American Journal of Sports Medicine

ACL or ACL+

31-01-2020 – Bruce Reider

Editorial

Lateral Extra-articular Tenodesis Reduces Failure of Hamstring Tendon Autograft Anterior Cruciate Ligament Reconstruction: 2-Year Outcomes From the STABILITY Study Randomized Clinical Trial

15-01-2020 – Alan M.J. Getgood,Dianne M. Bryant,Robert Litchfield,Mark Heard,Robert G. McCormack,Alex Rezansoff,Devin Peterson,Davide Bardana,Peter B. MacDonald,Peter C.M. Verdonk,Tim Spalding,Kevin Willits,Trevor Birmingham,Chris Hewison,Stacey Wanlin,Andrew Firth,Ryan Pinto,Ashley Martindale,Lindsey O’Neill,Morgan Jennings,Michal Daniluk,Dory Boyer,Mauri Zomar,Karyn Moon,Raely Pritchett,Krystan Payne,Brenda Fan,Bindu Mohan,Gregory M. Buchko,Laurie A. Hiemstra,Sarah Kerslake,Jeremy Tynedal,Greg Stranges,Sheila Mcrae,LeeAnne Gullett,Holly Brown,Alexandra Legary,Alison Longo,Mat Christian,Celeste Ferguson,Nick Mohtadi,Rhamona Barber,Denise Chan,Caitlin Campbell,Alexandra Garven,Karen Pulsifer,Michelle Mayer,Nicole Simunovic,Andrew Duong,David Robinson,David Levy,Matt Skelly,Ajaykumar Shanmugaraj,Fiona Howells,Murray Tough,Tim Spalding,Pete Thompson,Andrew Metcalfe,Laura Asplin,Alisen Dube,Louise Clarkson,Jaclyn Brown,Alison Bolsover,Carolyn Bradshaw,Larissa Belgrove,Francis Millan,Sylvia Turner,Sarah Verdugo,Janet Lowe,Debra Dunne,Kerri McGowan,Charlie-Marie Suddens,Geert Declercq,Kristien Vuylsteke,Mieke Van Haver

Journal Article

Persistent anterolateral rotatory laxity after anterior cruciate ligament (ACL) reconstruction (ACLR) has been correlated with poor clinical outcomes and graft failure. We hypothesized that a single-bundle, hamstring ACLR in combination with a lateral extra-articular tenodesis (LET) would reduce the risk of ACLR failure in young, active individuals. Randomized controlled trial; Level of evidence, 1. This is a multicenter, prospective, randomized clinical trial comparing a single-bundle, hamstring tendon ACLR with or without LET performed using a strip of iliotibial band. Patients 25 years or younger with an ACL-deficient knee were included and also had to meet at least 2 of the following 3 criteria: (1) grade 2 pivot shift or greater, (2) a desire to return to high-risk/pivoting sports, (3) and generalized ligamentous laxity (GLL). The primary outcome was ACLR clinical failure, a composite measure of rotatory laxity or a graft rupture. Secondary outcome measures included the P4 pain scale, Marx Activity Rating Scale, Knee injury Osteoarthritis and Outcome Score (KOOS), International Knee Documentation Committee score, and ACL Quality of Life Questionnaire. Patients were reviewed at 3, 6, 12, and 24 months postoperatively. A total of 618 patients (297 males; 48%) with a mean age of 18.9 years (range, 14-25 years) were randomized. A total of 436 (87.9%) patients presented preoperatively with high-grade rotatory laxity (grade 2 pivot shift or greater), and 215 (42.1%) were diagnosed as having GLL. There were 18 patients lost to follow-up and 11 who withdrew (~5%). In the ACLR group, 120/298 (40%) patients sustained the primary outcome of clinical failure, compared with 72/291 (25%) in the ACLR+LET group (relative risk reduction [RRR], 0.38; 95% CI, 0.21-0.52; The addition of LET to a single-bundle hamstring tendon autograft ACLR in young patients at high risk of failure results in a statistically significant, clinically relevant reduction in graft rupture and persistent rotatory laxity at 2 years after surgery. NCT02018354 ( Clinical
Trials.gov identifier).

Anterior Cruciate Ligament Reconstruction in High School and College-Aged Athletes: Does Autograft Choice Influence Anterior Cruciate Ligament Revision Rates?

09-01-2020 – Kurt P. Spindler,Laura J. Huston,Alexander Zajichek,Emily K. Reinke,Annunziato Amendola,Jack T. Andrish,Robert H. Brophy,Warren R. Dunn,David C. Flanigan,Morgan H. Jones,Christopher C. Kaeding,Robert G. Marx,Matthew J. Matava,Eric C. McCarty,Richard D. Parker,Armando F. Vidal,Michelle L. Wolcott,Brian R. Wolf,Rick W. Wright

Journal Article

Physicians’ and patients’ decision-making process between bone-patellar tendon-bone (BTB) and hamstring tendon autografts for anterior cruciate ligament (ACL) reconstruction (ACLR) may be influenced by a variety of factors in the young, active athlete. To determine the incidence of both ACL graft revisions and contralateral ACL tears resulting in subsequent ACLR in a cohort of high school- and college-aged athletes who initially underwent primary ACLR with either a BTB or a hamstring autograft. Cohort study; Level of evidence, 2. Study inclusion criteria were patients aged 14 to 22 years who were injured in sports, had a contralateral normal knee, and were scheduled to undergo unilateral primary ACLR with either a BTB or a hamstring autograft. All patients were prospectively followed for 6 years to determine whether any subsequent ACLR was performed in either knee after their initial ACLR. Multivariable regression modeling controlled for age, sex, ethnicity/race, body mass index, sport and competition level, baseline activity level, knee laxity, and graft type. The 6-year outcomes were the incidence of subsequent ACLR in either knee. A total of 839 patients were eligible, of which 770 (92%) had 6-year follow-up for the primary outcome measure of the incidence of subsequent ACLR. The median age was 17 years, with 48% female, and the distribution of BTB and hamstring grafts was 492 (64%) and 278 (36%), respectively. The incidence of subsequent ACLR at 6 years was 9.2% in the ipsilateral knee, 11.2% in the contralateral normal knee, and 19.7% for either knee. High-grade preoperative knee laxity (odds ratio [OR], 2.4 [95% confidence interval [CI], 1.4-3.9]; There was a high incidence of both ACL graft revisions and contralateral normal ACL tears resulting in subsequent ACLR in this young athletic cohort. The incidence of ACL graft revision at 6 years after index surgery was 2.1 times higher with a hamstring autograft compared with a BTB autograft.

More Than a 2-Fold Risk of Contralateral Anterior Cruciate Ligament Injuries Compared With Ipsilateral Graft Failure 10 Years After Primary Reconstruction

07-01-2020 – Alberto Grassi,Luca Macchiarola,Gian Andrea Lucidi,Federico Stefanelli,Mariapia Neri,Annamaria Silvestri,Francesco Della Villa,Stefano Zaffagnini

Journal Article

Failure of anterior cruciate ligament (ACL) reconstruction or an injury to the ACL in the contralateral knee represents a devastating event for patients, especially those young and physically active. However, controversies are still present regarding long-term failure rates and risk factors. To assess the long-term rate of ipsilateral graft failure and contralateral ACL injuries after ACL reconstruction performed at a single center using the same surgical technique with a hamstring autograft and to investigate the effect of sex, age, and preinjury activity level as predictors of second ACL injuries. Case series; Level of evidence, 4. The study cohort consisted of 244 consecutive patients (mean age, 30.7 years) who underwent ACL reconstruction with a single bundle plus lateral plasty technique using the hamstring tendon between November 2007 and May 2009. The number of subsequent ACL injuries (ipsilateral ACL revision or contralateral ACL reconstruction) was determined at a minimum follow-up of 10 years. Survivorship of either knee and subgroup analysis included sex, age, preoperative Tegner activity level, timing of ACL reconstruction, body mass index, and smoking status. Ipsilateral ACL revision was performed in 8 (3.4%) patients and contralateral ACL reconstruction in 19 (7.8%) patients. Only 1 patient had both ipsilateral and contralateral injuries. No predictors were found for ipsilateral ACL revision, while age <18 years and preoperative Tegner level ≥7 had a higher risk of contralateral ACL reconstruction. The highest rate of a second ACL reconstruction procedure was in young (<18 years) and active (Tegner ≥7) patients, in whom the 10-year survival of either knee was 61.1%. Six years after primary ACL reconstruction, the rate of contralateral ACL reconstruction was significantly higher than that of ipsilateral ACL revision (hazard ratio, 2.4-3.6). In the long term, a second injury to either the ipsilateral or the contralateral knee in young and active populations could reach 40%, with a more than double-fold risk of contralateral ACL reconstruction compared with ipsilateral ACL revision.

Morphologic Variants of Posterolateral Tibial Plateau Impaction Fractures in the Setting of Primary Anterior Cruciate Ligament Tear

04-01-2020 – David L. Bernholt,Nicholas N. DePhillipo,W. Jeffrey Grantham,Matthew D. Crawford,Zachary S. Aman,Mitchell Iung Kennedy,Robert F. LaPrade

Journal Article

Impaction fractures of the posterolateral tibial plateau commonly occur in the setting of anterior cruciate ligament (ACL) tears, with considerable variability found in fracture size and morphologic features. The primary objective was to characterize different morphologic variants of posterolateral tibial plateau impaction fractures. The secondary objective was to investigate the association between these impaction fracture variants and concomitant meniscal and ligamentous injuries. Cross-sectional study; Level of evidence 3. Patients treated for primary ACL tears and having magnetic resonance imaging available were included in this study, and magnetic resonance images were reviewed with denotation of displaced posterolateral tibial impaction fractures. A classification system was created based on morphologic variants of impaction fractures; associations were evaluated through use of independent chi-square testing. There were 825 knees meeting the inclusion criteria, with displaced posterolateral tibial plateau impaction fractures present in 407 knees (49.3%). We observed 3 distinct morphologic variants of lateral tibial plateau impaction fractures: (I) posterior cortical buckle not involving the articular surface; (II) posterior impaction fracture involving the articular surface, with subtypes based on (A) tibial plateau depth bone loss 10%; and (III) displaced osteochondral fragment, with subtypes for (A) shear or (B) depressed fragment. Type IIIA impaction fractures were associated with an increased incidence of lateral meniscus posterior root tears (33.3% vs 12.4%; A high prevalence of displaced posterolateral tibial plateau impaction fractures occur in the setting of ACL tears, and they can be classified into distinct morphologic subtypes. Posterolateral tibial plateau impaction fractures with displaced depressed or shear fragments were both associated with an increased incidence of lateral meniscal tears, whereas impaction fractures with a shear fragment were associated with an increased incidence of lateral meniscus posterior root tears and MCL tears.

Absolute Meniscal Extrusion After Lateral Meniscal Allograft Transplantation Does Not Progress During Long-term Follow-up: Average of 10.3 Years’ Follow-up Longitudinal Magnetic Resonance Imaging Study

11-12-2019 – Sang-Min Lee,Seong-Il Bin,Jong-Min Kim,Bum-Sik Lee,Jun-Gu Park

Journal Article

Long-term outcomes after lateral meniscal allograft transplantation (MAT) are not completely understood. We investigated changes in meniscal extrusion in the coronal and sagittal planes using magnetic resonance imaging (MRI) after lateral MAT through long-term follow-up. We hypothesized that meniscal extrusion would progress during follow-up. Case series; Level of evidence, 4. Patients subjected to lateral MAT were followed up by MRI evaluation in both planes at 1, 4 to 6, and >8 years after MAT. Meniscal extrusion and entire meniscal widths in the coronal plane and anterior (ACMD) and posterior (PCMD) cartilage meniscal distances in the sagittal plane were measured, and values were compared at each time point. Clinical outcomes were evaluated using the Lysholm score. A total of 27 lateral MATs were included with a mean MRI follow-up period of 10.3 years (range, 8.1-15.3 years). The mean absolute meniscal extrusion (coronal plane) was not significantly different at each time point. However, the relative value differed (0.27 ± 0.04 at 1 year; 0.33 ± 0.06 at >8 years after MAT) owing to entire meniscal width reduction. There was no difference in the mean absolute value of the ACMD in the sagittal plane. However, relative values differed (0.21 ± 0.01 at 1 year; 0.27 ± 0.06 at >8 years) owing to entire meniscal width reduction. Absolute and relative values of the PCMD remained unaffected at each time point. The Lysholm score increased after surgery but did not differ postoperatively. During the long-term follow-up of extrusion after lateral MAT using MRI, absolute extrusion remained unchanged across all planes. Relative extrusion in the coronal plane and of the ACMD in the sagittal plane significantly increased, with no differences in the PCMD on follow-up. Clinical outcomes after surgery improved compared with those before surgery and were maintained throughout the long-term follow-up period.

Posterior Medial Meniscus Root Tears Potentiate the Effect of Increased Tibial Slope on Anterior Cruciate Ligament Graft Forces

10-12-2019 – Brian T. Samuelsen,Zachary S. Aman,Mitchell Iung Kennedy,Grant J. Dornan,Hunter W. Storaci,Alex W. Brady,Travis Lee Turnbull,Robert F. LaPrade

Journal Article

Increased posterior tibial slope and posterior medial meniscus root tears increase the force experienced by the anterior cruciate ligament (ACL) and predispose patients to higher rates of primary ACL injury or ACL graft failure after an ACL reconstruction (ACLR). However, the interplay among sagittal plane tibial slope, medial meniscus root tears, and ACLR graft force remains inadequately defined. The purpose was to quantify the effect of sagittal plane tibial slope on ACLR graft force at varying knee flexion angles with an intact medial meniscus, a posterior medial meniscus root tear, and a medial meniscus root repair. Our null hypothesis was that changes in slope and meniscal state would have no effect on the forces experienced by the ACLR graft. Controlled laboratory study. Ten male fresh-frozen cadaveric human knees underwent a posteriorly based high tibial osteotomy. A spanning external fixator and wedges of varying sizes were used to stabilize the osteotomy and allow for accurate slope adjustment. After ACLR, specimens were compressed with a 1000-N axial load at flexion angles of 0° and 30° for each of the 3 meniscal states and at tibial slopes of 0° to 15° at 3° increments. Graft loads were recorded through a force transducer clamped to the graft. Increasing tibial slope led to a linear increase in ACLR graft force at 0° and 30° of knee flexion. Posterior medial meniscus root tear led to significant increases in ACLR graft forces over the intact state, while root repair restored the function of the medial meniscus as a secondary stabilizer. At 30° of knee flexion, the tibial slope effect on ACLR graft force was potentiated in the root tear state as compared with the intact and root repair states-test of interaction effect: Increases in tibial slope lead to a linear increase in ACLR graft forces, and this effect is magnified in the setting of a posterior medial meniscus root tear. At slopes >12°, a slope-changing osteotomy could be considered in the setting of a revision ACLR with a concomitant medial meniscus root tear. Defining the relationship between tibial slope and varying states of meniscal insufficiency can help determine when it may be necessary to perform a slope-decreasing proximal tibial osteotomy before ACLR and meniscal repair.

Patellofemoral Pain in Adolescents: Understanding Patellofemoral Morphology and Its Relationship to Maltracking

13-12-2019 – Cameron N. Fick,Camila Grant,Frances T. Sheehan

Journal Article

Developing bone is highly adaptable and, as such, is susceptible to pathological shape deformation. Thus, it is imperative to quantify if changes in patellofemoral morphology are associated with adolescent-onset patellofemoral pain, as a pathway to improve our understanding of this pain’s etiology. To quantify and compare patellofemoral morphology in adolescent patients with patellofemoral pain with matched healthy adolescent controls and determine if a relationship exists between patellofemoral shape and kinematics (measured during active flexion-extension). Cross-sectional study; Level of evidence, 3. Using 3-dimensional static magnetic resonance images acquired during a previous study, we measured patellar, trochlear, and lateral patellar width; trochlear and patellar depth; Wiberg index; patellar-height ratio; lateral trochlear inclination; cartilage length; and lateral femoral shaft length. Student Relative to controls, adolescents with patellofemoral pain had larger sulci (mean ± SD, 6.6 ± 0.7 vs 6.0 ± 1.1 mm; 95% CI, 0.6 mm; This study provides direct evidence that patellofemoral morphology is altered and influences maltracking in adolescents with patellofemoral pain, highlighting the multifactorial etiology of this pain. Neither morphology nor kinematics (measured during active flexion-extension) correlated with pain. Both increases and decreases in these parameters likely lead to pain, negating a direct linear correlation.

Predictors of Pain, Function, and Change in Patellofemoral Pain

10-12-2019 – Alexandra Hott,Jens Ivar Brox,Are Hugo Pripp,Niels Gunnar Juel,Sigurd Liavaag

Journal Article

Identification of factors predictive of outcome and change is important to improve treatment for patellofemoral pain (PFP). Few studies have examined the predictive value of psychological factors in PFP, although they have been reported to be important predictors in other musculoskeletal pain conditions. To evaluate predictors of pain, function, and change 1 year after an exercise-based intervention in PFP. Cohort study; Level of evidence, 3. In sum, 112 patients were recruited to a randomized controlled trial; 98 attended 1-year follow-up. There were no between-group differences in the trial; thus, the material was analyzed as 1 cohort. Nine baseline factors-sex, bilateral pain, worst pain, pain duration, Anterior Knee Pain Scale (AKPS), kinesiophobia, anxiety and depression, self-efficacy, and number of pain sites throughout the body-were investigated for their predictive ability on outcome at 1 year (AKPS, worst pain) and for change at 1 year (global change score, change in AKPS, and change in worst pain). Multivariable linear regression models with stepwise backward removal method were used to find predictors of poor outcome. Number of pain sites at baseline was a significant predictor of worse outcome for AKPS ( Higher number of pain sites throughout the body was a consistent predictor of poor outcome and less change at 1 year. Baseline levels for AKPS and worst pain predicted respective final scores and change scores. NCT02114294 ( Clinical
Trials.gov identifier).

Rethinking Patellar Tendinopathy and Partial Patellar Tendon Tears: A Novel Classification System

08-01-2020 – Mikhail Golman,Margaret L. Wright,Tony T. Wong,T. Sean Lynch,Christopher S. Ahmad,Stavros Thomopoulos,Charles A. Popkin

Journal Article

Patellar tendinopathy is an overuse injury of the patellar tendon frequently affecting athletes involved in jumping sports. The tendinopathy may progress to partial patellar tendon tears (PPTTs). Current classifications of patellar tendinopathy are based on symptoms and do not provide satisfactory evidence-based treatment guidelines. To define the relationship between PPTT characteristics and treatment guidelines, as well as to develop a magnetic resonance imaging (MRI)-based classification system for partial patellar tendon injuries. Cohort study (prognosis); Level of evidence, 2. MRI characteristics and clinical treatment outcomes were retrospectively reviewed for 85 patients with patellar tendinopathy, as well as 86 physically active control participants who underwent MRI of the knee for other conditions. A total of 56 patients had a PPTT and underwent further evaluation for tear size and location. The relationship between tear characteristics and clinical outcome was defined with use of statistical comparisons and univariate and logistic regression models. Of the 85 patients, 56 had partial-thickness patellar tendon tears. Of these tears, 91% involved the posterior and posteromedial regions of the proximal tendon. On axial MRI views, patients with a partial tear had a mean tendon thickness of 10 mm, as compared with 6.2 mm for those without ( Partial-thickness tears are located posterior or posteromedially in the proximal patellar tendon. The most sensitive predictor for detecting the presence of a partial tear was patellar tendon thickness, in which thickness >8.8 mm was strongly correlated with a tear of the tendon. Tracking thickness changes on axial MRI may predict the effectiveness of nonoperative therapy: athletes with patellar tendon thickness >11.5 mm and/or >50% tear thickness on axial MRI were less likely to improve with nonoperative treatment. A novel proposed classification system for partial tears, the Popkin-Golman classification, can be used to guide treatment decisions for these patients.

Accuracy and Reliability of the Visual Assessment of Patellar Tracking

08-01-2020 – Matthew J. Best,Miho J. Tanaka,Shadpour Demehri,Andrew J. Cosgarea

Journal Article

Abnormal patellar tracking is described as a “J-sign” when the patella exhibits excessive lateral displacement during active knee extension. To determine (1) the accuracy and reliability of the visual assessment of patellar tracking when viewed by surgeons with patellofemoral expertise and (2) whether surgeon experience (in years) correlates with the ability to accurately identify the presence and severity of patellar maltracking. Cohort study (diagnosis); Level of evidence, 2. Using a web-based assessment, 32 orthopaedic surgeon members of the International Patellofemoral Study Group determined the presence or absence of maltracking (≥2 quadrants of lateral translation) in 10 single-knee videos of patients with patellar instability during active knee extension (qualitative analysis). Surgeons then graded patellar tracking in 20 single-knee videos as follows: 0 (<1 patellar quadrant of lateral translation), 1 (1 to <2 quadrants), 2 (2 to <3 quadrants), or 3 (≥3 quadrants) (quantitative analysis). Responses were compared with a previously described grading system using patellar bisect offset measured with 4-dimensional computed tomography. We evaluated the association between number of years of surgeon experience and the ability to correctly identify and grade patellar tracking. A total of 22 surgeons repeated the survey 3 months later, and their answers were matched to the first survey, allowing for assessment of intraobserver reliability. In the qualitative analysis, surgeons correctly identified videos as showing patellar maltracking 68% of the time (κ = 0.45). In the quantitative analysis, 53%, 51%, 48%, and 68% of surgeons correctly identified maltracking of grades 3, 2, 1, and 0, respectively (κ = 0.42). Surgeon experience did not correlate with ability to identify the presence ( Using visual assessment alone, surgeons correctly identified patellar maltracking in approximately two-thirds of videos and correctly graded patellar maltracking in half. Inter- and intraobserver reliability were inadequate to support the use of visual assessment alone for detecting the presence or grade of patellar maltracking. Surgeon experience did not correlate with ability to identify the presence or grade of patellar maltracking.

Psychometric Properties of the Hip–Return to Sport After Injury Scale (Short Form) for Evaluating Psychological Readiness to Return to Sports After Arthroscopic Hip Surgery

04-12-2019 – Denise M. Jones,Kate E. Webster,Kay M. Crossley,Ilana N. Ackerman,Harvi F. Hart,Parminder J. Singh,Michael G. Pritchard,Gauguin Gamboa,Joanne L. Kemp

Journal Article

Successful return to sports activity after surgery requires both physical and psychological readiness. The Hip-Return to Sport After Injury (Short Form) has been developed to assess psychological readiness to return to sports after hip injury and hip surgery, including hip arthroscopy. To evaluate the reliability, validity, responsiveness, and interpretability of the scale for a cohort of patients after hip arthroscopy with a range of sports participation levels. Cohort study (diagnosis); Level of evidence, 2. Invitations to participate were sent to 145 patients from 3 specialist surgeons. The study included 77 participants 1 to 24 months after hip arthroscopy (mean ± SD age, 35 ± 9 years; 62% women) and 33 healthy age-matched controls (age, 37 ± 7 years; 52% women). The scale was administered electronically on 3 occasions to patients: baseline (≥1 month postarthroscopy), 1 week later, and 6 months later. In addition to the scale, participants were asked about sports participation status and their global rating of postsurgical change. The scale was administered to healthy controls on 1 occasion. The minimal detectable difference, discriminant validity, floor and ceiling effects, responsiveness, and interpretability (minimally important change) were determined for the scale. Among the postarthroscopy group, excellent test-retest reliability was found (intraclass correlation coefficient = 0.869; 95% CI, 0.756-0.932) with a minimal detectable difference of 26 points out of 100 at the individual level and 4 points out of 100 at the group level. At baseline discriminant validity was evident between those who had returned to sports (median = 69, n = 35) and those who had not returned to sports (median = 30, n = 42; Mann-Whitney Assessment of the Hip-Return to Sport After Injury (Short Form) supports its use as a reliable and valid measure of psychological readiness to return to sports in patients after hip arthroscopy.

PROMIS Versus Legacy Patient-Reported Outcome Measures in Patients Undergoing Surgical Treatment for Symptomatic Acetabular Dysplasia

07-01-2020 – Deborah J. Li,John C. Clohisy,Maria T. Schwabe,Elizabeth L. Yanik,Cecilia Pascual-Garrido

Journal Article

No previous study has investigated how the Patient-Reported Outcomes Measurement Information System (PROMIS) performs compared with legacy patient-reported outcome measures in patients with symptomatic acetabular dysplasia treated with periacetabular osteotomy (PAO). To (1) measure the strength of correlation between the PROMIS and legacy outcome measures and (2) assess floor and ceiling effects of the PROMIS and legacy outcome measures in patients treated with PAO for symptomatic acetabular dysplasia. Cohort study (Diagnosis); Level of evidence, 2. This study included 220 patients who underwent PAO for the treatment of symptomatic acetabular dysplasia. Outcome measures included the Hip disability and Osteoarthritis Outcome Score (HOOS) pain, HOOS activities of daily living (ADL), modified Harris Hip Score (m
HHS), PROMIS pain, and PROMIS physical function subsets, with scores collected preoperatively and/or postoperatively at a minimum 12-month follow-up. The change in mean scores from preoperatively to postoperatively was calculated only in a subgroup of 57 patients with scores at both time points. Distributions of the PROMIS and legacy scores were compared to evaluate floor and ceiling effects, and Pearson correlation coefficients were calculated to evaluate agreement. The mean age at the time of surgery was 27.7 years, and 83.6% were female. The mean follow-up time was 1.5 years. Preoperatively, neither the PROMIS nor the legacy measures showed significant floor or ceiling effects. Postoperatively, all legacy measures showed significant ceiling effects, with 15% of patients with a maximum HOOS pain score of 100, 29% with a HOOS ADL score of 100, and 21% with an m
HHS score of 100. The PROMIS and legacy instruments showed good agreement preoperatively and postoperatively. The PROMIS pain had a moderate to strong negative correlation with the HOOS pain ( We found good agreement between PROMIS and legacy scores preoperatively and postoperatively. PROMIS scores were largely normally distributed, demonstrating an expanded ability to capture variability in patients with improved outcomes after treatment.

Prospective Randomized Comparison of Capsular Management Techniques During Hip Arthroscopy

31-12-2019 – Kostas J. Economopoulos,Anikar Chhabra,Christopher Kweon

Journal Article

Capsular management during hip arthroscopy remains controversial. Studies evaluating this topic consist mostly of retrospective comparative reviews of prospectively gathered data on a large series of patients. The purpose was to perform a prospective randomized trial to comparatively assess 3 commonly performed capsular management techniques. It was hypothesized that capsular closure during hip arthroscopy would result in superior outcomes when compared with unclosed capsulotomy management techniques. Randomized controlled trial; Level of evidence, 2. Patients (N = 150) who had hip arthroscopy with labral repairs and femoral osteoplasties performed by the senior author were randomly assigned into 3 groups at the time of their surgery: T-capsulotomy without closure (TC), interportal capsulotomy without closure (IC), and interportal capsulotomy with closure (CC). All patients underwent labral repair and femoral osteoplasty. Patient-reported outcomes were obtained preoperatively and at 3, 6, 12, and 24 months postoperatively. Other outcomes obtained included the need for future hip surgery. Patient demographics, preoperative patient-reported outcomes, and radiographic measurements were similar among all 3 groups. Revision hip arthroscopy was performed in 5 TC cases, 2 IC cases, and 1 CC case ( Patients undergoing complete capsular closure during hip arthroscopy showed improved patient-reported and surgical outcomes when compared with those with unrepaired T-capsulotomy or interportal capsulotomy. These results suggest that repair after capsulotomy may be a favorable arthroscopic capsular management technique.

The Influence of Lumbosacral Spine Pathology on Minimum 2-Year Outcome After Hip Arthroscopy: A Nested Case-Control Analysis

26-12-2019 – Edward C. Beck,Benedict U. Nwachukwu,Reagan Chapman,Anirudh K. Gowd,Brian R. Waterman,Shane J. Nho

Journal Article

Previous literature has examined the association between lumbosacral pathology and hip pathomechanics. However, the effect of lumbosacral pathologies and previous lumbosacral surgery on achieving meaningful outcomes after hip arthroscopy for femoroacetabular impingement syndrome (FAIS) has yet to be studied conclusively. To determine whether a history of lumbosacral spine pathology has an influence on achieving minimal clinically important differences (MCIDs) after hip arthroscopy for FAIS. Cohort study; Level of evidence, 3. Patients undergoing hip arthroscopy for FAIS by a single, fellowship-trained orthopaedic surgeon between January 2012 and April 2017 with minimum 2-year follow-up were retrospectively reviewed. Patients with a history of lumbosacral spine pathology (eg, lumbosacral fusion, disc or vertebral pathology, or history of lumbosacral fractures) were matched 1:2 by age, body mass index, and sex to patients without spine pathology. Clinical outcomes including the Hip Outcome Score-activities of daily living subscale (HOS-ADL), HOS-sports subscale (HOS-SS), modified Harris Hip Score (m
HHS), international Hip Outcome Tool-12 (i
HOT-12), visual analog scale (VAS) pain, and VAS satisfaction were compared between the groups using an independent A total of 83 of 108 eligible patients with lumbosacral pathology were identified and matched to 166 patients without any spine pathology. When compared with the non-spine pathology group, the lumbosacral pathology group had significantly lower 2-year postoperative outcome score averages across all reported outcome tools (all Patients with a history of lumbosacral pathology achieved significantly lower short-term meaningful clinical outcomes after undergoing hip arthroscopy for FAIS when compared with patients without spine pathology. The present study findings have implications for preoperative patient screening, shared decision-making processes/expectation management, and rehabilitation strategies.

What Neuromonitoring Changes Can Be Expected During Hip Arthroscopy in the Pediatric Population?

05-12-2019 – Trevor J. Shelton,Akash Patel,Lauren Agatstein,Brian M. Haus

Journal Article

As its indications have evolved, hip arthroscopy is now performed more frequently in pediatric patients. However, despite this increase, there is a lack of evidence in the literature about its safety in this population in regard to traction injury of the nerves of the lower extremity. To determine neuromonitoring changes of the sciatic, femoral, and obturator nerves during hip arthroscopy in the pediatric population and determine the rate of and risk factors for clinical neurapraxia. Case series; Level of evidence, 4. A retrospective review was performed of all pediatric patients who underwent hip arthroscopy with neuromonitoring from December 2013 to October 2018. Neuromonitoring included somatosensory evoked potentials (SSEPs) in the peroneal and posterior tibial nerves and electromyography (EMG) signal for the obturator, femoral, and peroneal and posterior tibial nerves. Traction was applied using a radiolucent traction table. We recorded total traction time, surgery time, SSEP changes >50% after traction application, and EMG activity. We also recorded whether there was a clinical neurapraxia and when nerve function returned, and analyzed surgical and patient characteristic data for risk factors for neurapraxia. A total of 89 patients had hip arthroscopy (median traction time, 69 minutes). SSEP changes >50% occurred in 78% of patients in the peroneal nerve and 73% in the posterior tibial nerve. EMG activity was observed in 9% of patients in the obturator nerve, 8% in the femoral nerve, 12% in the peroneal nerve, and 8% in the posterior tibial nerve. Clinical neurapraxia was seen in 19% of patients in either the peroneal nerve or posterior tibial nerve but resolved by 2 days postoperatively. Those who sustained a neurapraxia had a 32-minute longer surgery and 6-minute longer traction time. The clinical rate of neurapraxia of the pudendal nerve was 0%. Neuromonitoring changes are common during hip arthroscopy and nearly 1 in 5 pediatric patients will have some decreased sensation in either the peroneal or the posterior tibial nerve that resolves within 1 to 2 days after surgery. In pediatric patients, longer surgery and traction times during hip arthroscopy are associated with a higher rate of neurapraxia than that reported for adults.

Application of Machine Learning for Predicting Clinically Meaningful Outcome After Arthroscopic Femoroacetabular Impingement Surgery

23-12-2019 – Benedict U. Nwachukwu,Edward C. Beck,Elaine K. Lee,Jourdan M. Cancienne,Brian R. Waterman,Katlynn Paul,Shane J. Nho

Journal Article

Hip arthroscopy has become an important tool for surgical treatment of intra-articular hip pathology. Predictive models for clinically meaningful outcomes in patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS) are unknown. To apply a machine learning model to determine preoperative variables predictive for achieving the minimal clinically important difference (MCID) at 2 years after hip arthroscopy for FAIS. Case-control study; Level of evidence, 3. Data were analyzed for patients who underwent hip arthroscopy for FAIS by a high-volume fellowship-trained surgeon between January 2012 and July 2016. The MCID cutoffs for the Hip Outcome Score-Activities of Daily Living (HOS-ADL), HOS-Sport Specific (HOS-SS), and modified Harris Hip Score (m
HHS) were 9.8, 14.4, and 9.14, respectively. Predictive models for achieving the MCID with respect to each were built with the LASSO algorithm (least absolute shrinkage and selection operator) for feature selection, followed by logistic regression on the selected features. Study data were analyzed with Patient
IQ, a cloud-based research and analytics platform for health care. Of 1103 patients who met inclusion criteria, 898 (81.4%) had a minimum of 2-year reported outcomes and were entered into the modeling algorithm. A total of 74.0%, 73.5%, and 79.9% met the HOS-ADL, HOS-SS, and m
HHS threshold scores for achieving the MCID. Predictors of not achieving the HOS-ADL MCID included anxiety/depression, symptom duration for >2 years before surgery, higher body mass index, high preoperative HOS-ADL score, and preoperative hip injection (all This study identified predictive variables for achieving clinically meaningful outcome after hip arthroscopy for FAIS. Patient factors including anxiety/depression, symptom duration >2 years, preoperative intra-articular injection, and high preoperative outcome scores are most consistently predictive of inability to achieve clinically meaningful outcome. These findings have important implications for shared decision-making algorithms and management of preoperative expectations after hip arthroscopy for FAI.

Pathoanatomy of the Jones Fracture in Male University Soccer Players

30-12-2019 – Kohei Fujitaka,Yasuhito Tanaka,Akira Taniguchi,Munehiro Ogawa,Shinji Isomoto,Shingo Otuki,Mamoru Okubo

Journal Article

Jones fractures are relatively common in soccer players and require an extended recovery period because this type of fracture has a high incidence of delayed union, nonunion, and refracture. There has been some previous research on risk factors for Jones fracture, but no study has yet investigated the effect of the length of the fifth metatarsal bone and the positional relationship of the articular surface of the fifth metatarsal bones and the tarsal bones. Clarification of the characteristics of the foot structure that predispose soccer players to Jones fracture may aid in the prevention of this injury. To investigate the association between Jones fracture and foot structure as assessed with a mapping system on weightbearing dorsoplantar and lateral foot radiographs. Cohort study; Level of evidence, 3. We used a mapping system to evaluate the radiographs of 60 feet from 30 university soccer players with Jones fractures and a control group of 60 feet from 60 male university soccer players without Jones fracture. The groups were compared regarding the length of the fifth metatarsal and the positions of the metatarsal and tarsal bones. Analysis of weightbearing dorsoplantar foot radiographs showed that the fifth metatarsal was significantly longer and that its proximal tip was positioned more proximally in the Jones fracture group as compared with the control group. Analysis of weightbearing lateral foot radiographs showed that the reference points for the medial arch were significantly higher in the Jones fracture group than in the control group. This study indicated that the proximally longer fifth metatarsal may cause greater stress at the base of the fifth metatarsal bone because the lever arm becomes long. In addition, high medial longitudinal arch may contribute to increased load on the lateral side of the foot. Thus, these anatomic features may be useful to identify soccer players at high risk of Jones fracture at medical checkup.

Associations of Preoperative Patient Mental Health and Sociodemographic and Clinical Characteristics With Baseline Pain, Function, and Satisfaction in Patients Undergoing Rotator Cuff Repairs

18-12-2019 – Sambit Sahoo,Eric T. Ricchetti,Alexander Zajichek,Peter J. Evans,Lutul D. Farrow,Brett W. McCoy,Morgan H. Jones,Anthony A. Miniaci,Vani J. Sabesan,Mark S. Schickendantz,William H. Seitz,Kurt P. Spindler,Kim L. Stearns,Greg Strnad,Alparslan Turan,Vahid Entezari,Peter B. Imrey,Joseph P. Iannotti,Kathleen A. Derwin

Journal Article

Shoulder pain and dysfunction are common indications for rotator cuff repair surgery, yet the factors that are associated with these symptoms are not fully understood. This study aimed to investigate the associations of patient and disease-specific factors with baseline patient-reported outcome measures (PROMs) in patients undergoing rotator cuff repair. We hypothesized that tear size and mental health status, as assessed by the Veterans RAND 12-Item Health Survey mental component score (VR-12 MCS), would be associated with baseline total Penn Shoulder Score (PSS) and its pain, function, and satisfaction subscale scores. Cross-sectional study; Level of evidence, 3. We prospectively identified 12 patient factors and 12 disease-specific factors as possible statistical predictors for baseline PROMs in patients undergoing surgical repair of superior-posterior rotator cuff tears at a single institution over a 3-year period. Multivariable statistical modeling and Akaike information criterion comparisons were used to investigate the unique associations with, and relative importance of, these factors in accounting for variation in baseline PSS and its subscale scores. A total of 1442 patients who had undergone surgery by 23 surgeons met inclusion criteria, with a baseline median total PSS of 38.5 (pain, 12; function, 24.2; satisfaction, 2). Adjusted Large/massive tear size, lower VR-12 MCS, and several additional patient and disease-specific factors are associated with baseline PROMs in patients undergoing rotator cuff repair. Further studies are needed to investigate whether these factors will also predict poor postoperative PROMs.

Improved Rotator Cuff Footprint Contact Characteristics With an Augmented Repair Construct Using Lateral Edge Fixation

04-12-2019 – Ekaterina Urch,Charles C. Lin,Yasuo Itami,Nilay A. Patel,Michelle H. McGarry,Orr Limpisvasti,Thay Q. Lee

Journal Article

The transosseous-equivalent (TOE) rotator cuff repair construct has become the gold standard for the repair of medium and large rotator cuff tears. Repair failure, however, continues to be a problem. One contributing factor may be the inability of the TOE repair to replicate the native footprint contact characteristics during shoulder movement, especially in rotation. This results in higher strain across the repair, which leads to gapping and predisposes the construct to failure. In an effort to better reproduce the native compression forces throughout the footprint, an augmented TOE construct supplemented with lateral edge fixation is proposed, and the contact characteristics were compared with those of the gold standard TOE construct. The augmented TOE repair will demonstrate improved footprint contact characteristics when compared with the classic TOE repair. Controlled laboratory study. Ten fresh-frozen cadaveric shoulders underwent supraspinatus repair using both the classic TOE double-row construct and the augmented TOE repair. For the augmented repair, 2 luggage tag sutures were used to secure the lateral edge and incorporated into the lateral row anchors. A Tekscan pressure sensor (Tekscan Inc) placed under the repaired tendon was used to collect footprint contact area, force, peak pressure, and contact pressure data for each construct. The augmented construct demonstrated significantly greater contact forces (average difference, 4.9 N) and significantly greater contact pressures (average difference, 23.1 k
Pa) at all degrees of abduction and all degrees of rotation. At 30° of internal and 30° of external rotation at both 0° and 30° of shoulder abduction, the augmented construct demonstrated significantly greater peak contact pressures. The augmented construct showed superior contact characteristics when compared with the classic TOE technique. The addition of lateral edge fixation to the classic TOE repair significantly improves bone-tendon contact characteristics with minimal additional surgical effort. The results of this study indicate that lateral augmentation of the classic TOE repair produces a biomechanically superior construct that may optimize tendon healing.

Rotator Cuff Repair With Autologous Tenocytes and Biodegradable Collagen Scaffold: A Histological and Biomechanical Study in Sheep

16-12-2019 – Björn P. Roßbach,Mehmet F. Gülecyüz,Lena Kempfert,Matthias F. Pietschmann,Tina Ullamann,Andreas Ficklscherer,Thomas R. Niethammer,Anja Zhang,Roland M. Klar,Peter E. Müller

Journal Article

Large rotator cuff tears still represent a challenging problem in orthopaedics. The use of tenocytes on biomaterials/scaffolds for the repair of large rotator cuff defects might be a promising approach in the field of tendon regeneration. Cultivated autologous tenocytes seeded on a collagen scaffold lead to enhanced histological and biomechanical results after rotator cuff repair in a sheep model as compared with unseeded scaffolds in an acute setting. Controlled laboratory study. At the tendon-bone junction of the infraspinatus tendon of the right foreleg of 24 sheep, a 3.5 × 1.5-cm tendon defect was created. Sheep were randomly allocated to group 1, a defect; group 2, where an unseeded collagen scaffold was implanted; or group 3, which received the implantation of a collagen scaffold seeded with autologous tenocytes. Twelve weeks postoperatively, tendon regeneration was examined histologically and biomechanically. The histology of the neotendons of group 3 showed better fiber patterns, a higher production of proteoglycans, and an increased genesis of collagen III in contrast to groups 1 and 2. Immunostaining revealed less tissue dedifferentiation, a more structured cartilage layer, and homogeneous cartilage-bone transition in group 3 in comparison with groups 1 and 2. Biomechanically, the tensile strength of the reconstructed tendons in group 3 (mean load to failure, 2516 N; SD, 407.5 N) was approximately 84% that of the native tendons (mean load to failure, 2995 N; SD, 223.1 N) without statistical significance. A significant difference ( Autologous tenocytes seeded on collagen scaffolds yield enhanced biomechanical results after tendon-bone reconstruction as compared with unseeded scaffolds in an acute setting. Biomechanical results and histological outcomes were promising, showing that the use of autologous tenocytes with specific carrier matrices could be a novel approach for repairing rotator cuff tears. This study supports the use of tenocytes and scaffolds for improving the quality of tendon-bone regeneration.

Management of Failed Proximal Biceps Surgery: Clinical Outcomes After Revision to Subpectoral Biceps Tenodesis

19-12-2019 – David D. Savin,Brian R. Waterman,Shelby Sumner,Catherine Richardson,John Newgren,Anirudh K. Gowd,Anthony A. Romeo

Journal Article

The preferred surgical technique to manage biceps-superior labral pathology is often debated, and rates of revision and persistence of pain vary widely according to surgical technique and patient characteristics. To evaluate the clinical and functional outcomes of patients undergoing revision subpectoral tenodesis after failed primary tenodesis or tenotomy of the long head of the biceps. Case series; Level of evidence, 4. All patients undergoing revision biceps management by the senior surgeon between 2006 and 2016 and with a minimum 24-month follow-up were retrospectively identified. Patients being treated with concomitant rotator cuff repair or capsular release were excluded. Patient characteristic variables were recorded. Patient-reported outcomes including the functional score, Single Assessment Numeric Evaluation (SANE), visual analog scale (VAS), Simple Shoulder Test (SST), and American Shoulder and Elbow Surgeons were obtained, and range of motion, strength, and complications were quantified. In total, 25 patients with revision biceps tenodesis were identified at a mean follow-up of 76.5 ± 31.5 months. The average age was 44.4 ± 14.3 years, and the surgical indications included failure of index suprapectoral biceps tenodesis (56%), subpectoral biceps tenodesis (36%), and patient dissatisfaction after tenotomy (8%). There was a significant improvement in the VAS score ( The current study demonstrates high patient satisfaction (88%) and significant improvement in functional outcomes with revision biceps tenodesis, a mini-open subpectoral technique, after previous failed tenodesis or tenotomy. Although this may be an effective strategy to address failed prior biceps surgery, the potential complication of persistent pain must be emphasized. Patients should be counseled on the high complication rate (48%), with persistent pain being the most common complaint.

Progressive Elbow Magnetic Resonance Imaging Abnormalities in Little League Baseball Players Are Common: A 3-Year Longitudinal Evaluation

04-12-2019 – Joshua B. Holt,Jason M. Pedowitz,Philip H. Stearns,Tracey P. Bastrom,M. Morgan Dennis,Jerry R. Dwek,Andrew T. Pennock

Journal Article

Prior studies have revealed magnetic resonance imaging (MRI) evidence of elbow pathology in single-season evaluation of competitive youth baseball players. The natural history of these findings and risk factors for progression have not been reported. To characterize the natural history of bilateral elbow MRI findings in a 3-year longitudinal study and to correlate abnormalities with prior MRI findings, throwing history, playing status, and physical examination. Cohort study; Level of evidence, 2. A prospective study of Little League players aged 12 to 15 years was performed. All players had preseason and postseason bilateral elbow MRI performed 3 years before this study. Players underwent repeat bilateral elbow MRI, physical examination, and detailed assessment of throwing history, playing status, and arm pain. Imaging was read by a blinded musculoskeletal radiologist and compared with prior MR images to assess for progression or resolution of previously identified pathology. All 26 players who participated in the previous single-season study returned for a 3-year assessment. At the completion of the study, 15 players (58%) had dominant arm MRI pathology. Eighty percent (12/15 players) of MRI findings were new or progressive lesions. Players with postseason MRI pathology at the beginning of the study were more likely to have MRI pathology at the 3-year follow-up than players with previously normal postseason MRI ( Dominant elbow MRI abnormalities are common in competitive Little League Baseball players. Year-round play imparts significant risk for progression of MRI pathology and physical examination abnormalities.

Shoe Cushioning Influences the Running Injury Risk According to Body Mass: A Randomized Controlled Trial Involving 848 Recreational Runners

26-12-2019 – Laurent Malisoux,Nicolas Delattre,Axel Urhausen,Daniel Theisen

Journal Article

Shoe cushioning is expected to protect runners against repetitive loading of the musculoskeletal system and therefore running-related injuries. Also, it is a common belief that heavier runners should use footwear with increased shock absorption properties to prevent injuries. The aim of this study was to determine if shoe cushioning influences the injury risk in recreational runners and whether the association depends on the runner’s body mass. Randomized controlled trial; Level of evidence, 1. Healthy runners (n = 848) randomly received 1 of 2 shoe prototypes that only differed in their cushioning properties. Global stiffness was 61.3 ± 2.7 and 94.9 ± 5.9 N/mm in the soft and hard versions, respectively. Participants were classified as light or heavy according to their body mass using the median as a cut-off (78.2 and 62.8 kg in male and female runners, respectively). They were followed over 6 months regarding running activity and injury (any physical complaint reducing/interrupting running activity for at least 7 days). Data were analyzed through time-to-event models with the subhazard rate ratio (SHR) and their 95% confidence interval (CI) as measures of association. A stratified analysis was conducted to investigate the effect of shoe cushioning on the injury risk in lighter and heavier runners. The runners who had received the hard shoes had a higher injury risk (SHR, 1.52 [95% CI, 1.07-2.16]), while body mass was not associated with the injury risk (SHR, 1.00 [95% CI, 0.99-1.01]). However, after stratification according to body mass, results showed that lighter runners had a higher injury risk in hard shoes (SHR, 1.80 [95% CI, 1.09-2.98]) while heavier runners did not (SHR, 1.23 [95% CI, 0.75-2.03]). The injury risk was higher in participants running in the hard shoes compared with those using the soft shoes. However, the relative protective effect of greater shoe cushioning was found only in lighter runners. NCT03115437 (Clinical
Trials.gov identifier).

Upper Extremity and Hip Range of Motion Changes Throughout a Season in Professional Baseball Players

31-12-2019 – Justin M. Chan,John Zajac,Brandon J. Erickson,David W. Altchek,Christopher Camp,Struan H. Coleman,Joshua S. Dines

Journal Article

Loss of upper and lower extremity range of motion (ROM) is a significant risk factor for injuries in professional baseball players. The purpose was to determine changes in ROM in professional baseball players over the course of a single season and their careers. We hypothesized that pitchers and position players would lose ROM, specifically total shoulder motion (total ROM [TROM]) and hip internal rotation (IR), over the course of a season and their careers. Case series; Level of evidence, 4. Upper and lower extremity ROM measurements were recorded during pre-, mid-, and postseason on all professional baseball players for a single organization between 2011 and 2018. ROM measurements were compared for pitchers and position players over the course of the season and their careers. Also, ROM measurements over the pre-, mid-, and postseason were compared between pitchers and position players. A total of 166 professional baseball players (98 pitchers, 68 position players) were included. Pitcher hip external rotation (ER; Pitchers and position players saw overall decreases in hip ROM but increases in shoulder ROM over the course of the season and career.

A Practical Guide for the Current Use of Biologic Therapies in Sports Medicine

30-04-2019 – Joseph D. Lamplot,Scott A. Rodeo,Robert H. Brophy

Journal Article

Over the past decade, there has been an increased interest in the use of biologic therapies in sports medicine. Although these technologies are in relatively early stages of development, there have been substantial increases in marketing, patient demand, and clinical utilization of biologics, including platelet-rich plasma, bone marrow aspirate concentrate, and other cell-derived therapies. Direct-to-consumer marketing of biologics has also proliferated but is largely unregulated, and clinicians must accurately convey the safety and efficacy profiles of these therapies to patients. Because most insurance companies consider biologic treatments to be experimental or investigational for orthopaedic applications given the lack of high-quality evidence to support their efficacy, patients receiving these treatments often make substantial out-of-pocket payments. With a range of treatment costs among centers offering biologics, there is a need for appropriate and sustainable pricing and reimbursement models. Clinicians utilizing biologics must also have a thorough understanding of the recently clarified Food and Drug Administration guidelines that regulate the clinical use of cell and tissue products. There is a lack of consensus on the optimal preparation, source, delivery method, and dosing of biologic therapies, which has been exacerbated by a lack of sufficient experimental detail in most published studies. Future research must better identify the biologic target of treatment, adhere to better standards of reporting, and better integrate researchers, industry, and regulatory bodies to optimize applications.

Horizontal Instability of the Acromioclavicular Joint: A Systematic Review

23-04-2019 – Gianna M. Aliberti,Matthew J. Kraeutler,Jeffrey D. Trojan,Mary K. Mulcahey

Hop Testing Lacks Strong Association With Key Outcome Variables After Primary Anterior Cruciate Ligament Reconstruction: A Systematic Review

07-05-2019 – Justin M. Losciale,Garrett Bullock,Christina Cromwell,Leila Ledbetter,Laura Pietrosimone,Timothy C. Sell

Journal Article

Single-legged hop tests are commonly used assessments in return to sport (RTS) testing after anterior cruciate ligament reconstruction (ACLR). Although these tests are commonly used, their predictive validity has not yet been established. To determine the strength of association between hop testing and RTS, knee reinjury, subjective report of knee function, and posttraumatic knee osteoarthritis (PTOA) after primary ACLR. Secondarily, to determine whether hop testing is able to predict a favorable result on the same outcome variables. Systematic review. A systematic, computer-assisted literature search was performed in PubMed/MEDLINE, CINAHL, EMBASE, SPORTDiscus, Cochrane Library, and Clinical
Trials.gov. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed when conducting and reporting this review. Primary outcome variables for this review were self-report of knee function, return to preinjury level of activity, presence of reinjury, and presence of PTOA. The Oxford Centre for Evidence-Based Medicine Levels of Evidence tool was used to assess the level of evidence for each included study. Quality assessment of each included study was performed through use of a modified Downs and Black scale. Available metrics were tabulated based on outcome variables. Overall, 21 studies (4476 patients) met inclusion for this review. The majority of evidence (95.2%) was of moderate to high methodologic quality. The most commonly associated outcome measure was the International Knee Documentation Committee (IKDC) score, with Pearson correlation coefficients ranging from 0.20 to 0.60. The strength of association between the Knee injury and Osteoarthritis Outcome Score (KOOS) and hop testing ranged from -0.10 to 0.62 in 4 studies. In all, 10 studies examined the relationship between hop testing and RTS, with variable association statistics reported. No meaningful association was found between hop testing and knee reinjury in 2 studies. Worse preoperative hop testing was associated with PTOA in 1 study. Hop testing appears to possess fair association to subjective report of knee function measured by the KOOS and IKDC and a patient’s ability to RTS after ACLR. Insufficient evidence is available to determine the relationship between hop testing and PTOA and knee reinjury. Predictive validity cannot be established based on available literature.

Society News

31-01-2020 –

Musculoskeletal Injury Risk After Sport-Related Concussion: Letter to the Editor

31-01-2020 – Matthew Gammons

Letter

Musculoskeletal Injury Risk After Sport-Related Concussion: Response

31-01-2020 – April L. McPherson,Takashi Nagai,Kate E. Webster,Timothy E. Hewett

Journal Article

Comparative Clinical Outcomes After Intra-articular Injection With Adipose-Derived Cultured Stem Cells or Noncultured Stromal Vascular Fraction for the Treatment of Knee Osteoarthritis: Letter to the Editor

31-01-2020 – Anna Boada-Pladellorens,Mercè Avellanet,Arnau Pla,Didac Haro Cervantes

Letter

Comparative Clinical Outcomes After Intra-articular Injection With Adipose-Derived Cultured Stem Cells or Noncultured Stromal Vascular Fraction for the Treatment of Knee Osteoarthritis: Response

31-01-2020 – Norimasa Nakamura,Naomasa Yokota,Mari Hattori,Tadahiko Ohtsuru,Masaki Otsuji,Stephen Lyman,Kazunori Shimomura

Journal Article

Platelet-Rich Plasma for Patellar Tendinopathy: Letter to the Editor

31-01-2020 – Michael R. Baria,W. Kelton Vasileff,Christopher Kaeding

Letter

Platelet-Rich Plasma for Patellar Tendinopathy: Response

31-01-2020 – Alex Scott,Kimberly G. Harmon

Journal Article

Effect of Meniscal Ramp Lesion Repair on Knee Kinematics, Bony Contact Forces, and In Situ Forces in the Anterior Cruciate Ligament: Letter to Editor

31-01-2020 – Thais Dutra Vieira,William G. Blakeney,Sergio Canuto,Etienne Cavaignac,Steven Claes,Matt Daggett,Camilo Partezani Helito,Koichi Muramatsu,Vitor B.C. de Padua,Herve Ouanezar,Adnan Saithna,Bertrand Sonnery-Cottet

Letter

Effect of Meniscal Ramp Lesion Repair on Knee Kinematics, Bony Contact Forces, and In Situ Forces in the Anterior Cruciate Ligament: Response

31-01-2020 – Jan-Hendrik Naendrup,Thomas R. Pfeiffer,Calvin Chan,Kanto Nagai,João V. Novaretti,Andrew J. Sheean,Sven T. Shafizadeh,Richard E. Debski,Volker Musahl

Journal Article

Positive Effect of Platelet-Rich Plasma on Pain in Plantar Fasciitis: Letter to the Editor

31-01-2020 – Vivek Tiwari,Samir Dwidmuthe,Samrat S. Sahoo

Letter

Positive Effect of Platelet-Rich Plasma on Pain in Plantar Fasciitis: Response

31-01-2020 – J.C. Peerbooms

Journal Article

Corrigendum

31-01-2020 –

Published Erratum

Pathogenesis and Development of Patellar Tendon Fibrosis in a Rabbit Overuse Model

20-02-2020 – Haitao Liu,Feng Gao,Xiaotian Liang,Xiaolan Chen,Yi Qu,Lin Wang

Journal Article

The pathogenesis of patellar tendon fibrosis caused by overuse remains unclear. In an effort to further investigate effective treatments for patellar tendon fibrosis attributed to overuse, it is necessary to construct a reliable animal model. A rabbit patellar tendon fibrosis model was developed with the use of electrical stimulation to induce jumping. The pathogenesis and development of patellar tendon fibrosis were subsequently investigated with this model. Controlled laboratory study. A total of 32 New Zealand White rabbits were randomly divided into a jumping group and a control group. Rabbits in the control group did not receive any treatment, while those in the jumping group jumped 150 times daily, 5 days per week. At 2, 4, 6, and 8 weeks after the initiation of treatment, the patellar tendons of 4 rabbits from each group were harvested and subjected to hematoxylin and eosin staining, immunohistochemical staining, and real-time polymerase chain reaction. The influence of jumping training on the expressions of histology- and fibrosis-related factors in the patellar tendon was assessed. The histological changes of patellar tendon fibrosis in the jumping group were most pronounced at 4 weeks. When compared with the control group at corresponding time points, the m
RNA and protein expressions of TGF-β1, CTGF, COL-I, and COL-III were upregulated significantly in the patellar tendon after jumping training for 4 weeks ( It was found that patellar tendon fibrosis occurred because of overuse and the peak changes occurred at 4 weeks. Jumping load increased the secretions of TGF-β1 and Smad3 in the patellar tendon, with CTGF upregulation and higher synthesis of COL-I and COL-III, which were considered the pathogenesis of fibrosis. This study simulated the effects of jumping load on tendon fibrosis at different time points. Moreover, the time course relationship between jumping training and patellar tendon fibrosis in the rabbit model was determined, which provided a new animal model for the study of patellar tendon fibrosis.

Defining the Minimal Clinically Important Difference and Patient Acceptable Symptom State for Microfracture of the Knee: A Psychometric Analysis at Short-term Follow-up

14-02-2020 – Jorge Chahla,Kyle N. Kunze,Tracy Tauro,Joshua Wright-Chisem,Brady T. Williams,Alexander Beletsky,Adam B. Yanke,Brian J. Cole

Journal Article

Several studies have investigated failure rates and magnitude of improvement in patient-reported outcome measures after microfracture surgery for focal chondral defects of the knee; however; what constitutes clinically significant improvement in this patient population is poorly understood. To (1) establish the minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) thresholds for microfracture surgery including the time-dependent nature of these thresholds and (2) identify predictors of achieving the MCID and PASS in patients specifically undergoing microfracture of the knee. Case series; Level of evidence, 4. A secure institutional cartilage preservation repository was queried for all patients who underwent microfracture between 2004 and 2017. The distribution method was used to calculate MCID thresholds for the International Knee Documentation Committee (IKDC) score and the Knee injury and Osteoarthritis Outcome Score (KOOS), whereas an anchor-based method was used for the PASS. Multivariate logistic regressions were constructed to determine predictors of achieving the MCID and PASS. A total of 206 patients with a mean ± SD age of 33.7 ± 13.2 years and body mass index of 26.9 ± 5.3 kg/m The MCID and PASS thresholds for the IKDC and KOOS in patients undergoing microfracture of the knee are dynamic, with an increasing number of patients achieving the MCID over time. The percentage achieving the PASS increased between 6 and 12 months and then declined slightly at 24 months. Independent predictors of achieving the MCID were lesion size and age at surgery, whereas predictors of achieving the PASS included lesion size, male sex, and greater preoperative KOOS Symptoms and Pain scores.

Lateral Meniscus Posterior Root Lesion Influences Anterior Tibial Subluxation of the Lateral Compartment in Extension After Anterior Cruciate Ligament Injury

14-02-2020 – Tong Zheng,Guan-yang Song,Hua Feng,Hui Zhang,Yue Li,Xu Li,Zhi-jun Zhang,Qian-kun Ni,Zheng Feng

Journal Article

The lateral meniscus posterior root (LMPR) lesion further decreases dynamic knee stability after anterior cruciate ligament (ACL) injury owing to the loss of the “wedge effect” maintained by the posterior horn of the lateral meniscus. However, the effect of LMPR lesions on the static tibiofemoral relationship in extension after ACL injuries is not determined. To (1) determine the effect of LMPR lesions on anterior tibial subluxation of the lateral compartment (ATSLC) in extension in patients with ACL injuries and to (2) identify the LMPR-related factors associated with excessive ATSLC in extension. Cohort study; Level of evidence, 3. Between January 2015 and December 2017, 405 consecutive patients with diagnosed ACL injuries who underwent primary ACL reconstructions were retrospectively reviewed. Among them, 45 patients with combined ACL injuries and LMPR lesions (ACL+LMPR group) and 51 patients with isolated ACL injuries (ACL group) were identified. Values of ATSLC in extension were measured on preoperative supine magnetic resonance imaging and classified into high grade (≥6 mm) and low grade (<6 mm). The mean ATSLC in extension and the proportion of patients with high-grade ATSLC in extension were compared between the groups by univariate analysis. In the ACL+LMPR group, predictors of high-grade ATSLC in extension-including age, sex, body mass index, affected side, cause of injury, period from injury (<12 or ≥12 weeks), LMPR lesion pattern (radial tear or root avulsion), and meniscofemoral ligament integrity (intact or impaired)-were assessed by univariate analysis and multivariate logistic regression analysis. The mean ATSLC in extension in the ACL+LMPR group was significantly greater than that in the ACL group (5.6 mm vs 3.1 mm; After ACL injuries, concomitant LMPR lesion further increased ATSLC in extension. Chronic LMPR avulsion was associated with high-grade ATSLC in extension.

How Does Isolated Medial Patellofemoral Ligament Reconstruction Influence Patellar Height?

14-02-2020 – Francesco Luceri,Julien Roger,Pietro Simone Randelli,Sébastien Lustig,Elvire Servien

Journal Article

Reconstruction of the medial patellofemoral ligament (MPFL) is the gold standard treatment for recurrent patellar dislocation. Patella alta has been reported in about half of patients with recurrent patellofemoral instability. MPFL reconstruction (MPFLr) has a beneficial role in the correction of patellar height in patients with mild patella alta (Caton-Deschamps index [CDI] between 1.20 and 1.40). Case series; Level of evidence, 4. Skeletally mature patients, with no history of previous or concomitant knee surgical procedures, who underwent isolated MPFLr using hamstring autograft for recurrent patellar instability between 2005 and 2018, were included in this study. The authors calculated CDI, modified Insall-Salvati index (MISI), and Blackburne-Peel index (BPI) ratios. Measurements done by 2 independent observers were calculated and used to compare pre- and postoperative patellar height (patella alta: CDI >1.20). A total of 89 patients (95 knees) were included in the study, with a mean age of 25.0 years (range, 15.0-45.0 years). There were 70% women and 30% men. We found patella alta in 35.8% of cases preoperatively. Among them, 79.4% had reduced patellar height indices, within normal limits, postoperatively (mean follow-up, 18.4 ± 12.0 months). All the ratios showed a significant reduction in patellar height after surgery (CDI: 0.19 [range, -0.05, 0.60]; MISI: 0.22 [-0.14, 0.76]; BPI: 0.18 [-0.08, 0.59]; The higher the preoperative patellar height, the more important is the lowering effect of MPFLr using the hamstring for patellar instability. Bony procedures should not be indicated in patients with patellar instability and a CDI between 1.20 and 1.40.

Effect of Initial Graft Tension During Anterior Talofibular Ligament Reconstruction on Ankle Kinematics, Laxity, and In Situ Forces of the Reconstructed Graft

13-02-2020 – Yuzuru Sakakibara,Atsushi Teramoto,Tetsuya Takagi,Satoshi Yamakawa,Hiroaki Shoji,Yohei Okada,Takuma Kobayashi,Tomoaki Kamiya,Mineko Fujimiya,Hiromichi Fujie,Kota Watanabe,Toshihiko Yamashita

Journal Article

Although a variety of surgical procedures for anterior talofibular ligament (ATFL) reconstruction have been reported, the effect of initial graft tension during ATFL reconstruction remains unclear. This study investigated the effects of initial graft tension on ATFL reconstruction. We hypothesized that a high degree of initial graft tension would cause abnormal kinematics and laxity. Controlled laboratory study. Twelve cadaveric ankles were tested with a robotic system with 6 degrees of freedom to apply passive plantarflexion and dorsiflexion motions and a multidirectional load. A repeated measures experiment was designed with the intact ATFL, transected ATFL, and reconstructed ATFL at initial tension conditions of 10, 30, 50, and 70 N. The 3-dimensional path and reconstructed graft tension were simultaneously recorded, and the in situ forces of the ATFL and reconstructed graft were calculated with the principle of superposition. Initial tension of 10 N was sufficient to imitate normal ankle kinematics and laxity, which were not significantly different when compared with those of the intact ankles. The in situ force on the reconstructed graft tended to increase as the initial tension increased. In situ force on the reconstructed graft >30 N was significantly greater than that of intact ankles. The in situ force on the ATFL was 19 N at 30° of plantarflexion. In situ forces of 21.9, 30.4, 38.2, and 46.8 N were observed at initial tensions of 10, 30, 50, and 70 N, respectively, at 30° of plantarflexion. Approximate ankle kinematic patterns and sufficient laxity, even with an initial tension of 10 N, could be obtained immediately after ATFL reconstruction. Moreover, excessive initial graft tension during ATFL reconstruction caused excessive in situ force on the reconstructed graft. This study revealed the effects of initial graft tension during ATFL reconstruction. These data suggest that excessive tension during ATFL reconstruction should be avoided to ensure restoration of normal ankle motion.

Early Radiographic Healing and Functional Results After Autologous Osteochondral Grafting for Osteochondritis Dissecans of the Capitellum: Introduction of a New Magnetic Resonance Imaging–Based Scoring System

13-02-2020 – Kemble K. Wang,Kathryn Williams,Donald S. Bae

Journal Article

Autologous osteochondral grafting (OG) is an option in the treatment of capitellar osteochondritis dissecans (COCD). However, radiographic healing after this procedure has not been well documented. To develop a magnetic resonance imaging (MRI)-based scoring system specific for evaluating healing after single-plug OG in COCD and to evaluate correlation between radiographic healing and early clinical outcomes. Cohort study (diagnosis); Level of evidence, 3. Between 2014 and 2017, 183 elbows with COCD were enrolled in a prospective registry. A total of 61 elbows in 59 patients underwent single-plug OG. Of these, 52 elbows in 50 patients had pre- and postoperative MRI scans. Postoperative MRI and clinical outcome data from this group were used to develop the novel BOGIE score (Boston Osteochondral Graft Incorporation in the Elbow), with a possible range of 4 to 12. Median age at surgery was 14.2 years (interquartile range, 13.1-15.0 years). Median clinical follow-up after OG was 12.4 months (interquartile range, 9.5-16.9 months; range, 6-53 months). Compared with before surgery, elbow function at 6 months after surgery and at latest follow-up was significantly improved as measured by the Timmerman and Andrews score (TAS; median: 145 before surgery, 185 at 6 months after surgery, 190 at latest follow-up; Quantitative evaluation for radiologic healing after single-plug OG in COCD is possible. The MRI-based BOGIE score appears to correlate with early clinical function and may be useful as an adjunct tool in decision making on activity progression. The use of a standardized MRI score may improve comparability of outcomes after OG in the literature.

Autologous Chondrocyte Implantation and Osteochondral Allograft Transplantation Render Comparable Outcomes in the Setting of Failed Marrow Stimulation

13-02-2020 – Andrew J. Riff,Hailey P. Huddleston,Brian J. Cole,Adam B. Yanke

Journal Article

Marrow stimulation techniques (MSTs) such as subchondral drilling and microfracture are often chosen as first-line treatment options for symptomatic cartilage defects of the knee. When an MST fails, many cartilage restoration techniques are employed, including autologous chondrocyte implantation (ACI) and osteochondral allograft (OCA). However, a few series in the literature suggest that ACI after a failed MST results in inferior outcomes as compared with primary ACI. The purpose of this study was (1) to evaluate the clinical outcomes of ACI and OCA after a failed MST (secondary ACI and OCA) and compare them with the outcomes of primary ACI and OCA and (2) to compare clinical outcomes of secondary ACI and secondary OCA for refractory lesions involving the femoral condyle. The hypotheses were as follows: (1) secondary ACI will render inferior functional outcomes and an increased clinical failure rate as compared with primary ACI, (2) secondary OCA will render comparable results to primary OCA, and (3) secondary OCA will render superior outcomes to secondary ACI. Cohort study; Level of evidence, 3. Patients were retrospectively identified who underwent ACI and OCA for symptomatic chondral lesions of the knee refractory to a previous MST. Age-, sex-, and body mass index-matched groups of patients undergoing primary ACI and OCA were used as controls. Postoperative data were prospectively collected using several subjective scoring systems (Tegner, Lysholm, International Knee Documentation Committee, Knee injury and Osteoarthritis Outcome Score, 12-Item Short Form Health Survey). Groups were compared with regard to patient-reported outcomes, subjective satisfaction, clinical failure rate, and reoperation. Student A total of 359 patients were examined: 92 patients undergoing secondary ACI, 100 primary ACI, 88 secondary OCA, and 79 primary OCA. The mean patient age was 30.3 years (range, 14.9-49.9 years) at the time of ACI and 35.4 (range, 15-54.5) at the time of OCA. There was no difference between the primary and secondary groups with regard to postoperative functional scores, subjective satisfaction, reoperation rate, and clinical failure rate. ACI and OCA are both viable treatment options for chondral defects of the knee, even in the setting of a failed MST. Secondary ACI renders functional outcomes, subjective satisfaction, and reoperation and failure rates comparable with primary ACI and secondary OCA.

Screw and Sheath Tibial Fixation Associated With a Higher Likelihood of Deep Infection After Hamstring Graft Anterior Cruciate Ligament Reconstruction

12-02-2020 – Andrew P. Hurvitz,Heather A. Prentice,Tadashi T. Funahashi,Gregory B. Maletis

Journal Article

Hamstring autograft anterior cruciate ligament reconstructions (ACLRs) have exhibited higher infection rates compared with bone-patellar tendon-bone (BPTB) autograft. The reason for this observed difference is unclear, warranting investigation. To evaluate the association between tibial fixation, either with or without a sheath and screw construct, and the risk of deep infection after hamstring autograft ACLR, using BPTB autograft as a reference group for comparison. Cohort study; Level of evidence, 3. Using the Kaiser Permanente ACLR Registry, we identified all primary isolated, unilateral, single-bundle ACLRs with a BPTB or hamstring autograft (January 1, 2008, to September 30, 2016). The exposure groups included the following: (1) BPTB ACLR, (2) hamstring ACLR using a screw and sheath construct for tibial fixation (HS with screw and sheath), and (3) hamstring ACLR using a method other than a screw and sheath construct for tibial fixation (HS without screw and sheath). We used logistic regression to evaluate the likelihood of 90-day postoperative deep infection using BPTB autograft as the reference group and adjusting for age, sex, and body mass index. The number needed to be exposed (NNE) was calculated. Of 15,671 ACLRs, 6745 (43.0%) used a BPTB graft, 2852 (18.2%) used HS with screw and sheath tibial fixation, and 6074 (38.8%) used HS without screw and sheath tibial fixation. There were 38 (0.2%) 90-day deep infections: 11 (0.2%) for BPTB, 14 (0.5%) for HS with screw and sheath, and 13 (0.2%) for HS without screw and sheath. Although the overall infection rate after ACLR is low, the higher likelihood of infections when sheath and screw combined are used for tibial fixation of a hamstring autograft ACLR should be a consideration when this procedure is performed.

Effect of Diagnosed Sleep Disorders on Baseline Concussion Symptom, Cognitive, and Balance Assessments in Collegiate Athletes

12-02-2020 – Jamie McAllister-Deitrick,Alicia M. Trbovich,Steven P. Broglio,Michael McCrea,Thomas W. McAllister,Anthony P. Kontos

Journal Article

Symptoms, cognition, balance, and other domains are commonly assessed at baseline testing as part of comprehensive preseason evaluations among collegiate student-athletes. Although approximately 27% of college students have at least 1 sleep disorder, researchers have yet to examine the role of a preexisting sleep disorder on preinjury baseline performance. To compare athletes with and without a reported history of diagnosed sleep disorders on commonly used baseline concussion assessments. Cross-sectional study; Level of evidence, 3. A total of 666 National Collegiate Athletic Association student-athletes completed baseline measures including the Balance Error Scoring System (BESS), Brief Symptom Inventory-18 (BSI-18), Immediate Post-Concussion Assessment and Cognitive Testing (Im
PACT), Post-Concussion Symptom Scale (PCSS), Sport Concussion Assessment Tool-5th Edition (SCAT5), and Standardized Assessment of Concussion (SAC). There were 333 athletes with a history of diagnosed sleep disorders who were matched on age, sex, sport, and concussion history to 333 athletes with no history of diagnosed sleep disorders. Participants in both groups had a mean age of 19.89 ± 1.36 years and included 182 (54.7%) male athletes, and 126 (37.8%) reported a history of ≥1 concussions. A series of 1-way analyses of covariance with Bonferroni corrections revealed significant group differences on the BESS (F Collegiate student-athletes with diagnosed sleep disorders reported elevated affective and concussion symptoms at baseline that could affect the interpretation of postinjury impairments and symptoms. Based on the small effect sizes of our findings, however, the magnitude of these differences is of questionable clinical significance. Still, clinicians should consider diagnosed sleep disorders as reported during preparticipation sports physical examinations when interpreting baseline and postinjury concussion assessments.

Are Patients Who Undergo the Latarjet Procedure Ready to Return to Play at 6 Months? A Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Group Cohort Study

11-02-2020 – Travis L. Frantz,Joshua S. Everhart,Gregory L. Cvetanovich,Andrew Neviaser,Grant L. Jones,Carolyn M. Hettrich,Brian R. Wolf,Keith M. Baumgarten,Matthew J. Bollier,Jonathan T. Bravman,John E. Kuhn,C. Benjamin Ma,Robert G. Marx,Eric C. McCarty,Shannon F. Ortiz,Alan L. Zhang,Julie Y. Bishop

Journal Article

The Latarjet procedure is growing in popularity for treating athletes with recurrent anterior shoulder instability, largely because of the high recurrence rate of arthroscopic stabilization, particularly among contact athletes with bone loss. (1) To evaluate return of strength and range of motion (ROM) 6 months after the Latarjet procedure and (2) to determine risk factors for failure to achieve return-to-play (RTP) criteria at 6 months. Case-control study; Level of evidence, 3. A total of 65 athletes (83% contact sports, 37% overhead sports; mean ± SD age, 24.5 ± 8.2 years; 59 male, 6 female) who enrolled in a prospective multicenter study underwent the Latarjet procedure for anterior instability (29% as primary procedure for instability, 71% for failed prior stabilization procedure). Strength and ROM were assessed preoperatively and 6 months after surgery. RTP criteria were defined as return to baseline strength and <20° side-to-side ROM deficits in all planes. The independent likelihood of achieving strength and motion RTP criteria at 6 months was assessed through multivariate logistic regression modeling with adjustment as needed for age, sex, subscapularis split versus tenotomy, preoperative strength/motion, percentage bone loss, number of prior dislocations, preoperative subjective shoulder function (American Shoulder and Elbow Surgeons and Western Ontario Shoulder Instability Index percentage), and participation in contact versus overhead sports. Of the patients, 55% failed to meet ≥1 RTP criteria: 6% failed for persistent weakness and 51% for ≥20° side-to-side loss of motion. There was no difference in failure to achieve RTP criteria at 6 months between subscapularis split (57%) versus tenotomy (47%) ( A large percentage of athletes fail to achieve full strength and ROM 6 months after the Latarjet procedure. Greater preoperative stiffness and subjective disability are risk factors for failure to meet ROM or strength RTP criteria.

Ischemic Therapy in Musculoskeletal Medicine

11-02-2020 – Austin J. Ramme,Brennan J. Rourke,Christopher M. Larson,Asheesh Bedi

Journal Article

The competitive environment of athletics has promoted the exploration of any technology application that may offer an edge with performance and recovery from injury. Ischemic therapy is one such technology that has rapidly been incorporated into training rooms and physical therapy clinics worldwide. This therapy modality is reported to increase an athlete’s ability to improve muscle mass, strength, and endurance. To provide the sports medicine physician with an understanding of the current state of ischemic therapy technology, including treatment specifications, known physiological effects, hypothesized mechanisms, biochemical effects, athletic applications, medical applications, animal models, and future research recommendations. Literature review. A computer-based search of the PubMed database was used to perform a comprehensive literature review on musculoskeletal ischemic therapy. The current research on ischemic therapy is largely composed of case series with varying equipment, methods, and therapy specifications. The publication of case series has value in identifying this technology for future research, but the results of these studies should not be justification for application to athletes without validation of safety and effectiveness. To date, ischemic therapy remains unvalidated, and the mechanism by which it improves muscle performance is not clear.

Effect of Normal Saline Injections on Lateral Epicondylitis Symptoms: A Systematic Review and Meta-analysis of Randomized Clinical Trials

11-02-2020 – Carlos Alberto Acosta-Olivo,Juan Manuel Millán-Alanís,Luis Ernesto Simental-Mendía,Neri Álvarez-Villalobos,Félix Vilchez-Cavazos,Víctor Manuel Peña-Martínez,Mario Simental-Mendía

Journal Article

Lateral epicondylitis, or tennis elbow, is a painful degenerative disorder that commonly occurs in adults between 40 and 60 years of age. Normal saline (NS) injections have been used as placebo through a large number of randomized controlled trials (RCTs) focused on the treatment of lateral epicondylitis. This meta-analysis of RCTs aimed to assess the therapeutic effect of NS injections on lateral epicondylitis symptoms and compare results with established minimal clinically important difference criteria. Systematic review and meta-analysis. MEDLINE, Embase, Web of Science, and Scopus databases were searched for clinical trials reporting pain and joint function with the visual analog scale, Patient-Rated Tennis Elbow Evaluation, and Disabilities of the Arm, Shoulder and Hand in patients with lateral epicondylitis. The meta-analysis was conducted with a random effects model and generic inverse variance method. Heterogeneity was tested with the A total of 15 RCTs included in this meta-analysis revealed a significant improvement in pain (mean difference, 3.61 cm [95% CI, 2.29-4.92 cm]; NS injections yielded a statistically significant and clinically meaningful improvement in pain and functional outcomes in patients with lateral epicondylitis. New research should focus on better methods to diminish the potential confounders that could lead to this effect because NS injections could mask the real effect of an active therapeutic intervention in RCT. CRD42019127547 (PROSPERO).

Retears and Concomitant Functional Impairments After Rotator Cuff Repair: Shoulder Activity as a Risk Factor

10-02-2020 – Yuzhou Chen,Fangyi Jiang,Hong Li,Shiyi Chen,Yang Qiao,Yunxia Li,Yinghui Hua,Jiwu Chen,Yunshen Ge

Journal Article

Most patients return successfully to shoulder involving sports or activity after rotator cuff repairs. It has not been decided yet whether postoperative participation in shoulder activity adds to the risk of retear. The purpose was to verify whether patients who participate in shoulder activities after rotator cuff repair have a higher risk of structural failure than nonactive patients and to investigate the relationship between postoperative shoulder function and tendon integrity in active and nonactive patients. The hypotheses were that (1) active patients have a higher retear rate than nonactive patients and (2) structural failure is associated with worse functional outcomes in active patients. Cohort study; Level of evidence, 3. A cohort study was performed using 145 patients who underwent arthroscopic rotator cuff repair from 2015 to 2017. Functional assessments and magnetic resonance imaging were performed at least 24 months postoperatively. Shoulder activities since 6 months after surgery were rated in 4 categories (sports, job, activities of daily life, and weight of general lifting) as sedentary, light, moderate, or strenuous. The activity level of each patient was defined by the highest rated category. Patients who were involved in light, moderate, and strenuous activity were identified as active for the present study, and the rest were defined as sedentary. The proportion of retears between groups and the functional conditions between retorn and intact tendons were compared. A total of 48 patients were enrolled in the active group, and 97 were enrolled in the sedentary group. The active group demonstrated a significantly higher retear rate than the sedentary group (27.1% vs 11.3%, respectively; Shoulder activity after the early postoperative period was associated with a high risk of retears in patients who underwent rotator cuff repair. A correlation between inhibited function and structural failure was detected but only in active patients, while sedentary patients with retears retained functional improvements similar to those with intact tendons.

Minimum 5-Year Clinical Outcomes, Survivorship, and Return to Sports After Hamstring Tendon Autograft Reconstruction for Sternoclavicular Joint Instability

10-02-2020 – Lucca Lacheta,Travis J. Dekker,Brandon T. Goldenberg,Marilee P. Horan,Samuel I. Rosenberg,Jonas Pogorzelski,Peter J. Millett

Journal Article

Instability of the sternoclavicular (SC) joint is a rare but potentially devastating pathologic condition, particularly when it occurs in young or active patients, where it can lead to persistent pain and impairment of shoulder function. SC joint reconstruction using a hamstring tendon autograft is a commonly used treatment option, but midterm results are still lacking. The purpose of this study was to assess the clinical outcomes, survivorship, and return-to-sports rate after SC joint reconstruction using a hamstring tendon autograft in patients suffering from SC joint instability. We hypothesized that SC joint reconstruction would result in good clinical outcomes, high rate of survivorship, and a high rate of return to sports. Case series; Level of evidence, 4. All patients who underwent SC joint reconstruction with a hamstring tendon autograft for SC joint instability, with a minimum 5-year follow-up, were included. Patient-reported outcomes were assessed prospectively by the use of the American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numerical Evaluation (SANE) score, short version of the Disabilities of the Arm, Shoulder and Hand (Quick
DASH) score, 12-Item Short Form Health Survey (SF-12) physical component summary (PCS), and patient satisfaction. Survivorship of reconstruction was defined as no further revision surgery or clinical failure such as recurrent instability or subluxation events. Return to sports and pain were assessed using a customized questionnaire. A total of 22 shoulders that underwent SC joint reconstruction, with a mean patient age of 31.3 years (range, 15.8-57.0 years) at the time of surgery, were included. At the final evaluation, 18 shoulders, with a mean follow-up of 6.0 years (range, 5.0-7.3 years), completed a minimum 5-year follow-up. All clinical outcome scores improved significantly from preoperatively to postoperatively: ASES (50.0 to 91.0; SC joint reconstruction with a hamstring tendon autograft for SC joint instability resulted in significantly improved clinical outcomes with high patient satisfaction and 90% survivorship at midterm follow-up. Furthermore, 94% of this young and high-demand patient population returned to their previous level of sports. Concerns in terms of advanced postinstability arthritis were not confirmed because a significant decrease in pain was found after a minimum 5-year follow-up.

Factors Influencing Return to Play and Second Anterior Cruciate Ligament Injury Rates in Level 1 Athletes After Primary Anterior Cruciate Ligament Reconstruction: 2-Year Follow-up on 1432 Reconstructions at a Single Center

07-02-2020 – Enda King,Chris Richter,Mark Jackson,Andy Franklyn-Miller,Eanna Falvey,Gregory D. Myer,Siobhan Strike,Dan Withers,Ray Moran

Journal Article

Despite the importance of return-to-play (RTP) rates, second anterior cruciate ligament (ACL) injury rates, and patient-reported outcomes of athletes returning to sports after ACL reconstruction (ACLR), these outcomes have not been evaluated together across a single cohort nor the pre- and intraoperative factors influencing outcomes explored. To prospectively report outcomes after ACLR relating to RTP, second ACL injury, and International Knee Document Committee (IKDC) scores in a large cohort of athletes at a single center to examine the influence of pre- and intraoperative variables on these outcomes. Cohort study; Level of evidence, 3. A consecutive cohort of 1432 athletes undergoing primary ACLR by 2 orthopaedic surgeons was followed up prospectively more than 2 years after surgery. Pre- and intraoperative findings were reported with outcomes at follow-up relating to RTP, second ACL injury, and IKDC. Between-group differences for each outcome were reported and the predictive ability of pre- and intraoperative variables relating to each outcome assessed with logistic regression. There was >95% follow-up 2 years after surgery. The RTP rate was 81%, and of those who returned, 1.3% of those with patellar tendon grafts and 8.3% of those with hamstring grafts experienced ipsilateral rerupture (hazard ratio, 0.17). The contralateral ACL injury rate was 6.6%, and the IKDC score at follow-up was 86.8, with a greater proportion of patients with patellar tendon grafts scoring <80 on the IKDC (odds ratio, 1.56; 95% CI, 1.15-3.12). There was no relationship between time to RTP and second ACL injury, and there was a moderate correlation between ACL-Return to Sport After Injury score and RTP at follow-up ( Findings demonstrated high overall RTP rates, lower reinjury rates with patellar tendon graft after 2-year follow-up in level 1 athletes, and no influence of time to RTP on second ACL injury. Despite differences between groups, there was poor predictive ability of pre- and intraoperative variables. Results suggest pre- and intraoperative variables for consideration to optimize outcomes in level 1 athletes after ACLR, but future research exploring other factors, such as physical and psychological recovery, may be needed to improve outcome prediction after ACLR. NCT02771548 (Clinical
Trials.gov identifier).

Biologically Regulated Marrow Stimulation by Blocking TGF-β1 With Losartan Oral Administration Results in Hyaline-like Cartilage Repair: A Rabbit Osteochondral Defect Model

06-02-2020 – Hajime Utsunomiya,Xueqin Gao,Zhenhan Deng,Haizi Cheng,Gilberto Nakama,Alex C. Scibetta,Sudheer K. Ravuri,Julia L. Goldman,Walter R. Lowe,William G. Rodkey,Tamara Alliston,Marc J. Philippon,Johnny Huard

Journal Article

Microfracture or bone marrow stimulation (BMS) is often the first choice for clinical treatment of cartilage injuries; however, fibrocartilage, not pure hyaline cartilage, has been reported because of the development of fibrosis in the repair tissue. Transforming growth factor β1 (TGF-β1), which can promote fibrosis, can be inhibited by losartan and potentially be used to reduce fibrocartilage. Blocking TGF-β1 would improve cartilage healing in a rabbit knee BMS model via decreasing the amount of fibrocartilage and increasing hyaline-like cartilage formation. Controlled laboratory study. An osteochondral defect was made in the patellar groove of 48 New Zealand White rabbits. The rabbits were divided into 3 groups: a defect group (defect only), a BMS group (osteochondral defect + BMS), and a BMS + losartan group (osteochondral defect + BMS + losartan). For the rabbits in the BMS + losartan group, losartan was administrated orally from the day after surgery through the day of euthanasia. Rabbits were sacrificed 6 or 12 weeks postoperatively. Macroscopic appearance, microcomputed tomography, histological assessment, and TGF-β1 signaling pathway were evaluated at 6 and 12 weeks postoperatively. The macroscopic assessment of the repair revealed that the BMS + losartan group was superior to the other groups tested. Microcomputed tomography showed superior healing of the bony defect in the BMS + losartan group in comparison with the other groups. Histologically, fibrosis in the repair tissue of the BMS + losartan group was significantly reduced when compared with the other groups. Results obtained with the modified O’Driscoll International Cartilage Repair Society grading system yielded significantly superior scores in the BMS + losartan group as compared with both the defect group and the BMS group ( By blocking TGF-β1 with losartan, the repair cartilage tissue after BMS was superior to the other groups and consisted primarily of hyaline cartilage. These results should be easily translated to the clinic because losartan is a Food and Drug Administration-approved drug and it can be combined with the BMS technique for optimal repair of chondral defects. Biologically regulated marrow stimulation by blocking TGF-β1 (oral intake of losartan) provides superior repair via decreasing fibrocartilage formation and resulting in hyaline-like cartilage as compared with outcomes from BMS only.

Excessive Preoperative Anterior Tibial Subluxation in Extension Is Associated With Inferior Knee Stability After Anatomic Anterior Cruciate Ligament Reconstruction

06-02-2020 – Guan-yang Song,Hui Zhang,Jin Zhang,Zhi-jun Zhang,Tong Zheng,Hua Feng

Journal Article

Anterior tibial subluxation (ATS) in extension after anterior cruciate ligament (ACL) injury highlights an increased anterior position of the tibia relative to the femur. Recent studies demonstrated that subluxation is sometimes irreducible and the normal tibiofemoral relationship is not restored by ACL reconstruction (ACLR), which raises concerns regarding clinical outcomes after ACLR. Excessive preoperative ATS in extension is associated with inferior knee stability after anatomic ACLR. Cohort study; Level of evidence, 3. From March 2016 to January 2017, a total of 487 consecutive patients with clinically diagnosed noncontact ACL injuries who underwent primary anatomic ACLR were retrospectively analyzed. Of these patients, 430 met the criteria for inclusion in this study. Anterior subluxation of the lateral and medial compartments (ASLC and ASMC) in extension relative to the femoral condyles was measured on preoperative magnetic resonance imaging. Twenty patients (study group) who demonstrated excessive (>10 mm) ASLC and ASMC in extension were matched 1:2 to 40 participants (control group) who showed minimal or no (10 mm) preoperative ATS in extension after ACL injury was associated with inferior knee stability after anatomic ACLR.

Adolescent Posterior-Superior Glenoid Labral Pathology: Does Involvement of the Biceps Anchor Make a Difference?

05-02-2020 – Cody H. Hansen,Alicia M. Asturias,Andrew T. Pennock,Eric W. Edmonds

Journal Article

Adolescent athletes are at risk of sustaining an injury to the posterior and superior labrum of the glenoid. Limited information is available regarding the outcomes of surgical intervention in this specific age cohort. To compare those patients with pure posterior pathology and those with posterior labral tears that involve the biceps anchor (superior labrum anterior-posterior [SLAP] tears) to determine risks for failure in the surgical management. Cohort study; Level of evidence, 3. A retrospective review was performed on all patients under the age of 19 years over an 8-year period to identify those treated for superior and posterior labral pathology, followed by chart review, radiographic review, and arthroscopic findings. Patient characteristics and other variables were recorded, including cause (traumatic vs atraumatic), activity/sports (overhead vs nonoverhead), involvement of the biceps anchor-crossing the 12-o’clock position (posterior vs SLAP), associated pathologies, outcome scores (Single Assessment Numerical Evaluation [SANE] and Pediatric/Adolescent Shoulder Survey [PASS] scores), and complications. Forty-eight patients (30 boys, 18 girls) with a mean age at surgery of 16.5 years (range, 13.5-19 years) were identified who met criteria, with a mean follow-up of 4.1 years (range, 1.3-6.9 years). Nineteen patients had SLAP tears and 29 patients had posterior tears. All but 2 regularly participated in sports at the time of their injury; of the athletes, 26 (56.5%) played an overhead sport and 20 (43.5%) played a nonoverhead sport. The cause of the injury was traumatic in 25 cases (52.1%) and atraumatic in 23 cases (47.9%). Outcome scores were not significantly different between cause or type of sports played; SANE scores were not significantly different by tear type (mean SLAP score, 88.4 compared with mean posterior score, 80.9; Posterior SLAP tears have better outcomes and lower failure rates than posterior-only tears in the adolescent population. Posterior-superior labral tears can occur in all sports types with multiple causes, but the only factor that appears to play a role in ultimate outcome is whether the tear crosses under the biceps anchor to the anterior side.

Tendon Healing Progression Evaluated With Magnetic Resonance Imaging Signal Intensity and Its Correlation With Clinical Outcomes Within 1 Year After Rotator Cuff Repair With the Suture-Bridge Technique

05-02-2020 – Shaohua Liu,Yuxue Xie,Qingyan Chen,Yaying Sun,Zheci Ding,Yuhan Zhang,Shiyi Chen,Jiwu Chen

Journal Article

After a rotator cuff (RC) is repaired, its signal intensity (SI) on magnetic resonance imaging (MRI) gradually changes to normal and could reflect the degree of RC healing. Nevertheless, it remains unclear how long it takes for SI to recover to normal and whether the SI progression correlates with clinical outcomes after RC repair (RCR). To serially evaluate the SIs of the repaired RC tendon on MRI and the postoperative clinical outcomes and then analyze the correlation between them. Case series; Level of evidence, 4. This study prospectively included 25 patients who underwent arthroscopic RCR with the suture-bridge technique between June 2016 and July 2017. Twenty-three patients accepted full follow-ups at 1, 3, 6, 9, and 12 months. Before surgery and at each follow-up, visual analog scale (VAS) for pain and 4 functional scores were evaluated: Constant-Murley score, American Shoulder and Elbow Surgeons shoulder evaluation form, modified University of California at Los Angeles score, and Fudan University shoulder score. The patients underwent MRI examinations at every follow-up. The values of the signal/noise quotient at the distal (SNQd) and proximal (SNQp) areas were calculated to evaluate the SI of the repaired tendon. The correlations of clinical outcomes with SNQd and SNQp values were analyzed, and subgroup analyses were performed. Overall, the mean postoperative VAS score significantly decreased at postoperative 1 month ( After RCR with the suture-bridge technique, it took longer for SI to become relatively normal than it did to have a significant clinical improvement. Early after surgery (1-3 months), worse clinical outcome correlated with higher SI on proximal cuff tendon.

An Intact Ligamentum Teres Predicts a Superior Prognosis in Patients With Borderline Dysplasia: A Matched-Pair Controlled Study With Minimum 5-Year Outcomes After Hip Arthroscopic Surgery

04-02-2020 – David R. Maldonado,Sarah L. Chen,Rafael Walker-Santiago,Jacob Shapira,Philip J. Rosinsky,Ajay C. Lall,Benjamin G. Domb

Journal Article

Hip arthroscopic surgery in patients with borderline dysplasia continues to be controversial. In addition, it has been suggested that ligamentum teres (LT) tears may lead to inferior short-term patient-reported outcomes (PROs) when compared with a match-controlled group. (1) To report minimum 5-year PROs in patients with borderline dysplasia and LT tears who underwent hip arthroscopic surgery and (2) to compare these PROs to those of a matched-pair control group of patients with borderline dysplastic hips without LT tears. Cohort study; Level of evidence, 3. Data were prospectively collected for patients who underwent hip arthroscopic surgery between September 2008 and August 2013. Patients were included if they had a preoperative diagnosis of borderline dysplasia (lateral center-edge angle [LCEA], 18°-25°) and had preoperative and minimum 5-year postoperative modified Harris Hip Score (m
HHS), Nonarthritic Hip Score (NAHS), and visual analog scale (VAS) for pain scores. Exclusion criteria were osteoarthritis of Tönnis grade >1, previous hip conditions, any previous ipsilateral hip surgery, or workers’ compensation status. There were 2 borderline dysplastic groups created. An LT tear group was matched 1:1 to a control group (no LT tear) with similar age, sex, body mass index (BMI), and laterality via propensity score matching. Significance was set at A total of 24 patients with an LT tear (24 hips) were matched to 24 patients without an LT tear (24 hips). There was no significant difference in age, sex, BMI, or laterality between groups. The mean age was 36.2 ± 17.2 and 34.9 ± 15.9 years for the control and LT tear groups, respectively ( After hip arthroscopic surgery, patients with borderline dysplasia and LT tears demonstrated favorable PROs at a minimum 5-year follow-up. Outcomes were similar to a matched-pair control group without LT tears, with the group with intact LTs showing higher VR-12 mental and SF-12 mental scores. Furthermore, patients with borderline dysplasia and intact LTs were significantly more likely to achieve the PASS for the m
HHS.

Effect of Lubricin Mimetics on the Inhibition of Osteoarthritis in a Rat Anterior Cruciate Ligament Transection Model

31-01-2020 – Daniel Nemirov,Yusuke Nakagawa,Zhexun Sun,Amir Lebaschi,Susumu Wada,Camila Carballo,Xiang-Hua Deng,David Putnam,Lawrence J. Bonassar,Scott A. Rodeo

Journal Article

Lubricin, a mucinous glycoprotein, plays a chondroprotective role as a constituent of synovial fluid. Structural analogs have been synthesized to mimic the structure and function of native lubricin in an effort to recapitulate this effect with the goal of delaying progression of osteoarthritis (OA). To investigate the efficacy of intra-articular injections of lubricin mimetics in slowing or preventing the progression of posttraumatic OA by using a rat anterior cruciate ligament transection model. Controlled laboratory design. Four lubricin mimetics were investigated, differing from one another in their binding orientations and steric interactions. Eighty skeletally mature Sprague-Dawley rats underwent bilateral anterior cruciate ligament transections and were randomly allocated to receive intra-articular injections (50 µL/injection) of 1 of the 4 mimetics in the right knee and equal volumes of saline injection in the contralateral knee (control). All rats were euthanized 8 weeks postoperatively and assessed via biomechanical analysis, which evaluated comparative friction coefficients across the 4 groups, and histological evaluation of articular cartilage, osteophytes, and synovitis. The Osteoarthritis Research Society International (OARSI) histopathological assessment system was used to evaluate the degree of articular cartilage degeneration and osteophytes, while synovitis was assessed through a semiquantitative scoring system. Binding efficacy of the 4 mimetics was assessed in vitro and in vivo through the immunohistochemical localization of polyethylene glycol. Articular cartilage degeneration and synovitis scoring data analyses were performed with generalized estimating equation modeling. Injection of the group 3 mimetic (random 24 + 400 + 30) directly correlated with improved OARSI scores for femoral articular cartilage degeneration when compared with saline-injected contralateral control knees ( We demonstrated that the tribosupplementation of a traumatically injured knee with a specific lubricin structural analog may attenuate the natural progression of OA. The current lack of efficacious clinical options to counter the onset and subsequent development of OA suggests that further investigation into the synthesis and behavior of lubricin analogs could yield novel translational applications.

Integrin α10β1-Selected Mesenchymal Stem Cells Mitigate the Progression of Osteoarthritis in an Equine Talar Impact Model

31-01-2020 – Michelle L. Delco,Margaret Goodale,Jan F. Talts,Sarah L. Pownder,Matthew F. Koff,Andrew D. Miller,Bridgette Nixon,Lawrence J. Bonassar,Evy Lundgren-Åkerlund,Lisa A. Fortier

Journal Article

Early intervention with mesenchymal stem cells (MSCs) after articular trauma has the potential to limit progression of focal lesions and prevent ongoing cartilage degeneration by modulating the joint environment and/or contributing to repair. Integrin α10β1 is the main collagen type II binding receptor on chondrocytes, and MSCs that are selected for high expression of the α10 subunit have improved chondrogenic potential. The ability of α10β1-selected (integrin α10 To investigate integrin α10 Controlled laboratory study. Focal cartilage injuries were created on the tali of horses (2-5 years, n = 8) by using an impacting device equipped to measure impact stress. Joints were treated with 20 × 10 Integrin α10 Intra-articular administration of integrin α10 This preclinical study indicates that intra-articular therapy with integrin α10

Mechanisms of Acute Knee Injuries in Bouldering and Rock Climbing Athletes

31-01-2020 – Christoph Lutter,Thomas Tischer,Carrie Cooper,Luisa Frank,Thilo Hotfiel,Robert Lenz,Volker Schöffl

Journal Article

There is limited insight into the mechanisms of knee injuries in rock climbing and bouldering in noncompetitive and competitive athletes. To examine the traumatic mechanisms of injury, demographics, distribution, and severity of knee injuries in affected athletes. Case series; Level of evidence, 4. During a 4-year period, we performed a retrospective multicenter analysis of acute knee injuries in competitive and noncompetitive climbing athletes. Traumatic mechanisms were inquired and severity levels, therapies, and outcomes recorded with visual analog scale, Tegner, Lysholm, and climbing-specific outcome scores. Within the observation period, 71 patients (35% competitive athletes, 65% noncompetitive athletes) with 77 independent acute knee injuries were recorded. Four trauma mechanisms were identified: high step (20.8%), drop knee (16.9%), heel hook (40.3%), and (ground) fall (22.1%). The leading structural damage was a medial meniscal tear (28.6%), found significantly more often in the noncompetitive group. A specific climbing injury is iliotibial band strain during the heel hook position. Most injuries resulted from indoor bouldering (46.8%). Surgical procedures were predominantly necessary in noncompetitive climbers. One year after the injury, the Tegner score was 5.9 ± 0.8 (mean ± SD; range, 3-7); the Lysholm score was 97 ± 4.8 (range, 74-100); and the climbing-specific outcome score was 4.8 ± 0.6 (range, 2-5). Increased attention should be placed on the climber’s knee, especially given the worldwide rise of indoor bouldering. Sport-specific awareness and training programs for noncompetitive and competitive climbing athletes to reduce knee injuries should be developed, and sports medical supervision is mandatory.

Increased Posterior Tibial Slope in Patients With Osgood-Schlatter Disease: A New Association

31-01-2020 – Daniel W. Green,Sreetha Sidharthan,Lindsay M. Schlichte,Alexandra H. Aitchison,Douglas N. Mintz

Journal Article

Osgood-Schlatter disease (OSD) is a traction apophysitis of the tibial tubercle caused by repetitive strain and chronic avulsion from the patellar tendon. No widely accepted anatomic risk factors have been associated with OSD. To determine if OSD is associated with increased posterior tibial slope (PTS). Cross-sectional study; Level of evidence, 3. Forty knees with OSD and 32 control knees examined by the senior author between 2008 and 2019 were included. Patients 10 to 15 years of age with a clinical diagnosis of OSD and available lateral radiograph and magnetic resonance imaging (MRI) were eligible. Age- and sex-matched patients with a history of knee pain but no evidence of OSD on clinical examination and without significant pathology on lateral radiograph and MRI were included in the control group. PTS was defined as the angle between a reference line perpendicular to the proximal anatomic axis and a line drawn tangent to the uppermost anterior and posterior edges of the medial tibial plateau. Measurements were carried out in duplicate on true lateral radiographs by 2 blinded investigators. Interrater reliability of PTS measurements was evaluated using intraclass correlation coefficient (ICC). The independent samples The mean age was 12.6 ± 1.6 years and 51% (37/72) of the knees were from male youth. There were no differences in age, sex, and laterality of knees between the OSD and control groups. The mean PTS was significantly higher in the OSD group (12.23°± 3.58°) compared with the control group (8.82°± 2.76°; This study identifies an association between OSD and increased PTS. The clinical implications of this finding have not yet been elucidated. It may be speculated that in patients with OSD, stress from the extensor mechanism through the patellar tendon loads the anterior portion of the tibia disproportionately to the posterior segment, thereby resulting in asymmetric growth and an increased PTS.

Corrigendum

31-01-2020 –

Published Erratum

Reduction of Postoperative Hip Arthroscopy Pain With an Ultrasound-Guided Fascia Iliaca Block: A Prospective Randomized Controlled Trial

30-01-2020 – John L. Glomset,Eugene Kim,John M. Tokish,Suzanne D. Renfro,Tyler B. Seckel,Kyle J. Adams,Jason Folk

Journal Article

Ultrasound-guided fascia iliaca blocks have been used for pain control after hip arthroscopy. There is little evidence regarding their effectiveness in comparison with other pain control modalities in patients who have undergone hip arthroscopy. To compare the efficacy of ultrasound-guided fascia iliac block with intra-articular ropivacaine in controlling pain after hip arthroscopy. Randomized controlled trial; Level of evidence, 2. Between 2015 and 2017, patients (N = 95) undergoing hip arthroscopy were randomly assigned to 2 groups. The first group received an ultrasound-guided fascia iliaca block with 50 to 60 m
L of 0.35% ropivacaine. The second group received an intra-articular injection of 20 m
L of 0.5% ropivacaine at the completion of the surgical case. Primary outcomes were postoperative pain scores in the recovery room; at postanesthesia care unit (PACU) discharge; and at 2 weeks, 6 weeks, and 3 months. Secondary outcomes included intraoperative and PACU narcotic usage (converted to morphine equivalent use) as well as readmission rates, PACU recovery time, and postoperative nausea and vomiting. Postoperative pain across all points did not significantly differ between the groups. Intraoperative and PACU narcotics did not differ significantly between the groups. Readmission rates, PACU recovery time, and postoperative nausea and vomiting did not significantly differ between the groups. There were no associated complications in either group. Ultrasound-guided fascia iliaca block for hip arthroscopy had no clinical advantage when compared with onetime intra-articular ropivacaine injection. NCT02365961 (Clinical
Trials.gov identifier).

Are Elite Soccer Teams’ Preseason Training Sessions Associated With Fewer In-Season Injuries? A 15-Year Analysis From the Union of European Football Associations (UEFA) Elite Club Injury Study

28-01-2020 – Jan Ekstrand,Armin Spreco,Johann Windt,Karim M. Khan

Journal Article

Preseason training develops players’ physical capacities and prepares them for the demands of the competitive season. In rugby, Australian football, and American football, preseason training may protect elite players against in-season injury. However, no study has evaluated this relationship at the team level in elite soccer. The aim of this study was to investigate whether the number of preseason training sessions completed by elite soccer teams was associated with team injury rates and player availability during the competitive season. It was hypothesized that elite soccer teams who participate in more preseason training will sustain fewer injuries during the competitive season. Descriptive epidemiology study. We used the Union of European Football Associations (UEFA) injury dataset to analyze 44 teams for up to 15 seasons (total, 244 team-seasons). Separate linear regression models examined the association between the number of team preseason training sessions and 5 in-season injury measures. Injury-related problems per team were quantified by totals of the following: (1) injury burden, (2) severe injury incidence, (3) training attendance, (4) match availability, and (5) injury incidence. Teams averaged 30 preseason training sessions (range, 10-51). A greater number of preseason training sessions was associated with less injury load during the competitive season in 4 out of 5 injury-related measures. Our linear regression models revealed that for every 10 additional preseason training sessions that the team performed, the in-season injury burden was 22 layoff days lower per 1000 hours ( Teams that performed a greater number of preseason training sessions had “healthier” in-season periods. Many other factors also contribute to in-season injury rates. Understanding the benefit of preseason training on in-season injury patterns may inform sport teams’ planning and preparation.

Professional Advancement and Performance of Amateur Baseball Players Selected in the Major League Baseball Draft With Previous Anterior Cruciate Ligament Reconstruction

28-01-2020 – Anthony Porter,Shawn Yang,Aakash Chauhan,Samuel Early,Sravya Challa,John D’Angelo,Daniel Keefe,Heinz Hoenecke,Jan Fronek

Journal Article

The effect that an anterior cruciate ligament injury requiring reconstructive surgery has on the professional advancement and performance of amateur baseball players selected in the Major League Baseball draft is not known. Return to sports after anterior cruciate ligament reconstruction (ACLR) in professional athletes has been shown to be high, but mixed results with regard to performance and return to preinjury level have been demonstrated in other sports. To (1) investigate the highest level of professional advancement among Major League Baseball draftees with a history of ACLR before entering the draft, (2) examine how much time these players spent on the disabled list (DL) and determine if it was related to the knee, and (3) compare the batting and pitching performance of these players against healthy matched controls. Cohort study; Level of evidence, 3. Predraft medical records of all players selected in the Major League Baseball draft from 2004 to 2008 were reviewed. Players with a documented anterior cruciate ligament injury treated with ACLR before the draft were included. For each study player, 3 controls were identified. Data were accumulated from the time when players were drafted through the 2015 season. Outcome variables included highest professional level of advancement, DL time, and batting and pitching performance. Forty draftees with a history of ACLR (22 pitchers, 18 position players) were identified and matched to 120 controls (66 pitchers, 54 position players). The difference in the highest level of professional advancement between the groups was not statistically significant ( There was no difference between draftees with a history of ACLR and their controls in terms of advancement from the minor to the major leagues. Additionally, pitching and batting performance were similar. Although the 2 groups spent similar time on the DL, the ACLR group spent more time on the DL because of a knee injury than the control group.

Repair of a Meniscal Defect in a Rabbit Model Through Use of a Thermosensitive, Injectable, In Situ Crosslinked Hydrogel With Encapsulated Bone Mesenchymal Stromal Cells and Transforming Growth Factor β1

22-01-2020 – Chen Chen,Jialin Song,Jiayu Qiu,Jinzhong Zhao

Journal Article

Meniscal injury repair with tissue engineering technique is promising. Among various scaffolds, the thermosensitive injectable hydrogel has recently attracted much attention. (1) Evaluate the biocompatibility of thermosensitive, injectable, in situ crosslinked hydrogel and (2) determine whether the hydrogel with or without transforming growth factor β1 (TGF-β1) could support the fibrochondrogenic differentiation of bone mesenchymal stromal cells (BMSCs) and promote the repair of a critical-sized defect in rabbit meniscus. Controlled laboratory study. The rheological and sustained release properties of the hydrogel were demonstrated. BMSCs were isolated and cultured. Cell viability, quantitative polymerase chain reaction (q
PCR), and Western blot were tested in vitro. In vivo, a critical-sized defect was introduced into the meniscus of 30 rabbits. Each defect was randomly assigned to be implanted with either phosphate-buffered saline (PBS); BMSC-laden hydrogel; or BMSC-laden, TGF-β1-incorporated hydrogel. Histological and immunohistochemical analyses were performed at 8 weeks after surgery. The Ishida scoring system was adopted to evaluate the healing quantitatively. The elastic modulus of the hydrogel was about 1000 Pa. The hydrogel demonstrated a sustained-release property and could promote proliferation and induce fibrochondrogenic differentiation of BMSCs after the incorporation of TGF-β1 ( The hydrogel was biocompatible and could stimulate strong fibrochondrogenic differentiation of BMSCs after the incorporation of TGF-β1. The local administration of the BMSC-laden, TGF-β1-incorporated hydrogel could promote the healing of rabbit meniscal injury. This hydrogel is an alternative scaffold for meniscus tissue engineering.

Morphological Changes of the Femoral Tunnel and Their Correlation With Hamstring Tendon Autograft Maturation up to 2 Years After Anterior Cruciate Ligament Reconstruction Using Femoral Cortical Suspension

22-01-2020 – Shurong Zhang,Shaohua Liu,Liqin Yang,Shuang Chen,Shiyi Chen,Jiwu Chen

Journal Article

Graft healing within the femoral tunnel after anterior cruciate ligament reconstruction (ACLR) using suspensory fixation could be reflected in graft maturation and tunnel morphological changes. However, the correlation between graft maturation and femoral tunnel changes remains unclear. To quantitatively evaluate femoral tunnel morphological changes and graft maturation and to analyze their correlation after ACLR using femoral cortical suspension. Case series; Level of evidence, 4. Patients who underwent single-bundle ACLR with a hamstring tendon autograft using femoral cortical suspension were included. Preoperative and postoperative (at 6, 12, and 24 months) knee function were evaluated using KT-1000 arthrometer testing, the Lysholm knee scoring scale, and the International Knee Documentation Committee (IKDC) questionnaire. At 1 day, 6 months, 12 months, and 24 months after ACLR, 3-dimensional magnetic resonance imaging was performed to observe the morphology of the femoral tunnel and to evaluate graft maturation using the graft signal/noise quotient (SNQ). The Pearson product moment correlation coefficients ( A total of 22 patients completed full follow-up. KT-1000 arthrometer, Lysholm, and IKDC scores improved over time postoperatively, but no significant improvement was seen after 12 months ( After ACLR using suspensory fixation, morphological changes of the femoral tunnel were mainly observed in the part of the tunnel containing the graft, which expanded at 6 months and reduced by 24 months. Expansion mainly occurred at the anteroinferior wall of the femoral tunnel. Femoral tunnel expansion was correlated with inferior graft maturation but not with clinical outcomes.

The Concept of Sport Sampling Versus Sport Specialization: Preventing Youth Athlete Injury: A Systematic Review and Meta-analysis

21-01-2020 – Seth L. Carder,Nicolas E. Giusti,Lisa M. Vopat,Armin Tarakemeh,Jordan Baker,Bryan G. Vopat,Mary K. Mulcahey

Journal Article

The prevalence of youth athletes specializing in 1 sport has been increasing over the past decade. Subsequently, the rate of youth athlete injury has also been increasing. It is possible that an association exists between youth specialization and sports injury rate. To determine if sport sampling is associated with a lower sports injury rate in youths compared with youths who specialize in 1 sport. Systematic review and meta-analysis. A systematic review was conducted following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using PubMed, Embase, and the Cochrane library. Inclusion criteria included studies written in the English language, studies with athletes between 7 and 18 years of age, studies that report injury rates, and studies that specify if athletes were sport samplers or specialized in a sport. Data relevant to this study, including injuries and patient characteristics, were extracted and statistically analyzed. The initial search identified 324 studies, 6 of which met inclusion criteria. From these 6 studies, the total participant number was 5736. Of those, 2451 (42.7%) were “sport samplers,” 1628 (28.4%) were “sport specializers,” and 1657 (28.9%) were considered “others” (ie, could not be classified as true samplers or true specializers). The average age of all the athletes was 14.6 years (range, 7-18 years). Sport specializers had a significantly higher injury risk than the sport samplers (RR, 1.37; 95% CI, 1.19-1.57; Sport sampling is associated with a decreased risk of sports injury in youth athletes when compared with those who specialize in 1 sport. Injury rates increase as a youth athlete becomes increasingly specialized. Youth athletes would benefit substantially from participating in sport sampling.

Location of Intra- and Extra-articular Hip Impingement Is Different in Patients With Pincer-Type and Mixed-Type Femoroacetabular Impingement Due to Acetabular Retroversion or Protrusio Acetabuli on 3D CT–Based Impingement Simulation

21-01-2020 – Till D. Lerch,Mathias Siegfried,Florian Schmaranzer,Christiane S. Leibold,Corinne A. Zurmühle,Markus S. Hanke,Michael K. Ryan,Simon D. Steppacher,Klaus A. Siebenrock,Moritz Tannast

Journal Article

Diagnosis and surgical treatment of hips with different types of pincer femoroacetabular impingement (FAI), such as protrusio acetabuli and acetabular retroversion, remain controversial because actual 3-dimensional (3D) acetabular coverage and location of impingement cannot be studied via standard 2-dimensional imaging. It remains unclear whether pincer hips exhibit intra- or extra-articular FAI. (1) To determine the 3D femoral head coverage in these subgroups of pincer FAI, (2) determine the impingement-free range of motion (ROM) through use of osseous models based on 3D-computed tomography (CT) scans, and (3) determine the osseous intra-and extra-articular 3D impingement zones by use of 3D impingement simulation. Cross-sectional study; Level of evidence, 3. This is a retrospective, comparative, controlled study involving 70 hips in 50 patients. There were 24 patients (44 hips) with symptomatic pincer-type or mixed-type FAI and 26 patients (26 hips) with normal hips. Surface models based on 3D-CT scans were reconstructed and compared for hips with acetabular retroversion (30 hips), hips with protrusio acetabuli (14 hips), and normal asymptomatic hips (26 hips). Impingement-free ROM and location of impingement were determined for all hips through use of validated 3D collision detection software based on CT-based 3D models. No abnormal morphologic features of the anterior iliac inferior spine were detected. (1) Mean total femoral head coverage was significantly ( Using CT-based 3D hip models, we found that hips with pincer-type and mixed-type FAI have significantly larger femoral head coverage and different osseous ROM and location of impingement compared with normal hips. Additionally, intra- and extra-articular subspine impingement was detected predominantly in hips with acetabular retroversion. Acetabular rim trimming during hip arthroscopy or open surgical hip dislocation should be performed with caution for these hips. Patient-specific analysis of location of impingement using 3D-CT could theoretically improve diagnosis and planning of surgical treatment.

Human Amniotic Mesenchymal Stem Cell Sheets Encapsulating Cartilage Particles Facilitate Repair of Rabbit Osteochondral Defects

15-01-2020 – Qi You,Ziming Liu,Jun Zhang,Mengjie Shen,Yuwan Li,Ying Jin,Yi Liu

Journal Article

Human amniotic mesenchymal stem cells (h
AMSCs) are being widely applied in various fields. Therefore, h
AMSCs represent a promising candidate to facilitate cartilage regeneration. Nonetheless, no studies have investigated the application of h
AMSC sheets to repair cartilage defects in vivo. To evaluate h
AMSC sheets encapsulating cartilage particles to promote repair of rabbit osteochondral defects. Controlled laboratory study. h
AMSC sheets were constructed with passage 3 h
AMSCs. The phenotypic and structural characteristics of h
AMSC sheets were evaluated by flow cytometry and scanning electron microscopy, respectively. The potential for chondrogenic differentiation of h
AMSC sheets was assessed by cartilage-specific marker staining, immunohistochemistry, and m
RNA and protein expression (SOX9, COLII, and ACAN). Osteochondral defects (diameter, 3.5 mm; depth, 3 mm) were created in the left patellar grooves of 20 New Zealand White rabbits (female or male). The defects were treated with h
AMSC sheet/cartilage particles (n = 5), cartilage particles (n = 5), h
AMSC sheets (n = 5), or fibrin glue (n = 5). Macroscopic and histological evaluations of the regenerated tissue were conducted after 3 months. The survival time and differentiation of transplanted h
AMSCs in the defect area were evaluated by immunofluorescence. h
AMSC sheets had a multilayered structure, with cells stacked layer by layer. Importantly, h
AMSC sheets highly expressed phenotypic markers of mesenchymal stem cells. Cartilage-specific marker staining and immunohistochemistry were positive, and m
RNA and protein expression was higher in the chondrogenically induced h
AMSC sheet group than in the h
AMSC sheet group ( h
AMSC sheets encapsulating cartilage particles facilitate osteochondral defect repair. Delivery of cells in the form of a cell sheet in conjunction with cartilage particles provides a novel approach for cell-based cartilage regeneration.

Minimum 5-Year Outcomes and Return to Sports After Resection Arthroplasty for the Treatment of Sternoclavicular Osteoarthritis

15-01-2020 – Travis J. Dekker,Lucca Lacheta,Brandon T. Goldenberg,Marilee P. Horan,Jonas Pogorzelski,Peter J. Millett

Journal Article

Osteoarthritis of the sternoclavicular (SC) joint is a rare condition that leads to decreased function and persistent pain, ultimately altering the function of the shoulder and keeping individuals from their desired activities. SC resection in the setting of primary and posttraumatic osteoarthritis is the most common surgical treatment for these patients, but midterm results are lacking. The purpose was to assess the clinical outcomes, pain levels, return to sports rate, and survivorship after open SC joint resection in the setting of painful primary SC joint osteoarthritis. We hypothesized that an SC joint resection of maximum 10 mm would result in a significant improvement in clinical outcomes, decreased pain levels, a high rate of return to sports, and a high survivorship. Case series; Level of evidence, 4. Patients who underwent SC joint resection (maximum 10 mm) by a single surgeon between the years 2006 and 2013 with minimum 5-year follow-up were reviewed. The following clinical outcomes were collected prospectively during this time period: 12-Item Short Form Health Survey Physical Component Score (SF-12 PCS), American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numerical Evaluation (SANE) score, Quick Disabilities of the Arm, Shoulder and Hand (Quick
DASH) score, and patient satisfaction. Return to sports and pain were assessed through use of a customized questionnaire. Survivorship of SC joint resection was defined as not requiring further surgery on the affected joint. A total of 21 SC joints were treated with resection of the medial clavicle and intra-articular disk and capsulorrhaphy for SC joint osteoarthritis in 19 patients with a mean age of 39.4 years (range, 12.5-66.7 years). At minimum 5-year follow-up, 19 SC joint resections were assessed in 16 of 19 patients (84%) with a mean follow-up of 6.7 years (range, 5.0-10.4 years). All outcome scores improved significantly from pre- to postoperative assessments: ASES (from 54 to 90.5; Open SC resection arthroplasty with capsulorrhaphy in the setting of pain for SC osteoarthritis results in significant improvement in clinical outcomes, patient satisfaction, return to sports, and pain reduction at minimum 5-year follow-up.

Knee Extension Deficit in the Early Postoperative Period Predisposes to Cyclops Syndrome After Anterior Cruciate Ligament Reconstruction: A Risk Factor Analysis in 3633 Patients From the SANTI Study Group Database

13-01-2020 – Jean-Romain Delaloye,Jozef Murar,Thais D. Vieira,Florent Franck,Charles Pioger,Lionel Helfer,Adnan Saithna,Bertrand Sonnery-Cottet

Journal Article

Cyclops syndrome is characterized by a symptomatic extension deficit attributed to impingement of a cyclops lesion within the intercondylar notch. The syndrome is an important cause of reoperation after anterior cruciate ligament reconstruction (ACLR). It has been suggested that remnant-preserving ACLR techniques may predispose to cyclops syndrome, but there is very limited evidence to support this. In general terms, risk factors for cyclops syndrome are not well-understood. To determine the frequency of and risk factors for reoperation for cyclops syndrome in a large series of patients after ACLR. Case-control study; Level of evidence, 3. A retrospective analysis of prospectively collected data was performed, including all patients who underwent primary ACLR between January 2011 to December 2017. Patients undergoing major concomitant procedures were excluded. Demographic data, intraoperative findings (including the size of preserved remnants), and postoperative outcomes were recorded. Those patients who underwent reoperation for cyclops syndrome were identified, and potential risk factors were evaluated in multivariate analysis. A total of 3633 patients were included in the study, among whom 65 (1.8%) underwent reoperation for cyclops syndrome. Multivariate analysis demonstrated that preservation of large remnants did not predispose to cyclops lesions (odds ratio [OR], 1.11; 95% CI, 0.63-1.93). The most important risk factor was extension deficit in the early postoperative period. If present at 3 weeks postoperatively, it was associated with a >2-fold increased risk of cyclops syndrome (OR, 2.302; 95% CI, 1.268-4.239; Failure to regain full extension in the early postoperative period was the only significant risk factor for cyclops syndrome after ACLR in a large cohort of patients. Other previously hypothesized risk factors, such as preservation of a large anterior cruciate ligament remnant, did not predispose to the development of this debilitating postoperative complication.

Small Subchondral Drill Holes Improve Marrow Stimulation of Rotator Cuff Repair in a Rabbit Model of Chronic Rotator Cuff Tear

13-01-2020 – Yucheng Sun,Jae-Man Kwak,Erica Kholinne,Youlang Zhou,Jun Tan,Kyoung Hwan Koh,In-Ho Jeon

Journal Article

Microfracture of the greater tuberosity has been proved effective for enhancing tendon-to-bone healing after rotator cuff repair. However, no standard diameter for the microfracture has been established. This study aimed to assess treatment with large- and small-diameter microfractures to enhance healing during rotator cuff repair surgery in a rabbit model of chronic rotator cuff tear. It was hypothesized that a small-diameter microfracture had advantages in terms of tendon-to-bone integration, bone-tendon interface maturity, microfracture healing, and biomechanical properties compared with a large-diameter microfracture. Controlled laboratory study. Bilateral supraspinatus tenotomy from the greater tuberosity was performed on 21 New Zealand White rabbits. Bilateral supraspinatus repair was performed 6 weeks later. Small-diameter (0.5 mm) microfracture and large-diameter microfracture (1 mm) were performed on the left side and right side, respectively, in 14 rabbits as a study group, and simple repair without microfracture was performed in 7 rabbits as a control group. At 12 weeks later, 7 of 14 rabbits in the study group were sacrificed for micro-computed tomography evaluation and biomechanical testing. Another 6 rabbits were sacrificed for histological evaluation. In the control group, 3 of the 7 rabbits were sacrificed for histological evaluation and the remaining rabbits were sacrificed for biomechanical testing. Significantly better bone-to-tendon integration was observed in the small-diameter microfracture group. Better histological formation and maturity of the bone-tendon interface corresponding to better biomechanical results (maximum load to failure and stiffness) were obtained on the small-diameter microfracture side compared with the large-diameter side and the control group. The large-diameter microfracture showed worse radiographic and histological properties for healing of the microfracture holes on the greater tuberosity. Additionally, the large-diameter microfracture showed inferior biomechanical properties but similar histological results compared with the control group. Small-diameter microfracture showed advantages with enhanced rotator cuff healing for biomechanical, histological, and radiographic outcomes compared with large-diameter microfracture, and large-diameter microfracture may worsen the rotator cuff healing. This animal study suggested that a smaller diameter microfracture may be a better choice to enhance healing in clinical rotator cuff repair surgery in humans.

Bilateral Hip Arthroscopy in High-Level Athletes: Results of a Shorter Interval Between Staged Bilateral Hip Arthroscopies

13-01-2020 – Jeffrey D. Hassebrock,Anikar Chhabra,Justin L. Makovicka,Kostas J. Economopoulos

Journal Article

Hip arthroscopy is a safe and effective mechanism for treating femoroacetabular impingement symptoms in high level athletes. Bilateral symptoms occur in a subset of this population. To discuss outcomes of bilateral hip arthroscopy in high-level athletes and compare a standard staged timeline for bilateral hip arthroscopic surgery versus an accelerated timeline. Cohort study; Level of evidence, 3. A retrospective review of all staged bilateral hip arthroscopies was performed on high-level athletes over a 3-year period. Patients were categorized into cohorts based upon when the second procedure was performed (4-6 weeks after the index procedure or >6 weeks after the index procedure). Exclusion criteria included any prior hip surgery, advanced arthritis, previous pelvic or femoral fracture, or inflammatory arthropathy. Demographics, radiographic measurements, operative reports of procedures performed, and patient-reported outcomes (Hip Outcome Score-Activities of Daily Living, Hip Outcome Score-Sport Specific Subscale, modified Harris Hip Score, return to sports, return to same level of play) were compared between groups at 6-month, 1-year, and 2-year intervals, with the Student 50 patients were identified: 22 in the accelerated surgery (AS) group and 28 in the standard surgery (SS) group. Age and number of collegiate participants were greater in the AS group, whereas the number of high school participants and the time away from sports were higher in the SS group. Preoperative alpha angles were significantly larger among the AS group, but no differences were found in postoperative alpha angles, center edge angles, or Tönnis grades. No significant difference was seen in patient-reported outcomes between the 2 groups at 6-month, 1-year, and 2-year follow-up. Bilateral hip arthroscopy performed 4 to 6 weeks apart is a safe and effective treatment option for athletes with bilateral femoroacetabular impingement and labral tears; the procedures entail a high rate of return to sports, return to the same level of sports, and decreased time lost from sports. This information could be useful for an athlete deciding on whether to proceed with bilateral hip arthroscopy and deciding on the timing for the procedures.

Female Team Physician Representation in Professional and Collegiate Athletics

10-01-2020 – Olivia C. O’Reilly,Molly A. Day,William T. Cates,Jaqueline E. Baron,Natalie A. Glass,Robert W. Westermann

Journal Article

Although a sex-based balance in US graduate medical education has been well-documented, a discrepancy remains in orthopaedic surgery. In orthopaedic sports medicine, the representation of women as team physicians has not previously been characterized. To quantify the sex-related composition of team physicians of select National Collegiate Athletic Association (NCAA) Division I collegiate and professional teams. Additionally, the authors assess the sex-related composition of orthopaedic surgeon team physicians specifically and compare these proportions to the sex-related composition of orthopaedic surgeon membership of the American Orthopaedic Society for Sports Medicine (AOSSM). Cross-sectional study. Publicly available sex-related data were collected for team physicians in select NCAA Division I collegiate conferences and professional sports organizations. Subspecialty characteristics and sex distribution were described by use of percentages. Chi-square tests were used to assess whether sex distributions of team physicians in collegiate and professional sports were (1) representative between the populations of female and male physicians compared with the general public and (2) representative of the sex-based composition of orthopaedic surgeons nationally. Women represented 12.7% (112/879) of all team physicians and 6.8% (30/443) of all orthopaedic surgeons ( Women comprise a minority of team physicians in select NCAA Division I collegiate and professional sports organizations. When compared with the composition of AOSSM orthopaedic surgeon membership, expected female orthopaedic surgeon representation varies between conferences and leagues with little statistical significance. Although efforts have been made to increase sex-based diversity in orthopaedic surgery, results of this study suggest that barriers affecting female orthopaedic surgeons as team physicians should be identified and addressed.

The Prevalence of Radiographic Findings of Structural Hip Deformities for Femoroacetabular Impingement in Patients With Hip Pain

10-01-2020 – Jun Zhou,Heath P. Melugin,Rena F. Hale,Devin P. Leland,Christopher D. Bernard,Bruce A. Levy,Aaron J. Krych

Journal Article

Radiography is the initial imaging modality used to evaluate femoroacetabular impingement (FAI), and diagnostic radiographic findings are well-established. However, the prevalence of these radiographic findings in patients with hip pain is unknown. The purpose was 3-fold: (1) to determine the overall prevalence of radiographic FAI deformities in young patients presenting with hip pain, (2) to identify the most common radiographic findings in patients with cam-type FAI, and (3) to identify the most common radiographic findings in patients with pincer-type FAI. Cross-sectional study; Level of evidence, 3. A geographic database was used to identify patients aged 14 to 50 years with hip pain between the years 2000 to 2016. The following were evaluated on radiographs: cam type: typical pistol grip deformity, alpha angle >55°; pincer type: crossover sign (COS), coxa profunda or protrusio acetabuli, lateral center edge angle (LCEA) ≥40°, Tönnis angle 55° was 577 (42.1%) and 1069 (78.0%), respectively. The mean alpha angle was 66.9°± 10.5°. The prevalence of pincer-type radiographic findings was the following: COS, 1062 (77.5%); coxa profunda, 844 (61.6%); ISS, 765 (55.8%); PWS, 764 (55.7%); Tönnis angle 55°. The most common radiographic finding for pincer-type FAI was the COS.

Prior Surgery Negatively Affects Cell Culture Identity in Patients Undergoing Autologous Chondrocyte Implantation

09-01-2020 – Jakob Ackermann,Alexandre Barbieri Mestriner,Courtney VanArsdale,Andreas H. Gomoll

Journal Article

Recently, a cell identity assay has been introduced to evaluate the identity of cultured chondrocytes before autologous chondrocyte implantation (ACI), which was shown to be associated with graft survival after ACI. To identify the influence of several patient- and lesion-specific factors on cell identity and viability assays. Cross-sectional study; Level of evidence, 3. A total of 187 patients with second-generation ACI were included in this study. Patient and lesion characteristics, cell viability, cell identity, and biopsy specimen weight were recorded for each patient. A binomial logistic regression model was utilized to determine patient-specific predictive factors for cell product quality. The implanted ACI cell products showed a cell viability of 93% ± 2.4% (mean ± SD; range, 84-98) with an identity score of 5.8 ± 2.1 (range, -0.08 to 9.46). Patients with multiple previous surgical procedures on the index knee had significantly lower cell identity scores when compared with patients without previous surgery (odds ratio = 0.31; 95% CI, 0.16-0.59; Cartilage biopsy specimens from patients with ≥1 previous surgical procedures resulted in implants with lower cell identity scores when compared with patients without previous operations. None of the other patient- or lesion-specific factors were correlated, specifically biopsy specimen weight.

Delaminated Rotator Cuff Tears Showed Lower Short-term Retear Rates After Arthroscopic Double-Layer Repair Versus Bursal Layer–Only Repair: A Randomized Controlled Trial

09-01-2020 – Philipp R. Heuberer,Leo Pauzenberger,Michael S. Gruber,Roman C. Ostermann,Michael Hexel,Brenda Laky,Werner Anderl

Journal Article

The rotator cuff is known to consist of 2 macroscopically visible layers that have different biomechanical properties. Sometimes the inferior layer may be neglected during rotator cuff repair. However, it is controversial whether double-layer (DL) repair is superior to single-layer (SL) repair in terms of retear rate and outcome. To investigate whether DL as compared with SL repair could decrease retear rates after arthroscopic reconstruction of posterosuperior rotator cuff tears. Randomized controlled trial; Level of evidence, 1. A total of 70 patients were 1:1 randomized to receive an arthroscopic DL reconstruction (study group: DL suture-bridge repair) or SL reconstruction (control group: SL suture-bridge repair) for posterosuperior tears of the rotator cuff between 2.0 and 3.5 cm of the footprint detachment. Exclusion criteria were subscapularis tendon rupture (Lafosse >1°), fatty muscular infiltration >2°, and nondelaminated tendons. Tendon integrity according to Sugaya, fatty degeneration, and muscular atrophy were evaluated by magnetic resonance tomography. Pre- and postoperative evaluations included the Constant score, range of motion, American Shoulder and Elbow Surgeons score, Simple Shoulder Test, subjective shoulder value, and postoperative satisfaction with the procedure. Complications were monitored throughout the study. Ninety percent of patients (n = 34, DL; n = 29, SL) were followed-up. There were no significant group differences regarding baseline characteristics and pre- and postoperative fatty degeneration of the supraspinatus and atrophy of the supraspinatus and infraspinatus. The rate of magnetic resonance-verified intact repairs (Sugaya grades 1 + 2) was significantly higher in the DL group (70.6%) than in the SL group (44.8%; This randomized controlled trial showed significantly lower retear rates after DL repair as compared with SL repair in delaminated rotator cuff tears. Clinical short-term outcome was not different between the DL and SL repair groups. NCT003362320 (Clinical
Trials.gov identifier).

Incidence of Displaced Posterolateral Tibial Plateau and Lateral Femoral Condyle Impaction Fractures in the Setting of Primary Anterior Cruciate Ligament Tear

09-01-2020 – David L. Bernholt,Nicholas N. DePhillipo,Matthew D. Crawford,Zachary S. Aman,W. Jeffrey Grantham,Robert F. LaPrade

Journal Article

Bone bruising of the posterolateral tibial plateau and the lateral femoral condyle sulcus terminalis has a well-established association with anterior cruciate ligament (ACL) tears. Impaction fractures of the femur and tibia may occur in these locations; however, there is a paucity of literature describing these fractures. The primary objective was to quantify the incidence, size, and location of impaction fractures of the posterolateral tibial plateau and lateral femoral condyle in patients with primary ACL tears. The secondary objective was to investigate the association between impaction fractures and concomitant meniscal and ligamentous injuries. Case series; Level of evidence 4. Patients with available magnetic resonance imaging (MRI) scans who were treated for primary ACL tear by a single surgeon were identified. MRI scans were reviewed with denotation of posterolateral tibial and femoral condylar contusions and displaced impaction fractures. Measurements of the lateral tibial plateau were taken in all patients with displaced lateral tibial plateau fractures and in a subset of control patients without tibial plateau fracture present to characterize the size and location of the bony lesion. Associations of impaction fractures with concomitant meniscal or ligamentous injuries were evaluated through use of chi-square testing. There were 825 knees identified with available MRI scans. Lateral tibial plateau bone bruising was present in 634 knees (76.8%), and lateral femoral condyle bone bruising was present in 407 knees (49.3%). Posterolateral tibial plateau impaction fractures were present in 407 knees (49.3%), and lateral femoral condylar impaction fractures were present in 214 knees (25.9%). Patients with posterolateral tibial plateau impaction fractures were older than patients without these fractures (42.6 vs 32.7 years; Posterolateral tibial plateau impaction fractures occurred with a high incidence (49.3%) in patients with primary ACL tears and demonstrated an increased association with lateral meniscus posterior horn root tears as their size increased. Lateral femoral condylar impaction fractures occurred in 25.9% of patients with primary ACL tears and entailed an increased incidence of lateral meniscal tears and medial meniscal ramp lesions.

Patellofemoral Cartilage Restoration: A Systematic Review and Meta-analysis of Clinical Outcomes

04-01-2020 – Betina B. Hinckel,Eli L. Pratte,Charles A. Baumann,Anirudh K. Gowd,Jack Farr,Joseph N. Liu,Adam B. Yanke,Jorge Chahla,Seth L. Sherman

Journal Article

Many surgical options for treating patellofemoral (PF) cartilage lesions are available but with limited evidence comparing their results. To determine and compare outcomes of PF cartilage restoration techniques. Systematic review and meta-analysis. PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) guidelines were followed by utilizing the PubMed, EMBASE, and Cochrane Library databases. Inclusion criteria were clinical studies in the English language, patient-reported outcomes after PF cartilage restoration surgery, and >12 months’ follow-up. Quality assessment was performed with the Coleman Methodology Score. Techniques were grouped as osteochondral allograft transplantation (OCA), osteochondral autograft transfer (OAT), chondrocyte cell-based therapy, bone marrow-based therapy, and scaffolds. A total of 59 articles were included. The mean Coleman Methodology Score was 71.8. There were 1937 lesions (1077 patellar, 390 trochlear, and 172 bipolar; 298 unspecified). The frequency of the procedures was as follows, in descending order: chondrocyte cell-based therapy (65.7%), bone marrow-based therapy (17.2%), OAT (8%), OCA (6.6%), and scaffolds (2.2%). When compared with the overall pooled lesion size (3.9 cm PF cartilage restoration leads to improved clinical outcomes, with low rates of minor and major complications. There was no difference among techniques; however, failures were higher with OCA.

Intra-articular Injection of Culture-Expanded Mesenchymal Stem Cells Without Adjuvant Surgery in Knee Osteoarthritis: A Systematic Review and Meta-analysis

24-12-2019 – Seong Hwan Kim,Yoshi Pratama Djaja,Yong-Beom Park,Jung-Gwan Park,Young-Bong Ko,Chul-Won Ha

Journal Article

Although many clinical studies have assessed the efficacy of mesenchymal stem cells (MSCs) in knee osteoarthritis, evidence on their efficacy remains unclear owing to heterogeneity of cell entity and concomitant procedures. To determine the efficacy of culture-expanded MSCs in knee osteoarthritis in terms of clinical outcome and cartilage repair via meta-analysis of randomized controlled trials (RCTs) without adjuvant surgery. Meta-analysis. PubMed, Embase, the Cochrane Library, CINAHL, and Scopus were searched from inception to December 31, 2018. RCTs with culture-expanded MSCs for treating knee osteoarthritis were included. Studies with adjuvant surgery or cell concentrate were excluded. Quality was assessed by the Cochrane Collaboration risk-of-bias tool. For meta-analysis, data on clinical outcomes were measured using a visual analog scale (VAS) and the Western Ontario and Mc
Master Universities Osteoarthritis Index (WOMAC), and data on cartilage repair were measured using the Whole-Organ Magnetic Resonance Imaging Score (WORMS); categorization related to improvement was extracted. Six RCTs (203 patients) were included. Two studies were deemed to have a low risk of bias. In pooled analysis, the only significant difference was in the VAS score (mean difference, -13.55; 95% CI, -22.19 to -4.9). In cumulative pain analysis with VAS and WOMAC pain scores, there was significant improvement after treatment (standardized mean difference, -0.54; 95% CI, -0.85 to -0.23). There was no significant difference in cartilage repair assessed by magnetic resonance imaging (standardized mean difference, 0.11; 95% CI, -0.51 to 0.73), WORMS (standardized mean difference, 1.68; 95% CI -14.84 to 18.21), or categorical results (odds ratio, 1.56; 95% CI, 0.32-7.59). Intra-articular injection of culture-expanded MSCs without adjuvant surgery can improve pain for patients experiencing knee osteoarthritis at short-term follow-up (6-12 months). However, evidence regarding function and cartilage repair remains limited.

The Effect of Psychological Impairment on Outcomes in Patients With Prearthritic Hip Disorders: A Systematic Review and Meta-analysis

12-12-2019 – Abby L. Cheng,Maria Schwabe,Michelle M. Doering,Graham A. Colditz,Heidi Prather

Journal Article

Recent studies have suggested that mental health disorders negatively affect postoperative outcomes in patients with femoroacetabular impingement (FAI). However, the outcome measures reported and the effect sizes have varied. Furthermore, it is unknown whether similar effects are present in young adults with other hip disorders such as acetabular dysplasia. To synthesize current evidence regarding the effect of baseline psychological impairment on postintervention outcomes in patients with prearthritic hip disorders. Systematic review and meta-analysis. In February 2019, the Ovid Medline, Embase, Scopus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Clinical
Trials.gov databases were searched for longitudinal studies that evaluated the effect of baseline psychological impairment (such as depression or anxiety) on a postintervention clinical outcome in patients with prearthritic hip disorders including FAI, acetabular dysplasia, and/or acetabular labral tears. Descriptive measures of study quality and bias were recorded, and studies that reported statistically comparable outcomes were analyzed in meta-analyses through use of random effects models. We identified 12 eligible studies, all of which specifically evaluated patients with FAI after hip arthroscopy. No eligible studies described patients with acetabular dysplasia. Of the included studies, 8 studies reported odds ratios (ORs). The other 4 studies reported mean postoperative scores on patient-reported outcome measures (PROMs), all of which were scored from 0 to 100, with higher numbers being favorable. Patients with psychological impairment were less likely to achieve a favorable outcome after arthroscopy (OR, 0.74; 95% CI, 0.62 to 0.88; Baseline psychological impairment is associated with clinically significantly worse outcomes in patients with femoroacetabular impingement who undergo hip arthroscopy. More standardized reporting would facilitate improved understanding of this important, potentially modifiable risk factor. CRD42019124836 (PROSPERO).

Factors Associated With an Increased Risk of Recurrence After a First-Time Patellar Dislocation: A Systematic Review and Meta-analysis

11-12-2019 – Lachlan S. Huntington,Kate E. Webster,Brian M. Devitt,John P. Scanlon,Julian A. Feller

Journal Article

Recurrent dislocations after a first-time lateral patellar dislocation may occur in more than 50% of patients and can cause long-term disability. Many factors have been suggested to influence the risk of recurrence. To systematically review and quantitatively synthesize the literature for factors associated with an increased risk of recurrence after a first-time patellar dislocation. Systematic review and meta-analysis of observational studies. A total of 4 electronic databases were searched to identify relevant studies published before February 7, 2019. A quality assessment was performed with the National Heart, Lung, and Bone Institute quality assessment score. Factors assessed for their effect on the recurrence rate were documented, and the rates of recurrence were compared. Pooled dichotomous data were analyzed using random-effects meta-analysis with odds ratios (ORs). A total of 17 studies met the criteria for inclusion. The overall rate of recurrent dislocations after a first-time lateral patellar dislocation was 33.6%. An increased risk of recurrence was reported in patients with a younger age (OR, 2.61; Younger age, open physes, trochlear dysplasia, elevated TT-TG distance, and patella alta were key risk factors for the recurrence of lateral patellar dislocations. Despite being not infrequently cited as risk factors, patient sex and a history of contralateral dislocations were not found to be significant risk factors. The presence of multiple risk factors increased the risk, and the development of predictive instability scores in large patient cohorts using all established risk factors should be a focus of future studies.

Platelet-Rich Plasma Versus Corticosteroid Injections in the Management of Elbow Epicondylitis and Plantar Fasciitis: An Updated Systematic Review and Meta-analysis

10-12-2019 – Kai Huang,Grey Giddins,Li-dong Wu

Journal Article

Platelet-rich plasma (PRP), as a promising alternative to traditional corticosteroid (CS), is now increasingly used in the treatment of elbow epicondylitis (EE) and plantar fasciitis (PF). To date, however, the synthesis of information on the clinical efficacy of PRP versus CS is limited with divergent conclusions. To compare the clinical efficacy of PRP and CS injections in reducing pain and improving function in EE and PF. Systematic review and meta-analysis. Online databases were searched from inception to October 2018 for prospective studies evaluating PRP versus CS injections for EE or PF. Independent reviewers undertook searches, screening, and risk-of-bias appraisals. The primary outcomes of interest were pain and function in both the short term (1-3 months) and the long term (≥6 months). Twenty trials with 1268 participants were included. For EE, PRP provides a statistically and clinically meaningful long-term improvement in pain, with a very large effect size of -1.3 (95% CI, -1.9 to -0.7) when compared with CS, but the evidence level was low. For EE, there was moderate evidence that CS provides a statistically meaningful improvement in pain in the short term, with a medium effect size of 0.56 (95% CI, 0.08-1.03) as compared with PRP; this improvement might not be clinically significant. For PF, there was low evidence that PRP provides a statistically and clinically meaningful long-term improvement in function (American Orthopedic Foot & Ankle Society score), with a very large effect size of 1.94 (95% CI, 0.61-3.28). There were no significant differences between the groups in improvement in function in EE and pain and short-term function in PF, but the quality of the evidence was low. The use of PRP yields statistically and clinically better improvement in long-term pain than does CS in the treatment of EE. The use of PRP yields statistically and clinically better long-term functional improvement than that of CS in the treatment of PF.

Effect of Adductor Canal Block Versus Femoral Nerve Block on Quadriceps Strength, Function, and Postoperative Pain After Anterior Cruciate Ligament Reconstruction: A Systematic Review of Level 1 Studies

04-12-2019 – Matthew Dean Edwards,Joseph Preston Bethea,Jennifer Lee Hunnicutt,Harris Scott Slone,Shane Kelby Woolf

Journal Article

Femoral nerve block (FNB) is a popular technique for reducing postoperative pain in patients with anterior cruciate ligament reconstruction (ACLR), but it is also linked to a number of adverse effects, such as quadriceps weakness, antalgic ambulation, and increased fall risk. Adductor canal block (ACB) has been offered as a motor nerve-sparing alternative to FNB. To evaluate available literature that compares the effects of ACB and FNB on functional outcomes after arthroscopic ACLR. Systematic review. Following the 2009 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a search of PubMed (Ovid), CINAHL, Scopus, Cochrane, and Google Scholar databases was conducted. Search terms were designed to capture studies comparing the effects of ACB and FNB in patients undergoing arthroscopic ACLR. Data were evaluated regarding study and patient characteristics, functional measures, opioid consumption, pain scores, and complications. Eight randomized controlled trials (N = 655 patients) comparing the efficacy of ACB versus FNB in arthroscopic ACLR were included. The heterogeneity of outcome measures precluded meta-analysis. Seven studies reported functional measures, which included isokinetic strength, straight-leg raise, and other various measures. Follow-up periods varied between 1 hour and 6 months. In 3 trials, ACB was found to preserve quadriceps strength as measured using straight-leg raise for the first 12 to 24 hours after surgery, while 3 other trials found no difference between the groups. No differences were reported in isokinetic strength at 6 months. In other functional measures, ACB either outperformed or was equivalent to FNB. The majority of studies reporting opioid consumption, pain scores, and complications found no differences between the blocks. This systematic review suggests that when compared with FNB, ACB preserves quadriceps function in the early postoperative period after ACLR while providing a similar level of analgesia. Limitations of this study include the use of various functional measures and limited long-term follow-up. More research evaluating long-term functional outcomes with standardized measures is needed to draw adequate conclusions regarding the effects of ACB and FNB on function after ACLR.

Physiotherapy as an Initial Treatment Option for Femoroacetabular Impingement: A Systematic Review of the Literature and Meta-analysis of 5 Randomized Controlled Trials

27-11-2019 – Graeme Hoit,Daniel B. Whelan,Tim Dwyer,Prabjit Ajrawat,Jaskarndip Chahal

Journal Article

Femoroacetabular impingement is a common and debilitating source of hip pain in young adults. Although physiotherapy is used as a mainstay of nonoperative care for femoroacetabular impingement, the evidence regarding different physiotherapy practices is poorly understood. To collect and synthesize the best available evidence and arrive at a summary estimate of treatment effect for the utility of physiotherapy in the management of femoroacetabular impingement. Meta-analysis. A systematic review was performed on February 2, 2019, of PubMed, EMBASE, and Cochrane Library databases using “femoroacetabular impingement OR hip pain” and “physiotherapy OR nonoperative management” and their synonyms as search terms. Central treatment themes were identified across protocols, and pooled analyses were conducted to assess for differences in patient-reported outcome measures across these themes. A total of 5 randomized controlled trials met our inclusion criteria. The studies included 124 patients with a mean age of 35 years, of whom 24% were male. The average follow-up was 9.4 weeks (range, 6-12 weeks), and the follow-up rate across all participants was 86%. Among these 5 studies, 4 studies used a physiotherapy protocol that focused on core strengthening versus no core strengthening, 4 studies compared active strengthening versus passive modalities, and 3 studies compared supervised versus unsupervised physiotherapy. Pooled analysis across all studies demonstrated improved outcomes in the treatment groups compared with the controls (standardized mean difference [SMD], 0.76; 95% CI, 0.38-1.13; Supervised physiotherapy programs focusing on active strengthening and core strengthening are more effective than unsupervised, passive, and non-core focused programs. Future studies with longer term follow-up and validated femoroacetabular impingement specific outcome measures are required to determine prognostic factors for success with nonoperative care as well as to determine the ideal patient profile and structured rehabilitation protocol.

Return to Work and Sport After Proximal Tibial Osteotomy and the Effects of Opening Versus Closing Wedge Techniques on Adverse Outcomes: A Systematic Review and Meta-analysis

27-11-2019 – Kyle N. Kunze,Alexander Beletsky,Charles P. Hannon,Robert F. LaPrade,Adam B. Yanke,Brian J. Cole,Brian Forsythe,Jorge Chahla

Journal Article

Although many studies have reported successful functional outcomes after proximal tibial osteotomy (PTO), a paucity of literature has sought to quantify outcomes and current rates of return to sport (RTS) and return to work (RTW) after PTO. To (1) determine current rates of RTS and RTW after PTO and (2) quantify the incidence of complications and conversion to total knee arthroplasty (TKA) after PTO for all patients as well as those undergoing opening and closing wedge PTO. Systematic review and meta-analysis; Level of evidence, 4. The Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed (2008-2019), EMBASE (2008-2019), and MEDLINE (2008-2019) databases were queried. Data pertaining to article information, patient demographics, surgical techniques, rates of complication and conversion to TKA, patient-reported outcome scores, RTS, and RTW were extracted. Data were synthesized, and a random effects meta-analysis of proportions using continuity correction methods was performed to determine the proportion of patients receiving opening and closing wedge PTO who experienced adverse events. The review and meta-analysis included 33 studies involving 1914 patients who underwent PTO with a weighted mean ± SD age of 50.3 ± 9.9 years and body mass index of 26.9 ± 2.3 kg/m Patients undergoing PTO for osteoarthritis, cartilage defects, and symptomatic malalignment of the knee experience high rates of RTS and RTW. These patients also experience low rates of complications and conversion to TKA, regardless of opening or closing wedge technique. Significant heterogeneity exists with regard to criteria used to define RTS and RTW and patient-reported outcome measures used to assess clinical and functional improvements after PTO.

Outcome Comparison of Graft Bridging and Superior Capsule Reconstruction for Large to Massive Rotator Cuff Tears: A Systematic Review

26-11-2019 – Jinrong Lin,Yaying Sun,Qingyan Chen,Shaohua Liu,Zheci Ding,Jiwu Chen

Journal Article

Graft bridging (GB) and superior capsule reconstruction (SCR) were developed to treat large to massive rotator cuff tears (RCTs); however, the outcome differences between GB and SCR remain unclear. To systematically review and compare the outcomes of GB and SCR for large to massive RCT. Systematic review. A systematic review was performed via a comprehensive search of PubMed, Embase, and the Cochrane Library. Studies of GB or SCR were included according to the inclusion and exclusion criteria. The primary outcome was Constant-Murley score at the final follow-up. Secondary outcomes included the American Shoulder and Elbow Surgeons score, visual analog scale score for pain, active shoulder range of motion, and graft healing rate. Complication rate was the safety outcome measure. Outcomes were summarized into group SCR and group GB, and the results were compared statistically ( A total of 23 studies were included in this review: 238 repairs from the 5 studies in group SCR and 593 repairs from the 18 studies in group GB. For group SCR and group GB, the mean age was 61.6 and 63.3 years, and the mean follow-up was 18.0 and 40.1 months, respectively. Overall, both procedures demonstrated improvement of clinical outcomes. When compared with group SCR, group GB had significantly higher mean differences of the Constant-Murley score (41.9 vs 19.8), American Shoulder and Elbow Surgeons score (39.3 vs 33.8), visual analog scale score for pain (4.4 vs 3.4), and active external rotation at side (15.3 vs 9.3). No statistically significant difference was detected in the mean difference of active forward flexion, internal rotation, abduction, and graft healing rate between the groups. The complication rates were 0.84% (2 of 238) in group SCR and 0.67% (4 of 593) in group GB. In general, GB showed significantly better clinical and functional outcomes postoperatively than SCR, with a similar complication rate. The available fair-quality evidence suggested that GB might be a better choice for large to massive RCT. More high-quality randomized controlled studies are required to further evaluate the relative benefits of the 2 procedures.

Use of Platelet-Rich Plasma for the Improvement of Pain and Function in Rotator Cuff Tears: A Systematic Review and Meta-analysis With Bias Assessment

19-11-2019 – Xiao Chen,Ian A. Jones,Ryan Togashi,Caron Park,C. Thomas Vangsness

Journal Article

Many clinical trials have investigated the use of platelet-rich plasma (PRP) to treat rotator cuff-related abnormalities. Several meta-analyses have been published, but none have focused exclusively on level 1 randomized controlled trials. To assess the efficacy of PRP for rotator cuff-related abnormalities and evaluate how specific tendon involvement, the inclusion of leukocytes, and the use of gel/nongel formulations affect pain and functional outcomes. Systematic review and meta-analysis. The literature was screened following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Baseline, short-term, and long-term data were extracted for the Constant score, University of California, Los Angeles (UCLA) score, visual analog scale (VAS) for pain, retear rate, Simple Shoulder Test (SST), and American Shoulder and Elbow Surgeons (ASES) score. The 100-point modified Coleman Methodology Score (CMS) was used to assess methodological quality. Funnel plots and the Egger test were used to screen for publication bias, and sensitivity analysis was performed to evaluate the effect of potential outliers. A total of 18 level 1 studies were included in this review, 17 (1116 patients) of which could be included in quantitative analysis. The mean modified CMS was 79.4 ± 10.39. The Constant scores of patients who received PRP were significantly better short term (weighted mean difference [WMD], 2.89 [95% CI, 0.89-4.90]; Long-term retear rates were significantly decreased in patients with rotator cuff-related abnormalities who received PRP. Significant improvements in PRP-treated patients were noted for multiple functional outcomes, but none reached their respective minimal clinically important differences. Overall, our results suggest that PRP may positively affect clinical outcomes, but limited data, study heterogeneity, and poor methodological quality hinder firm conclusions.

A Contemporary Look at the Evaluation and Treatment of Adult Borderline and Frank Hip Dysplasia

14-11-2019 – Matthew J. Kraeutler,Marc R. Safran,Anthony J. Scillia,Olufemi R. Ayeni,Tigran Garabekyan,Omer Mei-Dan

Journal Article

Adult hip dysplasia is often diagnosed according to the lateral center-edge angle (LCEA). Patients with frank hip dysplasia (LCEA <20°) traditionally require treatment with bony realignment through a periacetabular osteotomy (PAO) and/or derotational femoral osteotomy, while patients with borderline hip dysplasia (BHD) present a challenging treatment dilemma, as it remains unknown when they should be treated with hip arthroscopy and/or a PAO. To perform a narrative review to report the differences in hip morphology and clinical outcomes between adult patients with frank hip dysplasia and BHD. Narrative review. A systematic search of the literature was conducted through the Medline, EMBASE, and Cochrane databases with the search phrase The search identified 305 articles, of which 48 were considered relevant to this study after screening of titles and abstracts. Four articles discussed new radiographic means of evaluating adult hip dysplasia, 16 articles analyzed morphology of dysplastic hips, and 28 articles described the clinical outcomes of patients with frank hip dysplasia or BHD treated with hip arthroscopy and/or PAO. Because the level of evidence obtained from this search was not adequate for systematic review or meta-analysis, a current concepts review on the diagnosis, hip morphology, and clinical outcomes of patients with frank hip dysplasia or BHD is presented. Adult hip dysplasia is most commonly diagnosed based on the LCEA; however, the LCEA is an unreliable sole marker for dysplasia, and additional radiographic parameters should be utilized. Furthermore, specific pathology identified on imaging and/or during hip arthroscopy can provide clues to a surgeon when the diagnosis is inconclusive according to history and physical examination alone. While the data support that patients with frank dysplasia are best treated with PAO, there is no such preferred treatment for patients with BHD, who have a wide spectrum of instability. Selective use of arthroscopic labral and capsular treatment alone may provide good results in carefully chosen patients with BHD, while some may end up requiring a bony realignment procedure.

The Safety of Blood Flow Restriction Training as a Therapeutic Intervention for Patients With Musculoskeletal Disorders: A Systematic Review

11-11-2019 – Melissa C. Minniti,Andrew P. Statkevich,Ryan L. Kelly,Victoria P. Rigsby,Meghan M. Exline,Daniel I. Rhon,Derek Clewley

Journal Article

The effectiveness of blood flow restriction training (BFRT) as compared with other forms of training, such as resistance training, has been evaluated in the literature in clinical and nonclinical populations. However, the safety of this intervention has been summarized only in healthy populations and not in clinical populations with musculoskeletal disorders. To evaluate the safety and adverse events associated with BFRT in patients with musculoskeletal disorders. Systematic review. A literature search was conducted with 3 online databases (MEDLINE, CINAHL, and Embase). Eligibility criteria for selecting studies were as follows: (1) BFRT was used as a clinical intervention, (2) study participants had a disorder of the musculoskeletal system, (3) authors addressed adverse events, (4) studies were published in English, and (5) the intervention was performed with human participants. Nineteen studies met eligibility criteria, with a pooled sample size of 322. Diagnoses included various knee-related disorders, inclusion body myositis, polymyositis or dermatomyositis, thoracic outlet syndrome, Achilles tendon rupture, and bony fractures. Nine studies reported no adverse events, while 3 reported rare adverse events, including an upper extremity deep vein thrombosis and rhabdomyolysis. Three case studies reported common adverse events, including acute muscle pain and acute muscle fatigue. In the randomized controlled trials, individuals exposed to BFRT were not more likely to have an adverse event than individuals exposed to exercise alone. Of the 19 studies, the adverse events were as follows: overall, 14 of 322; rare overall, 3 of 322; rare BFRT, 3 of 168; rare control, 0 of 154; any adverse BFRT, 10 of 168; any adverse control, 4 of 154. A majority of studies were excluded because they did not address safety. BFRT appears to be a safe strengthening approach for knee-related musculoskeletal disorders, but further research is needed to make definitive conclusions and to evaluate the safety in other musculoskeletal conditions. Improved definitions of adverse events related to BFRT are needed to include clear criteria for differentiating among common, uncommon, and rare adverse events. Finally, further research is needed to effectively screen who might be at risk for rare adverse events.

The Influence of Psychological Factors on the Incidence and Severity of Sports-Related Concussions: A Systematic Review

08-11-2019 – Lily N. Trinh,Symone M. Brown,Mary K. Mulcahey

Journal Article

An athlete’s preexisting psychological factors may influence the incidence and/or severity of sports-related concussions (SRCs). To determine if emotional states, personality traits, temperament, life stressors, and explanatory styles (optimism vs pessimism) influence the incidence and severity of SRCs in athletes. Systematic review. A systematic literature search of multiple major medical reference databases was performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies were included that evaluated the effect of preexisting psychological factors on the incidence and severity of SRCs in male and female athletes participating in all sports. The initial search identified 1195 articles. Ten studies met our inclusion criteria and were included in our analysis. Factors such as meanness, aggression, and psychoticism were associated with an increased incidence of SRCs. Baseline traits of irritability, sadness, nervousness, and depressive symptoms were associated with worse symptomatology after SRCs. In young athletes, preexisting psychiatric illnesses, family history of psychiatric illness, and significant life stressors were associated with an increased risk of developing postconcussion syndrome after SRCs. This systematic review demonstrated a potential relationship between an athlete’s preexisting psychological factors and the incidence and severity of SRCs. These associations are not entirely clear owing to the heterogeneity across included studies and the low-to-moderate certainty of evidence. Future studies should attempt to evaluate men and women independently, use well-validated psychological questionnaires, and limit the usage of self-reported SRCs, when possible. Furthermore, the potential efficacy of baseline psychological factor and/or symptom reports on the prevention and management of SRCs should be explored.

Diagnostic Performance of Magnetic Resonance Imaging for Detecting Meniscal Ramp Lesions in Patients With Anterior Cruciate Ligament Tears: A Systematic Review and Meta-analysis

05-11-2019 – Boyeon Koo,Sun Hwa Lee,Seong Jong Yun,Jae Gwang Song

Journal Article

The clinical importance of meniscal ramp lesions in patients with anterior cruciate ligament (ACL) tear has emerged as a major issue. However, the diagnostic accuracy of magnetic resonance imaging (MRI) for detecting ramp lesions has a wide range. To perform a systematic review and meta-analysis of the diagnostic performance of MRI for diagnosing ramp lesion in patients with ACL tear. Systematic review and meta-analysis. A literature search of PubMed, EMBASE, and the Cochrane Library was performed based on the revised guidelines for the PRISMA DTA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses of Diagnostic Accuracy Studies) statement. Diagnostic performance studies using MRI as the index test and arthroscopy as the reference standard for ramp lesion were included. Bivariate and hierarchical summary receiver operating characteristic modeling was used to evaluate the diagnostic performance. Meta-regression analyses were performed to identify potential sources of heterogeneity. The review and meta-analysis included 9 studies from 8 articles (883 patients with ACL tear and reconstruction). The summary sensitivity, summary specificity, and area under the hierarchical summary receiver operating characteristic for ramp lesion were 0.71 (95% CI, 0.59-0.81), 0.94 (95% CI, 0.88-0.97), and 0.90 (95% CI, 0.87-0.92), respectively. Among the potential covariates, magnet strength ( MRI demonstrated moderate sensitivity and excellent specificity for diagnosing ramp lesion. Routine arthroscopic assessment is recommended for the presence of ramp lesion, regardless of whether it is suspected on MRI. Further clinicoradiological studies of diagnostic algorithms are needed for identifying ramp lesion, including high-resolution MRI with appropriate knee position.

Outcomes After Arthroscopic Hip Labral Reconstruction: A Systematic Review and Meta-analysis

21-10-2019 – Michael D. Rahl,Collin LaPorte,Gabrielle K. Steinl,Michaela O’Connor,T. Sean Lynch,Travis J. Menge

Journal Article

The acetabular labrum is critical to maintenance of hip stability and has been found to play a key role in preservation of the hip fluid seal. For irreparable labral damage, arthroscopic labral reconstruction is an evolving technique that has been shown to decrease hip pain and restore function. To provide a comprehensive review of current literature for arthroscopic hip labral reconstruction, with a focus on determining if outcomes differ between autograft or allograft tissue. Systematic review and meta-analysis. PubMed and Scopus online databases were searched with the key terms “hip,”labrum,”reconstruction,” and “graft” in varying combinations. Procedures performed, complications, failures, and functional outcome measures were included in this analysis. The inverse variance method was used to calculate pooled estimates and 95% CIs. Eight studies with 537 hips were included. Mean age was 37.4 years (95% CI, 34.5-40.4 years), and mean follow-up time was 29 months (95% CI, 26-33 months). Survivorship after autograft reconstruction ranged from 75.7% to 100%, as compared with 86.3% to 90.0% in the allograft cohort. In the autograft cohort, failures included 0% to 13.2% conversion to total hip arthroplasty and 0% to 11.0% revision hip arthroscopy. Failures in the allograft cohort included 0% to 12.9% total hip arthroplasty conversion, 0% to 10.0% revision arthroscopy, and 0% to 0.8% open revision surgery. Based on 6 studies, the modified Harris Hip Score improved by a mean 29.0 points after labral reconstruction ( Arthroscopic hip labral reconstruction results in clinically significant improvements in patient-reported outcomes. Our analysis indicates that there are no significant differences in outcomes based on graft type alone. A number of factors may determine graft choice, including patient preference, surgeon experience, operative time, morbidity, and cost. Proper patient selection based on age and severity of degenerative joint disease will also optimize outcomes after labral reconstruction.

Are Implant Choice and Surgical Approach Associated With Biceps Tenodesis Construct Strength? A Systematic Review and Meta-regression

04-10-2019 – Hiroshi F. Aida,Brendan Y. Shi,Eric G. Huish,Edward G. McFarland,Uma Srikumaran

Journal Article

Despite the increasing use of biceps tenodesis, there is a lack of consensus regarding optimal implant choice (suture anchor vs interference screw) and implant placement (suprapectoral vs subpectoral). The purpose was to determine the associations of procedural parameters with the biomechanical performance of biceps tenodesis constructs. The authors hypothesized that ultimate failure load (UFL) would not differ between sub- and suprapectoral repairs or between interference screw and suture anchor constructs and that the number of implants and number of sutures would be positively associated with construct strength. Meta-analysis. The authors conducted a systematic literature search for studies that measured the biomechanical performance of biceps tenodesis repairs in human cadaveric specimens. Two independent reviewers extracted data from studies that met the inclusion criteria. Meta-regression was then performed on the pooled data set. Outcome variables were UFL and mode of failure. Procedural parameters (fixation type, fixation site, implant diameter, and numbers of implants and sutures used) were included as covariates. Twenty-five biomechanical studies, representing 494 cadaveric specimens, met the inclusion criteria. The use of interference screws (vs suture anchors) was associated with a mean 86 N-greater UFL (95% CI, 34-138 N; These findings suggest that fixation with interference screws, rather than suture anchors, and the use of more sutures are associated with greater biceps tenodesis strength, as well as higher odds of native tissue failure versus implant pullout. Although constructs with suture anchors show inferior UFL compared with those with interference screws, incorporation of additional sutures may increase the strength of suture anchor constructs. Supra- and subpectoral repairs provide equivalent biomechanical strength when controlling for potential confounders.

Outcomes of Hip Arthroscopic Surgery in Adolescents With a Subanalysis on Return to Sport: A Systematic Review

20-09-2019 – Sarah L. Chen,David R. Maldonado,Cammille C. Go,Cynthia Kyin,Ajay C. Lall,Benjamin G. Domb

Journal Article

There is a plethora of literature on outcomes after hip arthroscopic surgery in the adult population; however, outcomes in the adolescent population have not been as widely reported. Additionally, as adolescents represent a very active population, it is imperative to understand their athletic activity and return to sport after hip arthroscopic surgery. To analyze patient-reported outcomes (PROs) after hip arthroscopic surgery in adolescents (aged 10-19 years) and present a return-to-sport analysis in the athletic adolescent subgroup. Systematic review; Level of evidence, 4. The PubMed, Embase, and Cochrane databases were searched according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to identify articles that reported PROs after hip arthroscopic surgery in adolescents. The standardized mean difference was calculated to compare the effect size of hip arthroscopic surgery on various PROs. For the athletic subgroup, a return-to-sport summary was also provided. Ten studies, with 618 adolescent hips and a collective study period of December 2004 to February 2015, were included in this systematic review. Across all studies, the mean age was 15.8 years (range, 11.0-19.9 years), and female patients composed approximately 56.7% of the entire cohort. The mean follow-up was 34.5 months (range, 12-120 months). The modified Harris Hip Score (m
HHS) was reported in 9 studies, and at latest follow-up, scores were excellent in 4 studies (range, 90-95) and good in the remaining 5 studies (range, 82.1-89.6). All adolescents also showed significant improvement on the Non-Arthritic Hip Score (NAHS), the Hip Outcome Score-Activities of Daily Living (HOS-ADL), the HOS-Sport-Specific Subscale (HOS-SSS), the physical component of the 12-Item Short Form Health Survey (SF-12P), a visual analog scale for pain (VAS), and both versions of the International Hip Outcome Tool (i
HOT-12 and i
HOT-33) at latest follow-up ( In the setting of labral tears and femoroacetabular impingement, hip arthroscopic surgery can safely be performed in adolescents and leads to significant functional improvement. Furthermore, athletic adolescents return to sport at high levels after hip arthroscopic surgery.

Outcomes of Revision Hip Arthroscopic Surgery: A Systematic Review and Meta-analysis

10-09-2019 – Michaela O’Connor,Gabrielle K. Steinl,Ajay S. Padaki,Kyle R. Duchman,Robert W. Westermann,T. Sean Lynch

Journal Article

While the indications for primary hip arthroscopic surgery in treating femoroacetabular abnormalities continue to be defined, the indications and outcomes for revision hip arthroscopic surgery remain ambiguous. However, revision hip arthroscopic surgery is performed in 5% to 14% of patients after their index procedure. While patient-reported outcomes (PROs) generally improve after revision procedures, the extent of their improvement is not well defined. To determine the outcomes and efficacy of revision hip arthroscopic surgery in patients who remain symptomatic after their index procedure. Meta-analysis and systematic review. The terms “hip arthroscopy,”revisions,”outcomes,” and “femoroacetabular impingement” were searched in PubMed, Web of Science, Scopus, Cochrane Library, and Google Scholar. After screening, 15 studies were included for review. In addition to hip-specific metrics, functional outcome measures were included. Pooled estimates and 95% CIs were calculated using inverse variance methods. A total of 4765 hips in 4316 patients were identified. The most common indication for revision surgery was inadequate bony resection during the index procedure. Meta-analysis showed that all PROs improved significantly from baseline to final follow-up after revision hip arthroscopic surgery. Notably, the modified Harris Hip Score (m
HHS) increased a mean of 17.20 points after revision hip arthroscopic surgery, the Hip Outcome Score-Activities of Daily Living (HOS-ADL) improved by 13.98, and the visual analog scale (VAS) for pain decreased by 3.16. However, when compared with primary hip arthroscopic surgery, the mean PRO scores after revision hip arthroscopic surgery were lower. After revision hip arthroscopic surgery, the rates of conversion to total hip arthroplasty ranged from 0% to 14.3%, and the rates of further arthroscopic revision ranged from 2% to 14%. Inadequate bony resection represents the most common indication for revision hip arthroscopic surgery. PROs improve significantly after revision hip arthroscopic surgery but remain lower than those of patients undergoing primary hip arthroscopic surgery.

A Majority of Anterior Cruciate Ligament Injuries Can Be Prevented by Injury Prevention Programs: A Systematic Review of Randomized Controlled Trials and Cluster–Randomized Controlled Trials With Meta-analysis

30-08-2019 – Yu-Lun Huang,Jaehun Jung,Colin M.S. Mulligan,Jaekeun Oh,Marc F. Norcross

Journal Article

Anterior cruciate ligament (ACL) injury prevention programs (IPPs) are generally accepted as being valuable for reducing injury risk. However, significant methodological limitations of previous meta-analyses raise questions about the efficacy of these programs and the extent to which meeting current best-practice ACL IPP recommendations influences the protective effect of these programs. To (1) estimate the protective effect of ACL IPPs while controlling for common methodological limitations of previous meta-analyses and (2) systematically categorize IPP components and factors related to IPP delivery to assess the validity of current best-practice IPP recommendations. Systematic review with meta-analysis. A systematic search of 5 electronic scientific databases was conducted to identify studies testing the efficacy of ACL IPPs. Studies were included if (1) the intervention aimed to prevent ACL injury, (2) the incidence rate (IR) or other outcome data that made it possible to calculate the IR for both the intervention and control groups were reported, and (3) the study design was a prospective randomized controlled trial (RCT) or cluster-RCT. Of the 2219 studies screened, 8 studies were included in the quantitative synthesis, and their analysis revealed a significant reduction in ACL IR when athletes received IPPs (IR ratio = 0.47; 95% CI, 0.30-0.73; Despite limiting the analysis to only high-quality studies and controlling for time at risk and potential clustering effects, the study showed that ACL IPPs had a significant protective effect and reduced injury rates by 53%. However, significant variability in the specific exercises and the manner of program delivery suggests that ACL IPPs may be able to be designed within an overarching best-practice framework. This may allow practitioners the flexibility to develop IPPs that meet the specific characteristics of the target population and potentially increase the likelihood that these programs will be widely adopted and implemented.

Anterior Cruciate Ligament Reconstruction Within 3 Weeks Does Not Increase Stiffness and Complications Compared With Delayed Reconstruction: A Meta-analysis of Randomized Controlled Trials

05-08-2019 – Luca Deabate,Davide Previtali,Alberto Grassi,Giuseppe Filardo,Christian Candrian,Marco Delcogliano

Journal Article

Injury-to-surgery time has been identified as a key point in anterior cruciate ligament (ACL) reconstruction, with early versus delayed treatment remaining a debated and controversial topic in the management of ACL tears. The aim was to quantitatively synthesize the best literature evidence by including only randomized controlled trials (RCTs) comparing early versus delayed ACL reconstruction, with a clear and univocal definition of cutoffs of early or delayed surgery. The hypothesis was that early treatment would lead to similar final clinical results compared with the delayed approach while providing a faster recovery without an increase in complications after ACL reconstruction. Meta-analysis. A systematic literature search was performed on February 12, 2019, using PubMed, Web of Science, Cochrane Library, and gray literature databases. According to previous literature, 2 analyses with different cutoffs for injury-to-surgery time (3 weeks and 10 weeks) were performed to distinguish early and delayed reconstruction. The influence of timing was analyzed through meta-analyses in terms of patient-reported outcome measures (PROMs), risk of complications, range of motion (ROM) limitation, risk of retears, and residual laxity. Risk of bias and quality of evidence were assessed following the Cochrane guidelines. Eight studies (5 in 3-week cutoff analysis and 3 in 10-week cutoff analysis) were included. No differences were found in terms of PROMs, risk of complications, ROM limitation, risk of retears, and residual laxity either in the 3-week cutoff analysis or in the 10-week cutoff analysis ( This meta-analysis did not confirm the previously advocated benefits of delaying ACL surgery to avoid the acute posttraumatic phase. In fact, RCTs demonstrated that timing of surgery after ACL tears has no influence on the final functional outcome, risk of retears, or residual instability. While no data were available about the recovery time, literature results showed that early ACL reconstruction could be performed without increasing the risk of complications. CRD42019119319 (PROSPERO).

Suture Button Versus Hook Plate for Acute Unstable Acromioclavicular Joint Dislocation: A Meta-analysis

17-07-2019 – Cong Wang,Jia-Hong Meng,Yi-Wen Zhang,Ming-Min Shi

Journal Article

Surgical treatment is indicated for unstable acromioclavicular (AC) joint dislocation. The hook plate (HP) technique is a commonly used treatment method, but the use of the suture button (SB) technique is increasing. To conduct a meta-analysis of clinical studies evaluating patient outcomes between the SB and HP techniques for acute unstable AC joint dislocation. Meta-analysis. A literature search of the Embase, PubMed, and Cochrane Library databases was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Cohort studies and case-control studies comparing the SB and HP procedures for acute unstable AC joint dislocation were included. Statistical analysis was performed with Rev
Man (v 5.3.5). Eight clinical studies that met the inclusion criteria were identified and included a total of 204 patients treated with the SB technique and 195 patients with the HP technique. Patients treated with the SB technique had a higher Constant score (mean difference [MD], 3.95; 95% CI, 1.20-6.70; This meta-analysis demonstrated that the SB technique resulted in better functional outcomes and a reduced visual analog scale pain score when compared with the HP technique. However, for operation time, coracoclavicular distance, complications, and loss of reduction, there were no statistically significant differences between the techniques. Compared with the open procedure, arthroscopic SB may be superior for better functional outcomes.

Dynamic Stabilization of Syndesmosis Injuries Reduces Complications and Reoperations as Compared With Screw Fixation: A Meta-analysis of Randomized Controlled Trials

12-06-2019 – Alberto Grassi,Kristian Samuelsson,Pieter D’Hooghe,Matteo Romagnoli,Massimiliano Mosca,Stefano Zaffagnini,Annunziato Amendola

Journal Article

Several devices for obtaining dynamic fixation of the syndesmosis have been introduced in recent years, but their efficacy has been tested in only a few randomized controlled trials (RCTs), without demonstrating any clear benefit over the traditional static fixation with screws. To perform a level 1 meta-analysis of RCTs to investigate the complications, subjective outcomes, and functional results after dynamic or static fixation of acute syndesmotic injuries. Meta-analysis of RCTs. A systematic literature search was performed of the Medline/PubMed, Cochrane Central Register of Controlled Trials, and Embase electronic databases, as well as Clinical
Trials.gov for unpublished studies. Eligible studies were RCTs comparing dynamic fixation and static fixation of acute syndesmosis injuries. A meta-analysis was performed, while bias and quality of evidence were rated according to the Cochrane Database questionnaire and the Grading of Recommendations Assessment, Development and Evaluation guidelines. Dynamic fixation had a significantly reduced relative risk (RR = 0.55, The dynamic fixation of syndesmotic injuries was able to reduce the number of complications and improve clinical outcomes as compared with static screw fixation-especially malreduction and clinical instability or diastasis-at a follow-up of 2 years. A lower risk of reoperation was found with dynamic fixation as compared with static fixation with permanent screws. However, the lack of patients or personnel blinding, treatment heterogeneity, small samples, and short follow-up limit the overall quality of this evidence.

Hamstring Autograft Versus Hybrid Graft for Anterior Cruciate Ligament Reconstruction: A Systematic Review

05-06-2019 – Hong-De Wang,Shi-Jun Gao,Ying-Ze Zhang

Journal Article

Hamstring tendon autografts are commonly used for primary anterior cruciate ligament (ACL) reconstruction. Some patients have small hamstring tendons however, which may compromise the clinical outcome of the autograft. To solve this problem, many surgeons use hybrid grafting that involves augmentation of small hamstring autografts with allograft tissue. The purpose was to compare the clinical outcomes between primary ACL reconstructions performed with hamstring autografts and those performed with hybrid grafts in terms of patient-reported evaluation, failure rate, and knee stability. The hypothesis was that primary ACL reconstruction performed with hamstring autograft alone will not differ significantly from that performed with a hybrid graft in terms of patient-reported evaluation, failure rate, or knee stability. Systematic review. A systematic review was performed to identify prospective and retrospective comparative studies and cohort studies (evidence levels 1-3) comparing outcomes of primary ACL reconstructions performed with hamstring autografting alone and hybrid grafting. Outcomes included patient-reported evaluation, failure rate, and knee stability. Ten studies were included: 1 of level 2 and 9 of level 3. Collectively, they included 398 autografts and 341 hybrid grafts. Mean respective follow-up durations ranged from 24.0 to 69.6 months and from 24.0 to 70.8 months. Patient-reported evaluations, including Lysholm, Tegner, and subjective International Knee Documentation Committee scores, were reported in 8 of 10 studies. Failure rates were reported in all 10 studies. Results of knee stability examinations-including KT-1000 arthrometer measurements, the pivot-shift test, Lachman test, and overall International Knee Documentation Committee results-were reported in 4 of 10 studies. In this review, there were no statistically significant differences between autografts and hybrid grafts in terms of patient-reported evaluations, failure rates, or KT-1000 measurements. In this systematic review, there was no significant difference in patient-reported evaluation or failure rate between primary ACL reconstructions performed with autografts alone and those performed with hybrid grafts. Whether there is a substantial difference in knee stability examination results between autografts and hybrid grafts remains unknown, given a relative lack of reports on knee stability.

Two-Stage Revision Anterior Cruciate Ligament Reconstruction: A Systematic Review of Bone Graft Options for Tunnel Augmentation

22-05-2019 – Hytham S. Salem,Derek P. Axibal,Michelle L. Wolcott,Armando F. Vidal,Eric C. McCarty,Jonathan T. Bravman,Rachel M. Frank

Journal Article

No consensus is available regarding the optimal choice of bone graft material for bone tunnel augmentation in revision anterior cruciate ligament (ACL) surgery. To compare the outcomes of different bone graft materials for staged revision ACL reconstruction. Systematic review. A systematic review using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed. PubMed, EMBASE, and the Cochrane Library were queried through use of the terms anterior cruciate ligament and revision to identify all studies reporting outcomes of bone tunnel grafting in 2-stage revision ACL reconstruction. Data extracted included indications for 2-stage surgery, surgical technique, graft material, time between surgeries, rehabilitation protocols, physical examination findings, patient-reported outcomes, and radiographic and histologic findings. The analysis included 7 studies with a total of 234 patients. The primary outcome in 2 studies was graft incorporation (mean follow-up, 8.8 months), whereas the other 5 studies reported clinical outcomes with follow-up mean ± SD of 4.2 ± 2.1 years. The indication for bone grafting and between-stage protocol varied among studies. Autograft was used in 4 studies: iliac crest bone autograft (ICBG, n = 3) and tibial bone autograft (TBA, n = 1). In 2 studies, the authors investigated the outcomes of allograft: allograft bone matrix (ABM) and allograft bone chips (AC). Finally, 1 study compared ICBG to a synthetic bone substitute. Radiographic evaluation of bone graft integration after the first stage was reported in 4 studies, with an average duration of 4.9 months. In 4 studies, the authors reported the time interval between first and second surgeries, with an average of 6.1 months for ICBG compared with 8.7 months for allogenic and synthetic grafts. Revision ACL graft failure rates were reported by 5 studies, including 1 study with ABM (6.1%), 1 study with AC (8.3%), 1 study with TBA (0%), and 2 studies with ICBG (0% and 2%). The indications for staged ACL reconstruction and the rehabilitation protocol between stages need to be clearly established. The available data indicate that autograft for bone tunnel grafting in 2-stage ACL revision may be associated with a lower risk of revision ACL reconstruction graft failure compared with allograft bone.

Properties and Function of the Medial Patellofemoral Ligament: A Systematic Review

15-05-2019 – Christian Huber,Qiang Zhang,William R. Taylor,Andrew A. Amis,Colin Smith,Seyyed Hamed Hosseini Nasab

Journal Article

As the main passive structure preventing patellar lateral subluxation, accurate knowledge of the anatomy, material properties, and functional behavior of the medial patellofemoral ligament (MPFL) is critical for improving its reconstruction. To provide a state-of-the-art understanding of the properties and function of the MPFL by undertaking a systematic review and statistical analysis of the literature. Systematic review. On June 26, 2018, data for this systematic review were obtained by searching PubMed and Scopus. Articles containing numerical information regarding the anatomy, mechanical properties, and/or functional behavior of the MPFL that met the inclusion criteria were reviewed, recorded, and statistically evaluated. A total of 55 articles met the inclusion criteria for this review. The MPFL presented as a fanlike structure spanning from the medial femoral epicondyle to the medial border of the patella. The reported data indicated ultimate failure loads from 72 N to 208 N, ultimate failure elongation from 8.4 mm to 26 mm, and stiffness values from 8.0 N/mm to 42.5 N/mm. In both cadaveric and in vivo studies, the average elongation pattern demonstrated close to isometric behavior of the ligament in the first 50° to 60° of knee flexion, followed by progressive shortening into deep flexion. Kinematic data suggested clear lateralization of the patella in the MPFL-deficient knee during early knee flexion under simulated muscle forces. A lack of knowledge regarding the morphology and attachment sites of the MPFL remains. The reported mechanical properties also lack consistency, thus requiring further investigations. However, the results regarding patellar tracking confirm that the lack of an MPFL leads to lateralization of the patella, followed by delayed engagement of the trochlear groove, plausibly leading to an increased risk of patellar dislocations. The observed isometric behavior up to 60° of knee flexion plausibly suggests that reconstruction of the ligament can occur at flexion angles below 60°, including the 30° and 60° range as recommended in previous studies.

Repair of Rotator Cuff Tears in the Elderly: Does It Make Sense? A Systematic Review

30-04-2019 – Burak Altintas,Nicole L. Anderson,Rafael Pitta,Patrick S. Buckley,Sanjeev Bhatia,Matthew T. Provencher,Peter J. Millett

Journal Article

The indications and outcomes for rotator cuff repair (RCR) among patients ≥70 years old are not widely reported. Many active patients in this age range desire a joint-preserving option, and several small series reported successful clinical outcomes after RCR among patients aged ≥70 years. The purpose of this study was to systematically review the literature on the outcomes of RCR among patients ≥70 years old. Systematic review; Level of evidence, 4. A systematic review of the literature was performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The electronic databases of PubMed and Cochrane were used for the literature search. The quality of the included studies was evaluated according to the Coleman Methodology Score. Studies in English evaluating repair of full-thickness rotator cuff tears among patients aged ≥70 years were included. Eleven studies were reviewed, including 680 patients (694 shoulders) who were treated with arthroscopic and/or open RCR with a mean follow-up of 24.2 months (range, 12-40.8 months). Forty patients were lost to follow-up, leaving 654 shoulders with outcome data. This age group demonstrated a significant increase in clinical and functional outcomes after RCR with high satisfaction. American Shoulder and Elbow Surgeons scores showed an improvement from 44.2 (range, 35.4-56) preoperatively to 87.9 (range, 84-90.3) postoperatively, while Constant scores improved from 41.7 (range, 22.6-53.6) to 70.8 (range, 58.6-76). Postoperative imaging evaluation was performed on 513 shoulders, revealing a retear rate of 27.1% (139 shoulders). There were 45 retears after open repair and 94 after arthroscopic repair. The difference in retear rate among patients receiving arthroscopic repairs was not significantly different than open repairs ( P = .831). Pain according to a visual analog scale improved from 5.5 (range, 4.6-6.4) preoperatively to 1.3 (range, 0.5-2.3) postoperatively. RCR among patients ≥70 years old shows high clinical success rates with good outcomes and overall excellent pain relief. Although patients in this age group have a high potential for retear or persistent defects on imaging studies, RCR offers a joint-preserving option with significant functional and clinical improvement for the appropriately indicated patient.