision ACL reconstruction that can modify clinical outcomes at 2 years. Whenever possible, opting for an anteromedial portal or transtibial surgical exposure, choosing a metal interference screw for femoral fixation, and not performing notchplasty are associated with significantly better 2-year clinical outcomes.

Background: While revision anterior cruciate ligament reconstruction (ACLR) can be performed to restore knee stability and improve patient activity levels, outcomes after this surgery are reported to be inferior to those after primary ACLR. Further reoperations after revision ACLR can have an even more profound effect on patient satisfaction and outcomes. However, there is a current lack of information regarding the rate and risk factors for subsequent surgery after revision ACLR. Purpose: To report the rate of reoperations, procedures performed, and risk factors for a reoperation 2 years after revision ACLR. Study Design: Case-control study; Level of evidence, 3. Methods: A total of 1205 patients who underwent revision ACLR were enrolled in the Multicenter ACL Revision Study (MARS) between 2006 and 2011, composing the prospective cohort. Two-year questionnaire follow-up was obtained for 989 patients (82%), while telephone follow-up was obtained for 1112 patients (92%). If a patient reported having undergone subsequent surgery, operative reports detailing the subsequent procedure(s) were obtained and categorized. Multivariate regression analysis was performed to determine independent risk factors for a reoperation. Results: Of the 1112 patients included in the analysis, 122 patients (11%) underwent a total of 172 subsequent procedures on the ipsilateral knee at 2-year follow-up. Of the reoperations, 27% were meniscal procedures (69% meniscectomy, 26% repair), 19% were subsequent revision ACLR, 17% were cartilage procedures (61% chondroplasty, 17% microfracture, 13% mosaicplasty), 11% were hardware removal, and 9% were procedures for arthrofibrosis. Multivariate analysis revealed that patients aged Conclusion: There was a significant reoperation rate after revision ACLR at 2 years (11%), with meniscal procedures most commonly involved. Independent risk factors for subsequent surgery on the ipsilateral knee included age

Background: Most surgeons believe that graft choice for anterior cruciate ligament (ACL) reconstruction is an important factor related to outcome; however, graft choice for revision may be limited due to previously used grafts. Hypotheses: Autograft use would result in increased sports function, increased activity level, and decreased osteoarthritis symptoms (as measured by validated patient-reported outcome instruments). Autograft use would result in decreased graft failure and reoperation rate 2 years after revision ACL reconstruction. Study Design: Cohort study; Level of evidence, 2. Methods: Patients undergoing revision ACL reconstruction were identified and prospectively enrolled by 83 surgeons at 52 sites. Data collected included baseline demographics, surgical technique, pathologic abnormalities, and the results of a series of validated, patient-reported outcome instruments (International Knee Documentation Committee [IKDC], Knee injury and Osteoarthritis Outcome Score [KOOS], Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC], and Marx activity rating score). Patients were followed up at 2 years and asked to complete the identical set of outcome instruments. Incidences of additional surgery and reoperation due to graft failure were also recorded. Multivariate regression models were used to determine the predictors (risk factors) of IKDC, KOOS, WOMAC, Marx scores, graft rerupture, and reoperation rate at 2 years after revision surgery. Results: A total of 1205 patients (697 [58%] males) were enrolled. The median age was 26 years. In 88% of patients, this was their first revision, and 341 patients (28%) were undergoing revision by the surgeon who had performed the previous reconstruction. The median time since last ACL reconstruction was 3.4 years. Revision using an autograft was performed in 583 patients (48%), allograft was used in 590 (49%), and both types were used in 32 (3%). Questionnaire follow-up was obtained for 989 subjects (82%), while telephone follow-up was obtained for 1112 (92%). The IKDC, KOOS, and WOMAC scores (with the exception of the WOMAC stiffness subscale) all significantly improved at 2-year follow-up ( P < .001). In contrast, the 2-year Marx activity score demonstrated a significant decrease from the initial score at enrollment ( P < .001). Graft choice proved to be a significant predictor of 2-year IKDC scores ( P = .017). Specifically, the use of an autograft for revision reconstruction predicted improved score on the IKDC ( P = .045; odds ratio [OR] = 1.31; 95% CI, 1.01-1.70). The use of an autograft predicted an improved score on the KOOS sports and recreation subscale ( P = .037; OR = 1.33; 95% CI, 1.02-1.73). Use of an autograft also predicted improved scores on the KOOS quality of life subscale ( P = .031; OR = 1.33; 95% CI, 1.03-1.73). For the KOOS symptoms and KOOS activities of daily living subscales, graft choice did not predict outcome score. Graft choice was a significant predictor of 2-year Marx activity level scores ( P = .012). Graft rerupture was reported in 37 of 1112 patients (3.3%) by their 2-year follow-up: 24 allografts, 12 autografts, and 1 allograft and autograft. Use of an autograft for revision resulted in patients being 2.78 times less likely to sustain a subsequent graft rupture compared with allograft ( P = .047; 95% CI, 1.01-7.69). Conclusion: Improved sports function and patient-reported outcome measures are obtained when an autograft is used. Additionally, use of an autograft shows a decreased risk in graft rerupture at 2-year follow-up. No differences were noted in rerupture or patient-reported outcomes between soft tissue and bone–patellar tendon–bone grafts. Surgeon education regarding the findings of this study has the potential to improve the results of revision ACL reconstruction.

Background: Bankart repair with multiple anchor holes concentrated in the anterior-inferior glenoid may contribute to glenoid weakening and potentially may induce glenoid failure. Purpose: To compare the biomechanical strength of a Bankart repair construct that used 3 single-loaded suture anchors versus a repair construct that used 2 double-loaded suture anchors. Study Design: Comparative laboratory study. Methods: A standard Bankart lesion was created in 18 human cadaveric shoulders (9 matched pairs). Within each matched pair, 1 repair construct used 3 single-loaded anchors, whereas the other used 2 double-loaded suture anchors. Measured outcomes (load, stiffness, and energy absorbed) were recorded at failure and at 2 mm of labral displacement. Constructs were loaded to failure with a materials testing device that had differential variable reluctance transducers for displacement measurements. Results: The double-loaded anchor construct had a significantly higher ultimate tensile load (944 ± 231 vs 784 ± 287 N; P = .03). For the other measures (load at 2 mm of displacement, energy absorbed at failure and at 2 mm of displacement and stiffness), there were no significant differences between tested constructs. Conclusion: A Bankart repair construct that used 2 double-loaded anchors was either superior to or equal to a repair construct that used 3 single-loaded anchors in all measured outcomes. Clinical Relevance: Using 2 double-loaded suture anchors for a Bankart repair may limit anchor holes in the glenoid and reduce the risk of postsurgical glenoid fracture while providing a stable repair construct.

BACKGROUND: Patients have high reinjury rates after ACL reconstruction. Small knee flexion angles and large peak posterior ground reaction forces in landing tasks increase ACL loading. QUESTIONS/PURPOSES: We determined the effects of a knee extension constraint brace on knee flexion angle, peak posterior ground reaction force, and movement speed in functional activities of patients after ACL reconstruction. PATIENTS AND METHODS: Six male and six female patients 3.5 to 6.5 months after ACL reconstruction participated in the study. Three-dimensional videographic and force plate data were collected while patients performed level walking, jogging, and stair descent wearing a knee extension constraint brace, wearing a nonconstraint brace, and not wearing a knee brace. Knee flexion angle at initial foot contact with the ground, peak posterior ground reaction force, and movement speed were compared across brace conditions and between genders. RESULTS: Wearing the knee extension constraint brace increased the knee flexion angle at initial foot contact for each activity when compared with the other two brace conditions. Wearing the knee extension constraint brace also decreased peak posterior ground reaction force during walking but not during jogging and stair descent. CONCLUSIONS: Although the knee extension constraint brace did not consistently reduce the peak posterior ground reaction force in all functional activities, it consistently increased knee flexion angle and should reduce ACL loading as suggested by previous studies. These results suggest the knee extension constraint brace has potential as a rehabilitation tool to alter lower extremity movement patterns of patients after ACL reconstruction to address high reinjury rates.

Subscapularis dysfunction following total shoulder arthroplasty can result in permanent loss of function. The lesser tuberosity osteotomy (LTO) has been proposed as a method which utilizes bone-to-bone healing to improve subscapularis function. This study evaluates the biomechanical properties of two described techniques for LTO repair. We hypothesized that a Dual Row repair would be stronger and demonstrate less cyclic displacement than a Backpack repair.Ten matched pairs of cadaveric humeri were dissected, leaving the subscapularis intact, and a lesser tuberosity osteotomy was performed. Matched shoulders were randomized to either a Backpack repair or a Dual Row repair. Repairs were subjected to cyclic loading to 180 N for 500 cycles, followed by ramp-up loading to ultimate failure. Clinical failure was defined as displacement5 mm after 500 cycles.Displacement after 500 cycles was significantly greater for the Backpack repair (6.9 mm) than for the Dual Row repair (4.6 mm) (P = .007). Most displacement occurred on the first cycle (Backpack, 4.6 mm; Dual Row, 2.1 mm) (P.001). There was a trend toward a higher clinical failure rate for the Backpack repair (8/10) than the Dual Row repair (3/10). Ultimate tensile strength was significantly greater for the Dual Row repair (632.3 N) than for the Backpack repair (510.9 N) (P = .01).The Dual Row technique is significantly stronger and demonstrates less cyclic displacement than the Backpack technique. Clinical studies are needed to determine the impact of LTO repair technique on subscapularis function following shoulder arthroplasty.

Background:Tendon mechanical properties have been used to evaluate the effects of therapies on the healing of animal tendons, but these measures have not been convenient to record in vivo in humans due to their invasive nature. The aims of this study were to assess the capability of an ultrasonography technique to track the change in stiffness of the healing human patellar tendon and to assess the correlation between stiffness parameters and clinical recovery measurements.Method:Ten subjects undergoing anterior cruciate ligament reconstruction with a patellar tendon autograft were recruited for the study as well as 10 healthy control subjects. The surgical tendons' mechanical properties were evaluated at 2 and 6 months after surgery with a two-scan ultrasonography technique. A paired sign-rank test was performed to compare the change in biomechanical parameters and clinical recovery measurements across time between surgical and control groups.Results:Tendon stiffness of the surgical group increased from ~71% to ~94% when compared to the stiffness of the contralateral tendons at the first visit; however, the difference was not significant (P= 0.18). Significant improvements were shown in all the clinical recovery outcomes. Poor correlation was found between the clinical recovery measurements and tendon stiffness.Conclusions:No significant change in patellar tendon stiffness with healing was detected over the 2–6 month period after surgery, suggesting the tendon stiffness recovery in humans proceeds more slowly than other clinical measures.

The purpose of this paper is to review the management of long head biceps tendon pathology, with a particular emphasis on a prior failed biceps tenotomy or tenodesis. Failed biceps tenotomy generally results from a lack of thorough preoperative discussion of potential outcomes rather than from technical problems. Patients with unsatisfactory results can be treated with conversion to a biceps tenodesis. Failed biceps tenodesis is usually recognized with persistent pain in the area of the bicipital groove, often caused by either the mechanical failure of the tenodesis or associated shoulder pathology that is not addressed at the time of the primary surgery. Operative treatment options include revision tenodesis or biceps tenotomy. The subpectoral approach provides excellent versatility and ability to meet technical objectives when performing revision tenodesis, by removing the tendon completely from the groove and preserving biceps function.

Acute isolated rupture of the patellar tendon traditionally has been repaired via transpatellar suture tunnels. This retrospective study evaluated the demographics and epidemiology of this injury as well as the effectiveness and complication rates of our suture anchor technique. Between 1993 and 2005, a total of 82 cases of patellar tendon disruption in 71 patients were repaired. Fourteen cases involved basic primary repair with suture anchors of an acute isolated rupture of the patellar tendon and had an average follow-up of 29 months (range: 3-112 months). There were 3 (21%) failures of repair. The remaining 11 patients had excellent range of motion and strength and returned to their preoperative level of function. These results are comparable with other reports in the literature. The suture anchor technique thus represents a viable option for repair of patellar tendon ruptures and should be investigated further with a randomized, controlled trial.

To measure the influence of humeral torsion on interpretation of clinical indicators of posterior shoulder tightness in overhead athletes.Cross-sectional control group comparison.A university-based sports medicine research laboratory.Twenty-nine healthy intercollegiate baseball players and 25 college-aged control individuals with no history of participation in overhead athletics were enrolled.In all participants, bilateral humeral rotation and humeral horizontal adduction variables were measured with a digital inclinometry. Bilateral humeral torsion was measured with ultrasonography.Group and limb comparisons were made for clinical indicators of posterior shoulder tightness (humeral rotation and horizontal adduction variables) and humeral torsion variables. The relationship between humeral torsion and clinical indicators of posterior shoulder tightness were established.The dominant limb of the baseball players demonstrated greater humeral torsion, and less internal rotation and total rotation range of motion, compared with control participants and the nondominant limb in both groups. Once corrected for torsion, no group or limb differences in internal rotation were present. Statistically significant relationships existed between the amount of humeral torsion and measures of posterior shoulder tightness.Although limb differences in clinical indicators of posterior tightness exist in healthy overhead athletes, these measures appear to be influenced by humeral torsion rather than soft tissue tightness. Once torsion is accounted for, the limb differences observed clinically were minimal in healthy overhead athletes. When possible, accounting for humeral torsion when interpreting clinical measures of posterior shoulder tightness may aid in treatment decisions.

Instability of the shoulder is a common problem treated by many orthopaedists. Instability can result from baseline intrinsic ligamentous laxity or a traumatic event-often a dislocation that injures the stabilizing structures of the glenohumeral joint. Many cases involve soft-tissue injury only and can be treated successfully with repair of the labrum and ligamentous tissues. Both open and arthroscopic approaches have been well described, with recent studies of arthroscopic soft-tissue techniques reporting results equal to those of the more traditional open techniques. Over the last decade, attention has focused on the concept of instability of the shoulder mediated by bony pathology such as a large bony Bankart lesion or an engaging Hill-Sachs lesion. Recent literature has identified unrecognized large bony lesions as a primary cause of failure of arthroscopic reconstruction for instability, a major cause of recurrent instability, and a difficult diagnosis to make. Thus, although such bony lesions may be relatively rare compared with soft-tissue pathology, they constitute a critically important entity in the management of shoulder instability. Smaller bony lesions may be amenable to arthroscopic treatment, but larger lesions often require open surgery to prevent recurrent instability. This article reviews recent developments in the diagnosis and treatment of bony instability.

One proposed mechanism of tendon lengthening is the "sliding fibril" hypothesis, in which tendons lengthen through the sliding of discontinuous fibrils after release of decorin-fibronectin interfibrillar bonds. The pentapeptide NKISK has been reported to inhibit the binding of decorin, a proteoglycan on the surface of collagen fibrils, to fibronectin, a tissue adhesion molecule, which are thought to play a role in interfibrillar binding. Prior investigations have demonstrated that NKISK produces in vivo tendon lengthening. This study investigates the effect of potential clinically applicable NKISK injection regimens in an in vivo model. One hundred and thirteen male Sprague-Dawley rats were divided into 15 different treatment groups, each receiving percutaneous patellar tendon injections of NKISK, QKTSK (a "nonsense" pentapeptide), or PBS of varying volumes, concentrations, and injection schedules. Following sacrifice, the patellar tendon lengths were measured in all groups, and biomechanical testing was performed with comparisons made to the contralateral, untreated control limbs. Tendon lengthening was significantly greater (p < or = 0.05) in nearly all NKISK-treated tendons as compared to PBS- and QKTSK-treated tendons and was dose-dependent. Measured lengthening was less in rats whose sacrifice was delayed following the final injection of NKISK, which likely indicates recontraction of lengthened tendons, but they remained significantly longer than the controls. Biomechanical testing did not reveal significant differences in ultimate load, modulus, stiffness, or displacement. This study demonstrates that NKISK given in clinically plausible dosing regimens produces dose-dependent tendon lengthening in an in vivo setting with minimal effects on the mechanical properties of the treated tendons.

The objective of this study was to utilise an ultrasonic technique to assess the effect of patellofemoral pain syndrome (PFPS) on the mechanical properties of the patellar tendon. Seven subjects with PFPS and seven matched control subjects volunteered to participate in this study. Subjects were asked to perform isometric maximal voluntary contractions of the knee extensors while their knee extension torque was monitored and the displacement of the patellar tendon was recorded with an ultrasonic system. Our results showed significantly lower tendon stiffness (by ∼30%) in the PFPS subjects. Although tendon secant modulus was lower by 34% in the PFPS subjects, the difference was not statistically significant. Therefore, we conclude that the ultrasonic technique was able to detect a decrease in the structural stiffness of the patellar tendon associated with PFPS. The decrease in tendon stiffness was moderately correlated with the length of symptoms in these individuals.

ABSTRACT A humeral head impression fracture, more commonly known as a Hill-Sachs lesion, can play an important role in recurrent anterior shoulder instability. Lesions that are large enough and in the appropriate alignment to engage the anterior glenoid rim may require surgical treatment to reestablish functional shoulder stability. These lesions are occasionally treated with bone graft- ing, usually performed via an anterior deltopectoral ap- proach. We describe our Bhybrid( technique of treating this lesion via arthroscopic capsulolabral repair coupled with an open posterior approach to the humeral head, which involves splitting the posterior deltoid and the infraspinatus muscles. We also provide an illustrative ex- ample of a case in which this technique was used.

Background Biomechanical analysis of stop-jump tasks has demonstrated gender differences during landing and a potential increase in risk of noncontact anterior cruciate ligament injury for female athletes. Analysis of landing preparation could advance our understanding of neuromuscular control in movement patterns and be applied to the development of prevention strategies for noncontact anterior cruciate ligament injury. Hypothesis There are differences in the lower extremity joint angles and electromyography of male and female recreational athletes during the landing preparation of a stop-jump task. Study Design Controlled laboratory study. Methods Three-dimensional videographic and electromyographic data were collected for 36 recreational athletes (17 men and 19 women) performing vertical stop-jump tasks. Knee and hip angular motion patterns were determined during the flight phase before landing. Results Knee and hip motion patterns and quadriceps and hamstring activation patterns exhibited significant gender differences. Female subjects generally exhibited decreased knee flexion (P = .001), hip flexion (P = .001), hip abduction (P = .001), and hip external rotation (P = .03); increased knee internal rotation (P = .001); and increased quadriceps activation (P = .001) compared with male subjects. Female subjects also exhibited increased hamstring activation before landing but a trend of decreased hamstring activation after landing compared with male subjects (P = .001). Conclusion Lower extremity motion patterns during landing of the stop-jump task are preprogrammed before landing. Female subjects prepared for landing with decreased hip and knee flexion at landing, increased quadriceps activation, and decreased hamstring activation, which may result in increased anterior cruciate ligament loading during the landing of the stop-jump task and the risk for noncontact ACL injury.

Loss of motion of the knee is a challenging dilemma to both the patient and the treating physician. The causes of arthrofibrosis are many but can usually be traced to a traumatic event, intra-articular/ligament knee surgery, knee arthroplasty, and possibly sepsis. Prevention is the best form of treatment, but when this entity does present, early recognition and a supervised physical therapy program are often successful. If conservative treatment fails, operative intervention is warranted. The purpose of this article is to discuss how to appropriately evaluate a patient with loss of knee motion, understand the pathogenesis and classification of arthrofibrosis, review our operative technique and postoperative management of these difficult patients, review the results in the literature concerning arthrofibrosis, and make the reader aware of possible concerns and the future direction of treatment of patients with arthrofibrosis.

The medial collateral ligament (MCL) is one of the most extensively studied ligaments in our literature. This is due to the fact that it is the most commonly injured ligament of the knee and it is easily defined and mechanically studied in animal models. The purpose of this article is to (1) review the MCL' s response to injury, (2) evaluate the ligament's injury variables, and (3) take an in depth look at treatment options including past, present, and future.

Despite the marked advances in treatment and highly predictable success of anterior cruciate ligament (ACL) reconstruc- tion, an approximate 10% to 15% failure rate is noted in the literature. The mechanism of failure is often difficult to ascertain and is often multifactorial. A strong patient-physician relationship must be estab- lished to proceed with revision ACL reconstruction. After the deci- sion has been made to proceed with revision ACL reconstruction extensive preoperative planning is warranted. Revision ACL recon- tructions are a ''salvage'' procedure to allow the patient to perform activities of daily living. A return to sports is a possibility, but the patient's expectations should be realistic and individualized. This article focuses on the surgical technique of revision anterior cruciate ligament reconstruction with patellar tendon allograft.

The purpose of this study was to objectively assess glenohumeral volume changes after arthroscopic suture plication, arthroscopic thermal capsulorrhaphy, and combined suture and thermal treatment.Cadaveric study.Five matched pairs of cadaver shoulders were treated with either thermal capsulorrhaphy (n = 5) or arthroscopic suture plication (n = 5). The shoulders treated with plication were then treated with thermal capsulorrhaphy to form a combined treatment group (plication and thermal). Preoperative and postoperative glenohumeral volume measurements were obtained, and the techniques were statistically compared with a 1-factor analysis of variance.All 3 procedures produced marked decreases in glenohumeral capsular volume. Suture plication reduced intra-articular volume an average of 19.0%. Thermal capsulorrhaphy resulted in a mean capsular volume reduction of 33.4%. Combined treatment with suture plication and thermal capsulorrhaphy reduced glenohumeral volume an average of 41.0%. Both thermal capsulorrhaphy and the combined treatment produced significantly greater reduction in glenohumeral volume than plication alone (P.0001). Although combined suture plication and thermal capsulorrhaphy resulted in greater reduction in capsular volume than thermal capsulorrhaphy alone, the differences were not statistically significant.Our results indicate that arthroscopic suture plication and thermal capsulorrhaphy are both effective in reducing glenohumeral intra-articular volume. Thermal capsulorrhaphy alone or in combination with suture plication led to significantly greater reduction in capsular volume when compared with isolated suture plication.

Background: Graft survivorship, reinjury rates, and career length are poorly understood after anterior cruciate ligament (ACL) reconstruction in the elite collegiate athlete. The purpose of this study was to examine the outcomes of ACL reconstruction in a National Collegiate Athletic Association (NCAA) Division I athlete cohort. Study Design: Case series; Level of evidence, 4. Methods: A retrospective chart review was performed of all Division I athletes at a single public university from 2000 to 2009 until completion of eligibility. Athletes were separated into 2 cohorts: those who underwent precollegiate ACL reconstruction (PC group) and those who underwent intracollegiate reconstruction (IC group). Graft survivorship, reoperation rates, and career length information were collected. Results: Thirty-five athletes were identified with precollegiate reconstruction and 54 with intracollegiate reconstruction. The PC group had a 17.1% injury rate with the original graft, with a 20.0% rate of a contralateral ACL injury. For the IC group, the reinjury rates were 1.9% with an ACL graft, with an 11.1% rate of a contralateral ACL injury after intracollegiate ACL reconstruction. The athletes in the PC group used 78% of their total eligibility (average, 3.11 years). The athletes in the IC group used an average of 77% of their remaining NCAA eligibility; 88.3% of those in the IC group played an additional non-redshirt year after their injury. The reoperation rate for the PC group was 51.4% and was 20.4% for the IC group. Conclusion: Reoperation and reinjury rates are high after ACL reconstruction in the Division I athlete. Precollegiate ACL reconstruction is associated with a very high (37.1%) rate of repeat ACL reinjuries to the graft or opposite knee. The majority of athletes are able to return to play after successful reconstruction.

Background: After failure of nonoperative treatment, repair has long been the primary treatment option for symptomatic superior labrum anterior and posterior (SLAP) lesions of the shoulder. There is growing evidence to support both biceps tenotomy and tenodesis as effective alternative treatments for SLAP lesions. Hypotheses: For patients with isolated SLAP lesions, the frequency of SLAP repair has decreased, while treatment with biceps tenodesis and tenotomy has increased. Similar trends are expected in patients with SLAP lesions undergoing concomitant rotator cuff repair. Study Design: Cohort study; Level of evidence, 3. Methods: A query of the American Board of Orthopaedic Surgery part II database was performed from 2002 to 2011. The database was searched for patients with isolated SLAP lesions undergoing SLAP repair, open biceps tenodesis, arthroscopic biceps tenodesis, or biceps tenotomy. The database was then queried a second time for patients undergoing arthroscopic rotator cuff repair with concomitant SLAP repair, biceps tenodesis, or biceps tenotomy. Results: From 2002 to 2011, there were 8963 cases reported for the treatment of an isolated SLAP lesion and 1540 cases reported for the treatment of SLAP lesions with concomitant rotator cuff repair. For patients with isolated SLAP lesions, the proportion of SLAP repairs decreased from 69.3% to 44.8% ( P < .0001), while biceps tenodesis increased from 1.9% to 18.8% ( P < .0001), and biceps tenotomy increased from 0.4% to 1.7% ( P = .018). For patients undergoing concomitant rotator cuff repair, SLAP repair decreased from 60.2% to 15.3% ( P < .0001), while biceps tenodesis or tenotomy increased from 6.0% to 28.0% ( P < .0001). There was a significant difference in the mean age of patients undergoing SLAP repair (37.1 years) versus biceps tenodesis (47.2 years) versus biceps tenotomy (55.7 years) ( P < .0001). Conclusion: Practice trends for orthopaedic board candidates indicate that the proportion of SLAP repairs has decreased over time, with an increase in biceps tenodesis and tenotomy. Increased patient age correlates with the likelihood of treatment with biceps tenodesis or tenotomy versus SLAP repair.