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PURPOSE OF REVIEW: Anterior cruciate ligament reconstruction (ACLR) is a common surgical procedure with an estimated 120,000 cases performed in the USA each year. Physical therapy plays a critical role in the successful recovery of both surgically and non-surgically managed patients. Interestingly, ACL rehabilitation protocols vary greatly with little consensus among practitioners. Nonetheless, there has been agreement over the last decade to shift from conservative, standardized length protocols to more accelerated, individualized protocols that vary in length and modalities based on patient-specific findings and preferences. This review summarizes the most recent trends, opinions, and modalities in ACL rehabilitation research, with a specific focus on novel methods to treat the specific psychosocial needs of ACL deficient patients. RECENT FINDINGS: We found that new protocols emphasize early weight bearing, open kinetic chain (OKC) exercises, and other alternative modalities such as neuromuscular electrical stimulation and blood flow restriction. We also found a recent trend toward the use of clinical milestones to determine when a patient is ready for the next phase of a “step-up” rehabilitation program. One particularly nascent topic of research is the inclusion of methods to treat the psychosocial impacts of ACL injury, recovery, and the anxiety around return to sport. SUMMARY: Rehabilitation strategy has become increasingly patient-dependent, and the new modalities being utilized are accelerating patient recovery. Return to sport is a particularly important factor for many ACLR patients, and recovery has an important psychological component that has only recently been addressed in the literature, with positive preliminary findings.

Long head biceps tendon pathology is a substantial contributor to anterior shoulder pain and often requires surgical intervention to offer a return to normal functionality. Surgical treatment options consist of both open and arthroscopic tenodesis or tenotomy of the long head biceps brachii. Several techniques exist for tenodesis and tenotomy of the biceps, although current debate continues regarding which surgical approach is the optimal intervention for symptomatic bicep pathology. In this technical note, we describe a subpectoral biceps tenodesis of the long head bicep tendon using an all-suture anchor. Our technique offers the advantages of using an all-suture anchor that incorporates a self-tensioning mechanism with direct visualization of the tendon during biceps tenodesis and anchor insertion.

Anterior talofibular ligament (ATFL) tear is the most common ankle ligament injury. This can lead to recurrent ankle instability, which is detrimental to ankle function and the patient's quality of life. Currently, several techniques have shown successful outcomes for ATFL repair. In this technical note, we describe an open ATFL repair using a single knotless suture anchor at the distal fibula location. This approach is rapid, equipment-efficient, and reproducible, while promising excellent results and high patient satisfaction by restoring ATFL anatomy.

Pathology of the long head of the biceps tendon is a known cause of anterior shoulder pain. Current surgical management options include tenotomy and tenodesis. Tenodesis can be performed arthroscopically or as an open procedure. Arthroscopic tenodesis typically uses a suprapectoral attachment, which may fail to address tendon pathology in the bicipital groove. Open tenodesis carries iatrogenic risk to neurovascular structures and a fracture risk while drilling, as well as the morbidity of an open procedure. This technique paper describes a mini-open subpectoral approach using a suture anchor and bone bridge backup for dual fixation. Use of a suture anchor instead of an interference screw reduces drill hole diameter reducing the risk of iatrogenic humeral fracture. Dual fixation provides a robust repair which may be of use for athletic patients desiring an accelerated recovery., Technique Video Video 1 Mini-open subpectoral biceps tenodesis using a suture anchor with a bone-bridge backup. The patient is positioned in a beach-chair position for the right shoulder for posterior portal visualization. The biceps anchor shows significant fraying at the superior labrum. The biceps tendon has avulsed from the anchor and is adhered to the anterior capsule of the glenohumeral joint. Through an anterior portal, a shaver is introduced to debride the superior labrum and any adhesions holding the biceps tendon to the anterior capsule. An incision is made at the anterior axillary space at the inferior border of the pectoralis major. While retracting the pectoralis major tendon superiorly, the long head of the biceps tendon (LHBT) can be palpated within the bicipital groove. After releasing the LHBT from the groove with electrocautery, the tendon is whipstitched with a FiberLink suture. The inferior bicipital groove is prepared with electrocautery and a Cobb elevator, and a 5.5-mm reamer is drilled unicortically at the approximated location of the tenodesis. Proximally, a 2.4-mm drill is used to create the bone bridge hole 5 mm superior to the tenodesis hole. The LHBT is sized using with a sizer on the 5.5-mm SwiveLock Anchor, the tails of the suture are loaded into the anchor. One tail is passed from the distal to proximal hole and the other tail is passed from the proximal to distal hole using a suture passing flag or nitinol micro suture lasso. With tension on the suture tails, the SwiveLock anchor is inserted and placed into tenodesis hole. Using a free needle, the suture tails are passed through the LHBT multiple times and are tied down, securing the tendon onto the tenodesis site.

The osteochondral autograft transfer system (OATS) procedure is at the forefront of cartilage restoration surgeries of the knee, offering superior return to sport rates and long-term functionality. This technique reports an arthroscopic OATS procedure of the lateral femoral condyle with donor-site backfill using an osteochondral allograft plug. Potential complications from unfilled donor site sockets are eliminated through donor site backfill with an allograft plug., Technique Video Video 1 Arthroscopic osteochondral autograft transfer system (OATS) procedure of the lateral femoral condyle using allograft donor site backfill. The Arthrex Single-Use 2.0 OATS set for articular cartilage transfer and graft harvest of 10 mm osteochondral defects is our primary surgical instrument. The anterolateral portal of the operative knee is needle localized with an 18 gauge spinal needle perpendicular to the osteochondral defect of the lateral femoral condyle. A 10 × 15 mm autograft plug is then harvested from the medial trochlear edge of the medial femoral condyle donor site under direct arthroscopic visualization. Two 90˚ turns, clockwise and counterclockwise, are performed with the harvester before disengagement and autograft harvest withdrawal. The hollowed donor site of the medial femoral condyle is then backfilled with a precut osteochondral allograft plug and flushed adequately into the articular surface. After backfill insertion with the allograft plug, a guide pin is drilled perpendicular into the osteochondral defect of the lateral femoral condyle. A cannulated reamer, perpendicular and in line with the guide pin, is used to advance to the appropriate depth within the subchondral bone of the osteochondral defect. The harvested autograft plug from the medial femoral condyle donor site is then impacted into the hollowed recipient site with a clear cannula and implanted within 1 to 1.5 mm of the articular surface. Last, a soft tamp is used to firmly advance the donor plug until a flush chondral surface is observed.

Numerous techniques exist for arthroscopic subscapularis repair with varying degrees of complexity based on tear morphology, all of which have established satisfactory outcomes in function and patient satisfaction. Arthroscopic subscapularis repair can require several working portals and suture anchors, increasing both technical complexity and operative time. This Technical Note describes an arthroscopic repair of a superior one-third subscapularis tear using a self-punching knotless soft suture anchor through a single anterior working portal. Thus, we offer a unique approach to arthroscopic repair of superior one-third subscapularis tears that is time-saving, reproducible, and highly efficient while minimizing iatrogenic damage and postoperative complications., Technique Video Video 1 Arthroscopic single-portal and single-anchor superior third subscapularis repair. Patient is positioned in the right lateral decubitus position, and the left shoulder is visualized through the posterior portal. A superior third subscapularis tear is visualized, and the subscapularis is properly debrided prior to repair. Through a single anterior portal, a knotless 2.6-mm Fibertak Soft anchor with a self-punching mechanism from Arthrex is used to pierce the subscapularis tendon 1 cm proximal to the lateral edge of the tear. The anchor is malletted into the lesser tuberosity of the humerus to the laser line, while maintaining proper length-tension relationship of the subscapularis. The self-punching mechanism is removed, leaving three suture tails (1 blue and 2 black) through the cannula. The self-bunching mechanism of the anchor is deployed by pulling firmly on the blue suture anchor. A grasper is used to retrieve the blue no. 5 FiberWire suture around the subscapularis and through the anterior cannula. The surgeon then passes the tail of the blue no. 5 FiberWire suture through the shuttling loop of black suture. The nonlooped end of the black shuttling suture is gently pulled, guiding the blue no. 5 FiberWire suture through the subscapularis tendon and the soft suture anchor and back out of the anterior cannula. Through direct visualization, the surgeon is able to apply tension to the repair suture as necessary. Once the surgeon has applied appropriate tension to the repair, excess suture is removed with a suture cutter.

Background It is important to distinguish satisfaction regarding the outcome of care and satisfaction with the delivery of care. The Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys are modern assessments of hospitals and providers of delivery of care. The purpose of this study was to report inpatient satisfaction according to Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) scores after shoulder arthroplasty and to determine factors that influence them, as well as their correlation with surgical expectations, pain perception, quality of life, surgical setting, and functional outcomes. Methods All patients scheduled for a shoulder arthroplasty were prospectively asked to complete a demographic and initial shoulder assessment form, a shoulder surgery expectations survey, a pain catastrophizing scale, the SF-12 (12-item Short Form) survey, and a resiliency form (Resilience Scale 11). Patient satisfaction was measured with the CG-CAHPS and HCAHPS surveys. Legacy forms, patient-specific factors, type of surgery performed, location of surgery, length of hospital stay, and discharge disposition were evaluated on their ability to predict these survey scores. Linear regression was used to calculate correlations and predictions of continuous variables, and logistic regression was used to compared the satisfied vs. unsatisfied cohorts. Results The average HCAHPS and CG-CAHPS satisfaction scores for the population were 74.7 ± 20.7 and 82.1 ± 19.4, respectively. Nonsmokers had a mean HCAHPS score of 77.7 ± 22.0, whereas current smokers reported a mean of 59.6 ± 5.2 (P = .03). Patients who were discharged home had a mean HCAHPS score of 77.3 ± 21.9, whereas those discharged to a skilled nursing facility reported a mean of 59.3 ± 6.6 (P = .05). These same groups also had significantly higher odds of being satisfied with the hospital. No significant differences or higher odds were seen for comparisons between overall CG-CAHPS satisfaction and any of the patient-specific factors tested. There was no significant correlation between age, length of stay, pain (pain catastrophizing scale), resiliency (Resilience Scale 11), expectations (shoulder surgery expectations survey), or function (SF-12) and both the HCAHPS and CG-CAHPS satisfaction scores. Conclusion Overall, 37 patients (74%) had CG-CAHPS scores that indicated satisfaction and 34 patients (68%) had HCAHPS scores that indicated satisfaction. Nonsmokers and patients discharged home after surgery report higher levels of inpatient hospital (HCAHPS) satisfaction after shoulder arthroplasty. Patients with high preoperative surgical expectations, pain perception, and resiliency are not generally more satisfied with the hospital or clinician. Preoperative diagnosis, location of surgery, and length of stay do not reliably impact satisfaction with the hospital or clinician. Inpatient HCAHPS and CG-CAHPS satisfaction does not correlate with legacy functional outcome measures and, therefore, may not be predictive of long-term functional outcomes.

Football exposes its players to traumatic brain, neck, and spinal injury. It is unknown whether the adolescent football player develops imaging abnormalities of the brain and spine that are detectable on magnetic resonance imaging (MRI). The objective of this observational study was to identify potential MRI signatures of early brain and cervical spine (c-spine) injury in high school football players. Eighteen football players (mean age, 17.0 ± 1.5 years; mean career length, 6.3 ± 4.0 years) had a baseline brain MRI, and 7 had a follow-up scan 9-42 months later. C-spine MRIs were performed on 11 of the 18 subjects, and 5 had a follow-up scan. C-spine MRIs from 12 age-matched hospital controls were also retrospectively retrieved. Brain MRIs were reviewed by a neuroradiologist, and no cerebral microbleeds were detected. Three readers (a neuroradiologist, a neurosurgeon, and an orthopedic spine surgeon) studied the cervical intervertebral discs at six different cervical levels and graded degeneration using an established five-grade scoring system. We observed no statistically significant difference in disc degeneration or any trend toward increased disc degeneration in the c-spine of football players as compared with age-matched controls. Further research is needed to validate our findings and better understand the true impact of contact sports on young athletes.

Peroneal tendon subluxation often occurs because of sudden dorsiflexion of the ankle, leading to a traumatic rupture of the superior peroneal retinaculum. Currently, there are several surgical techniques to deepen the fibular groove, but there is no universally accepted gold standard. This technique article describes a fibular groove deepening with preservation of the fibrocartilage in conjunction with repair of the superior peroneal retinaculum. Addressing the main pathologies that may be leading to subluxation of the peroneal tendons, we offer an approach that avoids many of the common pitfalls from previously proposed techniques while preserving the natural fibrocartilage within the malleolar groove and repairing the retinaculum.