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Background: The meniscal roots are essential for preserving the structural and biomechanical properties of the tibiofemoral joint. Posterior meniscal root avulsions can cause meniscal extrusion, joint space narrowing, and progressive knee arthritis. Iatrogenic avulsions after malpositioning of the transtibial tunnels during anterior cruciate ligament (ACL) reconstruction have previously been reported in the literature to account for poor long-term outcomes seen in some patients following ACL reconstruction. Therefore, correct transtibial tunnel placement during ACL reconstruction is essential to avoid iatrogenic meniscal damage. Indication: Patients are indicated for surgery when presenting with a verified, symptomatic, complete meniscal root tear seen on advanced imaging or diagnostic arthroscopy. Contraindications for a root repair include the development of advanced osteoarthritis in the ipsilateral compartment, older age, and malalignment in the affected compartment. Technique Description: The ACL graft was appreciated and noted to be vertical and posterior relative to its native anatomical position, violating the lateral posterior horn root attachment. A full lateral posterior meniscal root avulsion was then confirmed directly adjacent to the graft tunnel. A curette was used to prepare the footprint of the lateral meniscal root on the posterolateral tibia for the 2-tunnel transtibial pull-out tunnels, and a grasper was used to position the torn meniscal root back into its anatomical site. Two ultrabraided sutures were passed through the posterior horn of the lateral meniscus using a suture passer. These were then passed through the tunnels into the body of the meniscal root and reduced to its native anatomical position. The suture repair was then secured over an Endobutton Fixation Device at 90° of knee flexion through each tunnel into its native anatomical position while confirming its adequate tension by viewing arthroscopically. Results: Within 2 years postoperatively, patients are expected to have improved overall knee-specific quality of life, reduced pain, and a successful return to activities. Discussion/Conclusion: This injury underscores the importance of an accurate tibial tunnel placement during ACL reconstruction to avoid posterior meniscal root injuries and other associated complications. Physicians should consider such pathology in the differential diagnosis of patients presenting with persistent pain and instability following a primary ACL reconstruction. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Background: Rotator cuff repair using graft augmentation for large-to-massive, full-thickness rotator cuff tears has been reported to have improved clinical outcomes relative to other therapeutic interventions. Although an effective and promising technique, graft augmentation can be technically challenging, particularly with deployment and positioning of the graft. CuffMend is a user-friendly rotator cuff augmentation technique that combines a decellularized dermal allograft with a novel graft deployment device, tendon anchor, and set of lateral knotless, tension-able anchors to allow for a reliable and stable implantation of the graft. Indications: Graft augmentation using CuffMend is indicated for tears with a high risk of retear or incomplete healing. This includes revision tears, poor-quality degenerative tissue, and massive full-thickness rotator cuff tears. Severe glenohumeral osteoarthritic change is the primary contraindication to this technique. Technique Description: The rotator cuff is reduced medially and secured using 3 anchors with sutures passed in a mattress configuration. Graft augmentation is then performed using the CuffMend graft spreader that facilitates placement and attachment of the graft onto the repaired tendon. Results: The patient is recovering as expected and started physical therapy 1 month postoperatively. He is able to perform light activities of daily living and reach the top of his head for daily self-care without pain. He will begin strengthening at 12 weeks postoperatively. Discussion/Conclusion: CuffMend is a new graft augmentation technique that uses a novel graft deployment device for consistent and precise deployment of a decellularized dermal allograft. This facilitates an expedited repair using the graft augmentation technique for optimal clinical and biomechanical outcomes in patients with rotator cuff tears with high risk of retear.

Background: Meniscal root tears are radial tears occurring at or within 1 cm of the meniscal root attachment. These injuries have been shown to be the biomechanical equivalent of a total meniscectomy and are thought to be responsible for a rapid progression of osteoarthritis if left untreated. Indications: Meniscal root repair is indicated if possible, with the exception of patients who have diffuse Outerbridge 3-4 osteoarthritis of the ipsilateral compartment, those who are poor surgical candidates due to age or medical comorbidity, or in whom nonsymptomatic tears are found incidentally. Technique Description: Standard 2-portal arthroscopy is performed. Once a medial root tear has been identified and concomitant pathology has been addressed, we typically begin the repair by trephinating the deep medial collateral ligament with an 18-gauge needle to enhance visualization and avoid iatrogenic cartilage injury. Arthroscopic shaver is used to debride the meniscal root as needed. A meniscal root guide is introduced into the joint and an incision is made on the anteromedial tibia for outside-in drilling of a transosseous tunnel. Drilling is performed with a 5-mm retroreaming device, and a 10-mm socket is created. Nonabsorbable suture is then passed through the meniscus using a self-capture device in an inverted mattress configuration, following by 2 cinch stitches. The sutures are then shuttled into the transosseous tunnel, and the meniscal root is reduced and tensioned in full extension, with the sutures being fixated into a suture anchor on the anteromedial tibia. Results: A recent large systematic review of 1086 patients undergoing treatment of meniscal root tear via either debridement or nonoperative management compared with meniscal repair found that conversion to total knee arthroplasty occurred in 11% to 54% of those managed via debridement or nonoperative care versus 0% to 1% for those with root repair. Discussion/Conclusion: Currently, meniscal root repair offers the greatest improvement and lowest risk of conversion to arthroplasty following meniscal root tear. The present technique offers a durable repair that we believe combines ease of execution with decreased risk of suture pull-out, by creating a ripstop-type construct. Long-term outcome studies are needed for this and other root repair techniques.

Background: Surgical repair of chronic quadriceps tendon ruptures can be daunting, especially after failure of a prior repair. In this setting, tissue quality is usually poor, necessitating graft augmentation. In this video, we describe our technique for Achilles tendon allograft augmentation for revision quadriceps tendon repair. Indications: Failed quadriceps tendon repair defined as ongoing extensor mechanism deficit including patella baja, functional deficit, or palpable quadriceps defect with confirmed retear on advanced imaging. Technique Description: Patient is placed in the supine position, and a midline incision is extended to the tibial tubercle. Full thickness medial and lateral flaps are raised, nonviable scar tissue is excised, and suprapatellar adhesions are released to ensure full mobilization of the viable remnant quadriceps. A plane is then developed deep to the patellar tendon paratenon from proximal to distal. A reamer is used to prepare a socket just medial to the tibial tubercle. The calcaneal bone block of the Achilles allograft is fashioned to match the recipient site on the tibia with a sagittal saw. The graft is shuttled deep to the paratenon, and the bone plug is fixed to the tibia with an interference screw. Suture from the patellar anchors is then used to place 2 running Krackow stitches spanning the remnant quadriceps tendon proximally. The remnant tissue is subsequently reduced and tied with an anchor pull-through technique. The soft tissue component of the Achilles graft is laid over the repair and oversewn with free nonabsorbable suture. Patient is placed in a brace locked in extension for 6 weeks and allowed to be weight bearing as tolerated. Results: Long-term patient-reported outcomes of Achilles allograft reconstruction for revision extensor mechanism repairs are limited. Two studies of 17 reconstructions each reported this to be a reliable and durable option at a mean follow-up of 65 and 52 months, respectively. Discussion/Conclusion: Revision surgery for extensor mechanism deficits can be a challenging procedure. Our preference is to perform augmentation with Achilles allograft with bone plug fixation on the tibial side. This allows for augmentation of the entire extensor mechanism, as well as bone-to-bone healing on the tibial side.

Background: Proximal hamstring injuries are increasingly common. While open repair with suture anchors placed in the ischial tuberosity has long been the gold standard technique for surgical management, endoscopic techniques can allow for smaller incisions, reduced wound complications, and an expedited recovery. Indications: Patients with full-thickness 3-tendon proximal hamstring tears, 2-tendon tears with retraction >2 cm, or partial tears that remain symptomatic despite conservative management are considered for surgery. High-demand patients are often treated acutely, and low-demand patients may be offered surgery after a conservative management period. Technique Description: In the prone position, 2 arthroscopic portals are created in the gluteal fold. Fluoroscopy is used to verify safe portal placement, and the sciatic nerve is visualized along with the retracted tendon origin. The ischial tuberosity is identified, and the hamstring origin is debrided and decorticated. An accessory portal is created for suture anchor placement. Two double-loaded anchors are placed in the tuberosity, the sutures of which are used to repair the hamstring tendons using a horizontal mattress configuration. Patients undergo a stepwise postoperative physical therapy protocol. Results: An 85% return to sport rate can be expected following all hamstring repairs, with some studies reporting as high as 95% after endoscopic repair. Compared with nonoperative treatment, proximal hamstring repair overall results in higher patient satisfaction and return to sport. While large studies have yet to report on outcomes compared with the traditional open technique, the smaller incisions look to reduce wound complications and postoperative pain. Discussion/Conclusion: Recent advancements in endoscopic techniques have allowed for adequate visualization and robust repair of proximal hamstring avulsions. We present our endoscopic technique of the proximal hamstring, which, compared with the traditional open repair, can decrease perioperative complications and accelerate recovery.

Category: Ankle, Ankle Arthritis Introduction/Purpose: Opiate pain medication is frequently prescribed following foot and ankle surgery for post-operative pain management. Opioid abuse has now reached epidemic levels and unfortunately become an all too common occurrence following small prescriptions of opiate pain medication. Total ankle arthroplasty and ankle fusion are two commonly performed procedures for the treatment of ankle arthritis. Understanding postoperative pain medication requirements following these procedures is useful both in the counseling of patients pre-operatively as well as in assisting surgeons with the management of postoperative pain. We aim to examine patient opioid usage following total ankle arthroplasty compared to ankle fusion and assess for potential clinical factors associated with increased post-operative opioid use. Methods: Adult patients (over 18 years of age) undergoing total ankle arthroplasty or ankle fusion were identified using CPT codes (27700, 27702, 27870, 29899) to query the Pearl Diver patient record database, a private insurance database. 1127 patients undergoing total ankle arthroplasty and 2695 patients undergoing ankle fusion were identified. Demographic data including age, sex, and medical history was collected. Patients were examined for opioid usage at pre-operative, 1-month, 3-month, 6-month, and 1-year time points. Post-operative complications and need for revision procedures within 1-year were also examined. Multivariate logistic regression analysis was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs) with p