American Journal of Sports Medicine

Placing the Latarjet in Context

01-01-2020 – Bruce Reider


Outcomes After Latarjet Procedure: Patients With First-Time Versus Recurrent Dislocations

01-01-2020 – Alexandre Hardy,Vincent Sabatier,Pierre Laboudie,Bradley Schoch,Geoffroy Nourissat,Philippe Valenti,Jean Kany,Julien Deranlot,Nicolas Solignac,Philippe Hardy,Marie Vigan,Jean-David Werthel

Journal Article

The preoperative number of dislocations has been previously proved to be a major factor influencing the results after Bankart repair with more preoperative dislocations correlated with higher recurrence rates and more reoperations. This could possibly be because of the lower quality of the tissue repaired during the procedure after multiple dislocations. On the other hand, the Latarjet procedure does not “repair” but rather reconstructs and augments the anterior glenoid. The main objective was to report the clinical outcomes of patients undergoing a Latarjet procedure after 1 dislocation versus multiple (≥2) dislocations. The hypothesis was that the preoperative number of dislocations would not influence clinical results. Cohort study; Level of evidence, 3. Patients older than 18 years who had undergone a primary Latarjet procedure for shoulder instability with at least 2 years of follow-up were included. Three different techniques were used: a mini-open technique using 2 screws, an arthroscopic technique using 2 screws, and an arthroscopic technique using 2 cortical buttons. Patients were evaluated and answered a questionnaire to assess the number of episodes of dislocation before surgery, the time between the first dislocation and surgery, recurrence of the dislocation, revision surgery, the Walch-Duplay score, the Simple Shoulder Test score, and the visual analog scale (VAS) score for pain. A total of 308 patients were included for analysis with a mean follow-up of 3.4 ± 0.8 years. Of that, 83 patients were included in the first-time dislocation group and 225 in the recurrent dislocation group. At last follow-up, the rates of recurrence and reoperation were not significantly different between groups: 4.8% in the first-time dislocation group versus 3.65% in the recurrent dislocation group and 6.1% versus 4.0%, respectively. The overall Walch-Duplay scores at last follow-up were also comparable between the 2 groups, 67.3 ± 24.85 and 71.8 ± 25.1, even though the first-time dislocation group showed a lower pain subscore (15.0 ± 8.6 vs 18.0 ± 7.5; The number of episodes of dislocation before surgery does not affect postoperative instability rates and reoperation rates after the Latarjet procedure. However, patients with first-time dislocations had more postoperative pain compared with patients with recurrent dislocations before surgery.

Outcomes of the Latarjet Procedure for the Treatment of Chronic Anterior Shoulder Instability: Patients With Prior Arthroscopic Bankart Repair Versus Primary Cases

01-01-2020 – Jean-David Werthel,Vincent Sabatier,Bradley Schoch,Lior Amsallem,Geoffroy Nourissat,Philippe Valenti,Jean Kany,Julien Deranlot,Nicolas Solignac,Philippe Hardy,Marie Vigan,Alexandre Hardy

Journal Article

It remains unclear whether results differ between a Latarjet procedure performed after a failed arthroscopic Bankart repair and one performed as the primary operation. To compare the postoperative outcomes of the Latarjet procedure when performed as primary surgery and as revision for a failed arthroscopic Bankart repair. Cohort study; Level of evidence, 3. A multicenter retrospective comparative case-cohort analysis was performed for all patients undergoing a Latarjet procedure for recurrent anterior shoulder instability. Patients were separated into 2 groups depending on if the Latarjet procedure was performed after a failed arthroscopic Bankart repair (group 1) or as the first operation (group 2). Outcome measures included recurrent instability, reoperation rates, complications, pain, Walch-Duplay scores, and Simple Shoulder Test. A total of 308 patients were eligible for participation in the study; 72 (23.4%) did not answer and were considered lost to follow-up, leaving 236 patients available for analysis. Mean follow-up was 3.4 ± 0.8 years. There were 20 patients in group 1 and 216 in group 2. Despite similar rates of recurrent instability (5.0% in group 1 vs 2.3% in group 2; Functional outcome scores and postoperative pain are significantly worse in patients undergoing a Latarjet procedure after a failed arthroscopic Bankart repair when compared with patients undergoing primary Latarjet. The assumption that a failed a Bankart repair can be revised by a Latarjet with a similar result to a primary Latarjet appears to be incorrect. Surgeons should consider these findings when deciding on the optimal surgical procedure for recurrent shoulder instability.

Peripheral-Track and Central-Track Hill-Sachs Lesions: A New Concept of Assessing an On-Track Lesion

01-01-2020 – Nobuyuki Yamamoto,Kiyotsugu Shinagawa,Taku Hatta,Eiji Itoi

Journal Article

It has been demonstrated biomechanically that 25% is a critical size defect of the glenoid. However, a recent clinical study reported that a bone loss between 13.5% and 20% (subcritical bone loss) led to impairment of quality of life but not a recurrence of instability. To clarify whether a subcritical bone loss exists in assessing a Hill-Sachs lesion via a disease-specific quality of life questionnaire. Cohort study; Level of evidence, 3. Fifty patients (mean age, 27 years) with <25% glenoid defect who were treated with arthroscopic Bankart repair for recurrent anterior dislocation were assessed at a mean follow-up of 28 months. All had an on-track Hill-Sachs lesion. The Western Ontario Shoulder Instability Index (WOSI) and Rowe scores were used for the clinical evaluation. The Hill-Sachs interval was measured on 3-dimensional computed tomography images and divided by the glenoid track width, defined as the Hill-Sachs occupancy (in percentages). The glenoid track was divided into 4 zones based on the percentage of the Hill-Sachs occupancy: zone 1, <25%; zone 2, 25% to <50%; zone 3, 50% to <75%; and zone 4, ≥75%. The recurrence rate was 6% (3 of 50 shoulders). The Rowe score significantly improved from 45.2 ± 4.7 (mean ± SD) preoperatively to 92.3 ± 6.5 at the final follow-up ( Patients with on-track lesions can be divided into 2 subgroups: those with the Hill-Sachs occupancy ≥75% (peripheral-track lesion) showed significantly worse WOSI score without recurrent instability events than those with the Hill-Sacks occupancy <75% (central-track lesion).

Modified Arthroscopic Latarjet Procedure: Suture-Button Fixation Achieves Excellent Remodeling at 3-Year Follow-up

01-01-2020 – Jian Xu,Haifeng Liu,Wei Lu,Zhenhan Deng,Weimin Zhu,Liangquan Peng,Kan Ouyang,Hao Li,Daping Wang

Journal Article

Some studies have advocated the use of suture-button fixation during the Latarjet procedure to reduce complications associated with screw fixation. However, the sample size of these studies is relatively small, and their follow-up period is short. To investigate the efficacy of the suture-button Latarjet procedure with at least 3 years of follow-up and remodeling of the coracoid graft. Case series; Level of evidence, 4. A total of 152 patients who underwent the suture-button Latarjet procedure between February 2013 and February 2016 were selected, and 128 patients who met the inclusion criteria were enrolled in this study. Preoperative and postoperative clinical results were assessed. The position and healing condition of the coracoid graft and arthropathy of the glenoid and humeral head were also assessed using radiography and 3-dimensional computed tomography (CT). The mean follow-up time was 40.3 ± 5.8 months. There were 102 patients included in this study. The mean visual analog scale score for pain during motion, the American Shoulder and Elbow Surgeons score, the Rowe score, and the Walch-Duplay score were improved considerably. A total of 100 grafts achieved bone union. The overall absorption rate was 12.6% ± 4.3%. Graft absorption mostly occurred on the edge and outside the “best-fit” circle of the glenoid. A vertical position was achieved in 98 grafts (96% of all cases) immediately postoperatively, with the mean graft midline center at the 4 o’clock position. In the axial view, CT showed that 89 grafts were flush to the glenoid, whereas 2 and 11 grafts were fixed medially and laterally, respectively. In all cases, the bone graft and glenoid tended to extend toward each other to form concentric circles during the remodeling process. During follow-up observations, the height of the 11 grafts that were positioned laterally (ie, above the glenoid level) exhibited a wave-curved change. No arthropathy was observed in any patient. Patient outcomes were satisfactory after the modified arthroscopic suture-button Latarjet technique. Graft absorption mostly occurred on the edge and outside the “best-fit” circle of the glenoid. The graft exhibited the phenomenon of ectatic growing when it fused with the glenoid and finally remodeled to a new concentric circle with the humeral head analogous to the original glenoid. Grafts positioned laterally did not cause arthropathy of the joints within the period of the study.

Postoperative Recurrence of Instability After Arthroscopic Bankart Repair for Shoulders With Primary Instability Compared With Recurrent Instability: Influence of Bipolar Bone Defect Size

01-01-2020 – Shigeto Nakagawa,Takehito Hirose,Ryohei Uchida,Makoto Tanaka,Tatsuo Mae

Journal Article

In shoulders with traumatic anterior instability, a bipolar bone defect has recently been recognized as an important indicator of the prognosis. To investigate the influence of bipolar bone defects on postoperative recurrence after arthroscopic Bankart repair performed at primary instability. Cohort study; Level of evidence, 3. The study group consisted of 45 patients (45 shoulders) who underwent arthroscopic Bankart repair at primary instability before recurrence and were followed for at least 2 years. The control group consisted of 95 patients (95 shoulders) with recurrent instability who underwent Bankart repair and were followed for at least 2 years. Glenoid defects and Hill-Sachs lesions were classified into 5 size categories on 3-dimensional computed tomography and were allocated scores ranging from 0 for no defect to 4 for the largest defect. The shoulders were classified according to the total score for both lesions (0-8 points). The postoperative recurrence rate was investigated for each score of bipolar bone defects and was compared between patients with primary instability and patients with recurrent instability. The same analysis was performed for the age at operation (<20 years, 20-29 years, or ≥30 years) and for the presence of an off-track Hill-Sachs lesion. Bipolar bone defects were smaller in shoulders with primary instability (mean ± SD defect score, 1.4 ± 1.5 points) than in those with recurrent instability (3.6 ± 1.9 points) and were larger in older patients than in younger patients at the time of primary instability. The postoperative recurrence rate was low (6.7%) in shoulders with primary instability regardless of the size of the bipolar bone defect and the patient's age, whereas the postoperative recurrence rate was high (23.2%) in shoulders with recurrent instability, especially among patients younger than 20 years with bipolar bone defects of 2 points or greater. An off-track Hill-Sachs lesion was found in only 1 patient in the oldest age group (2.2%) at primary instability, but it was found in 19 patients (20%) at recurrent instability, including 14 patients younger than 30 years. Among patients with an off-track lesion, the postoperative recurrence rate was significantly higher in patients younger than 20 years with recurrent instability (recurrence rates: <20 years, 71.4%; 20-29 years, 14.3%; ≥30 years, 0%). The recurrence rate was consistently low in patients with primary instability and was significantly influenced by bipolar bone defect size and patient age in patients with recurrent instability.

An Age-Based Approach to Anterior Shoulder Instability in Patients Under 40 Years Old: Analysis of a US Population

01-01-2020 – Devin P. Leland,Christopher D. Bernard,Lucas K. Keyt,Aaron J. Krych,Diane L. Dahm,Joaquin Sanchez-Sotelo,Christopher L. Camp

Journal Article

While a large volume of literature has focused on risk factors for anterior shoulder instability, the rates of recurrence are inconsistent and require additional population-based epidemiologic data. The purpose was to report the effect of patient age on the number of instability events before physician consultation, rate of surgical stabilization, recurrent instability, and progression to osteoarthritis in patients <40 years old with anterior shoulder instability, utilizing an established US geographic population. We hypothesized that younger patients would be more likely to experience multiple episodes of instability before evaluation, undergo surgery, and experience recurrent instability after surgical intervention. Descriptive epidemiologic study. An established geographic database of more than 500,000 patients was used to identify patients <40 years of age with anterior shoulder instability between 1994 and 2016. Medical records were reviewed to obtain patient characteristics, history, imaging, surgical details, and outcomes. Patients were divided into 5 groups based on age (≤15, 16-20, 21-25, 26-30, and 31-40 years) at initial instability. Comparative analysis was performed to identify differences between groups. The study population consisted of 654 patients with a mean follow-up of 11.1 years (range, 2.0-25.2 years). This resulted in 118 patients (18%) ≤15 years of age at initial instability; 250 (38%), 16 to 20 years; 110 (17%), 21 to 25 years; 80 (12%), 26 to 30 years; and 96 (15%), 31 to 40 years. Of patients ≤15 years old at initial instability 47% had 3+ instability events, compared with 12% of patients aged 31 to 40 years ( In a US epidemiologic population of patients <40 years old, the rate of recurrent anterior shoulder instability was roughly one-third after initial physician consultation. Younger patients, particularly those ≤15 and 16 to 20 years of age, were more likely to have experienced multiple instability events at the time of initial evaluation, require surgery, and experience recurrent instability compared with older patients. For every year of decrease in age at initial instability, the risk of recurrent instability or surgical intervention after physician consultation increased by 4.1% and 2.8%, respectively.

Effect of Graft Choice on Revision and Contralateral Anterior Cruciate Ligament Reconstruction: Results From the New Zealand ACL Registry

01-01-2020 – Richard Rahardja,Mark Zhu,Hamish Love,Mark G. Clatworthy,Andrew Paul Monk,Simon W. Young

Journal Article

The patellar tendon is often considered the “gold standard” graft for reducing the risk of graft rupture after anterior cruciate ligament (ACL) reconstruction. However, its use may also be associated with an increased risk of injury to the contralateral ACL. To clarify the association between graft choice and the risk of revision and contralateral ACL reconstruction. Cohort study; Level of evidence, 2. Prospective data captured by the New Zealand ACL Registry between April 2014 and December 2018 were reviewed. All primary ACL reconstructions performed using either a hamstring tendon or patellar tendon autograft were included. Cox regression survival analysis adjusting for patient factors was performed to compare the risk of revision and contralateral ACL reconstruction between the hamstring tendon graft and the patellar tendon graft. A total of 7155 primary ACL reconstructions were reviewed, of which 5563 (77.7%) were performed using a hamstring tendon graft and 1592 (22.3%) were performed using a patellar tendon graft. Patients with a hamstring tendon graft had a revision rate of 2.7% compared with 1.3% in patients with a patellar tendon graft (adjusted hazard ratio [HR], 2.51; 95% CI, 1.55-4.06; Use of a patellar tendon graft reduced the risk of graft rupture but was associated with an increased risk of injury to the contralateral ACL. Adequate rehabilitation and informed decision making on return to activity and injury prevention measures may be important in preventing subsequent injury to the healthy knee.

How Much Time Is Needed Between Serial “Return to Play” Assessments to Achieve Clinically Important Strength Gains in Patients Recovering From Anterior Cruciate Ligament Reconstruction?

01-01-2020 – Stephan G. Bodkin,Margaret H. Rutherford,David R. Diduch,Stephen F. Brockmeier,Joe M. Hart

Journal Article

Pass rates for return-to-play evaluations are alarmingly low for patients after anterior cruciate ligament reconstruction (ACLR). Since timing of return to play is a complicated decision, it is important that patients be given optimal time to realize meaningful improvements in strength that warrant additional testing. To (1) compare outcomes among patients assessed at different time points after ACLR, (2) determine strength gains indicative of improvements in subjective function, and (3) determine the amount of time necessary to achieve meaningful strength gains. Cross-sectional/case-control study; Level of evidence, 3. A total of 293 patients participated in the study after ACLR (mean ± SD, 23.2 ± 10.1 years old; n = 142 female participants; 6.4 ± 0.9 months after ACLR). Participants were stratified on the month of their evaluation after ACLR: 5 to 6 months (n = 122), 6 to 7 months (n = 102), 7 to 8 months (n = 43), and 8 to 9 months (n = 26). The International Knee Documentation Committee (IKDC) subjective form and knee extensor and flexor torque and symmetry, as assessed through an isokinetic dynamometer, were compared among groups. Forty patients (20 female participants, 20.4 ± 7.1 years old) were referred for subsequent testing (2.14 ± 0.78 months after initial visit). Subjective improvement between visits was defined as a ≥9-point change of the IKDC score. Thresholds of knee extensor torque and symmetry indicative of subjective improvement and the time between assessments needed to achieve these strength improvements were determined. Patients between 5 and 6 months (IKDC, 79.7; interquartile range [IQR], 70.1-88.5) had lower subjective function compared to patients between 6 and 7 months (IKDC, 83.9; IQR, 74.5-92.0; Patients demonstrate increasing subjective and quadriceps function when tested at later time points from surgery; however, the observed values are low, suggesting that at 9 months patients are demonstrating deficits that may be improving. Approximately 2 months is needed to observe clinically meaningful improvements.

No Relationship Between Strength and Power Scores and Anterior Cruciate Ligament Return to Sport After Injury Scale 9 Months After Anterior Cruciate Ligament Reconstruction

01-01-2020 – Richard F. O’Connor,Enda King,Chris Richter,Kate E. Webster,Éanna Cian Falvey

Journal Article

Psychological factors including self-reported readiness to return to sport (RTS) after anterior cruciate ligament reconstruction (ACLR) measured with the Anterior Cruciate Ligament Return to Sport After Injury (ACL-RSI) scale have been shown to correlate with RTS. Physical deficits have been shown to exist in the later stages after ACLR rehabilitation. No previous studies have investigated the relationship between self-reported readiness to RTS and objective physical measures of power and strength. To investigate the relationship between ACL-RSI scores and measures of strength and power scores after ACLR. Case control study; Level of evidence, 3. This study recruited 452 male athletes who had undergone primary ACLR. Each athlete completed the ACL-RSI questionnaire, isokinetic strength testing, and jump testing approximately 9 months after surgery. ACL-RSI scores showed a trivial or weak correlation with strength and power measures at 9 months after surgery ( Self-reported readiness to RTS as measured by the ACL-RSI had little or no relationship with athletes’ strength and power measures, and there was no meaningful difference in strength and power between athletes with higher and lower ACL-RSI scores at 9 months after ACLR. The findings suggest that psychological recovery and physical recovery after ACLR are different constructs, and strategies to measure and address each construct separately may be necessary to ensure successful RTS after ACLR.

The Effect of Oral Contraceptive Hormones on Anterior Cruciate Ligament Strength

01-01-2020 – Jaclyn A. Konopka,Lauren Hsue,Wenteh Chang,Timothy Thio,Jason L. Dragoo

Journal Article

Women are 2 to 9 times more likely to experience an anterior cruciate ligament (ACL) injury than men. Various hormones including relaxin, progesterone, and estrogen influence ACL strength. Oral contraceptives (OCs) alter these hormone levels; however, studies have yet to comprehensively compare different OCs’ effects on the ACL. OCs with increased progestin-to-estrogen ratios will (1) increase ACL collagen expression, (2) decrease ACL matrix metalloproteinase expression, and (3) increase ACL strength. Controlled laboratory study. Untreated female rats were compared with rats treated with 1 of 5 clinically used OCs: norethindrone (NE) only, NE plus ethinylestradiol (EE), etynodiol diacetate (ED) plus EE, norgestimate (NG) plus EE, and drospirenone (DS) plus EE. Doses were scaled from human doses to account for differences in bioavailability and body weight, and OCs were administered daily via oral gavage for 4 rat estrous cycles (20 days). A total of 36 rats were then sacrificed (6 rats/group). ACLs underwent biomechanical testing to assess ACL strength, stiffness, and maximum load before failure. ACL specimens were also isolated for quantitative real-time polymerase chain reaction analysis to assess collagen, matrix metalloproteinase, and relaxin receptor-1 expression. While the primary structural property of interest (ACL maximum load before failure) was not significantly improved by OC treatment, the main material property of interest (ACL strength) in rats treated with NE only, DS + EE, ED + EE, and NE + EE was significantly increased compared with untreated controls ( OC formulations with higher progestin-to-estrogen ratios may be more protective for the ACL than formulations with lower ratios. OC formulations with high progestin-to-estrogen ratios may benefit female athletes by reducing their ACL injury risk by decreasing the effects of relaxin on the ACL.

Outcomes of Quadriceps Tendon With Patellar Bone Block Anterior Cruciate Ligament Reconstruction in Adolescent Patients With a Minimum 2-Year Follow-up

01-01-2020 – Alexia G. Gagliardi,Patrick M. Carry,Harin B. Parikh,Jay C. Albright

Journal Article

The incidence of anterior cruciate ligament (ACL) injury in the adolescent population is increasing. The quadriceps tendon-patellar bone autograft (QPA) has been established as a reliable graft choice for ACL reconstruction in the adult population. To investigate graft failure, ability to return to sport, patient-reported functional outcomes, joint laxity, and subsequent injury among adolescent patients >2 years after primary ACL reconstruction with the QPA. Case series; Level of evidence, 4. Consecutive patients who underwent QPA ACL reconstruction performed by a single surgeon were identified from an existing database. Information available in the database included demographics, concomitant/subsequent injuries, surgical procedures, graft failure, return to sport, and Lachman examination collected by medical record review. Pediatric International Knee Documentation Committee (Pedi-IKDC) and Lysholm scores were collected by telephone or during a clinic visit >2 years postoperatively. The final cohort included 81 of 104 consecutive adolescent patients aged 10 to 18 years (mean ± SD, 15.9 ± 1.7 years at the time of surgery) for whom follow-up information was collected at >2 years after surgery. The cumulative incidence of graft failure within the 36-month follow-up period was 1.2% (95% CI, 0.1%-11.4%). The rate of ipsilateral non-ACL injuries was similar (1.2%; 95% CI, 0.2%-7.6%). Contralateral ACL and non-ACL injuries requiring surgical intervention were documented in 9.8% (95% CI, 4.9%-19.5%). The median Pedi-IKDC score was 94 (interquartile range, 89-98). The median Lysholm score was 99.5 (interquartile range, 89.0-100.0). At 36 months after surgery, 87.9% (95% CI, 81.4%-94.9%) of individuals had returned to play. The quadriceps tendon-patellar autograft is a novel graft that demonstrates excellent stability and favorable patient-reported outcomes. Based on these results, the QPA is a reliable choice for primary ACL reconstruction in adolescent patients.

Graft Size and Orientation Within the Femoral Notch Affect Graft Healing at 1 Year After Anterior Cruciate Ligament Reconstruction

01-01-2020 – Takeshi Oshima,Sven Putnis,Samuel Grasso,Antonio Klasan,David Anthony Parker

Journal Article

The combined influence of anatomic and operative factors affecting graft healing after anterior cruciate ligament (ACL) reconstruction within the femoral notch is not well understood. To determine the influence of graft size and orientation in relation to femoral notch anatomy, with the signal/noise quotient (SNQ) of the graft used as a measure of graft healing after primary single-bundle ACL reconstruction. Case series; Level of evidence, 4. A total of 98 patients with a minimum 2-year follow-up after primary single-bundle ACL reconstruction with hamstring tendon autografts were included. Graft healing was evaluated at 1 year on magnetic resonance imaging (MRI) scan as the mean SNQ measured from 3 regions situated at sites at the proximal, middle, and distal graft. Patient characteristics, chondropenia severity score, tunnel sizes, tunnel locations, graft bending angle (GBA), graft sagittal angle, posterior tibial slope (PTS), graft length, graft volume, femoral notch volume, and graft-notch volume ratio (measured using postoperative 3-T high-resolution MRI) were evaluated to determine any association with 1-year graft healing. The correlation between 1-year graft healing and clinical outcome at minimum 2 years was also assessed. There was no significant difference in mean SNQ between male and female patients ( The 1-year SNQ value had a significant positive association with graft-notch volume ratio and GBA. Both graft size and graft orientation appeared to have a significant influence on graft healing as assessed on 1-year high-resolution MRI scan.

Engagement of the Secondary Ligamentous and Meniscal Restraints Relative to the Anterior Cruciate Ligament Predicts Anterior Knee Laxity

01-01-2020 – Robert N. Kent,Carl W. Imhauser,Ran Thein,Niv Marom,Thomas L. Wickiewicz,Danyal H. Nawabi,Andrew D. Pearle

Journal Article

Patients with high-grade preoperative side-to-side differences in anterior laxity as assessed via the Lachman test after unilateral anterior cruciate ligament (ACL) rupture are at heightened risk of early ACL graft failure. Biomechanical factors that predict preoperative side-to-side differences in anterior laxity are poorly understood. To assess, in a cadaveric model, whether the increase in anterior laxity caused by sectioning the ACL (a surrogate for preoperative side-to-side differences in anterior laxity) during a simulated Lachman test is associated with two biomechanical factors: (1) the tibial translation at which the secondary anterior stabilizers, including the remaining ligaments and the menisci, begin to carry force, or Controlled laboratory study. Seventeen fresh-frozen human cadaveric knees underwent Lachman tests simulated through a robotic manipulator with the ACL intact and sectioned. The net forces carried by the ACL and secondary soft tissue stabilizers (the medial meniscus and all remaining ligaments, measured as a whole) were characterized as a function of anterior tibial translation. The engagement points of the ACL (with the ACL intact) and each secondary stabilizer (with the ACL sectioned) were defined as the anterior translation at which they began to carry force, or engaged, during a simulated Lachman test. Then, the relative engagement point of each secondary stabilizer was defined as the difference between the engagement point of each secondary stabilizer and that of the ACL. Linear regressions were performed to test each association ( The increase in anterior laxity caused by ACL sectioning was associated with increased relative engagement points of both the secondary ligaments (β = 0.87; The secondary ligaments and the medial meniscus require greater anterior tibial translation to engage (ie, begin to carry force) relative to the ACL in knees with greater changes in anterior laxity after ACL sectioning. Moreover, with the ACL intact, the medial meniscus carries more force in knees with smaller changes in anterior laxity after ACL sectioning. Relative tissue engagement is a new biomechanical measure to characterize in situ function of the ligaments and menisci. This measure may aid in developing more personalized surgical approaches to reduce high rates of ACL graft revision in patients with high-grade laxity.

A High-Grade J Sign Is More Likely to Yield Higher Postoperative Patellar Laxity and Residual Maltracking in Patients With Recurrent Patellar Dislocation Treated With Derotational Distal Femoral Osteotomy

01-01-2020 – ZhiJun Zhang,Hui Zhang,GuanYang Song,XueSong Wang,Jin Zhang,Tong Zheng,QianKun Ni,Hua Feng

Journal Article

It has been speculated that the patellar J sign may have a negative effect on the clinical outcomes of patients with recurrent patellar dislocation (RPD). To (1) evaluate clinical outcomes, postoperative patellar stability, and patellar maltracking correction in patients with RPD treated with derotational distal femoral osteotomy (DDFO) and combined procedures and (2) investigate the influence of J sign severity on the clinical outcomes. Cohort study; Level of evidence, 3. Between January 2015 and December 2016, a total of 78 patients (81 knees) with RPD, a positive J sign, and an excessive femoral anteversion angle (FAA; ≥30°) were surgically treated with DDFO and combined procedures. J sign severity was graded according to a previously described classification system (grades 1-3). Routine radiography and computed tomography were performed on every patient to evaluate the patellar height, trochlear dysplasia, genu valgum, tibial tuberosity-trochlear groove distance, patellar lateral tilt angle, and patella-trochlear groove distance. The patellar lateral shift distance during stress radiography was measured preoperatively and postoperatively to quantify medial patellofemoral ligament (MPFL) graft laxity under anesthesia, and “MPFL residual graft laxity” was defined as the patellar ridge surpassing the apex of the lateral femoral trochlea. Patients were evaluated using the Kujala, International Knee Documentation Committee (IKDC), and Lysholm scores preoperatively and postoperatively. Patients were allocated into 3 subgroups in terms of the severity of the J sign: low-grade group 1 (grade 1; n = 19), low-grade group 2 (grade 2; n = 16), and high-grade group (grade 3; n = 12). Subgroup analyses were performed to investigate the influence of a high-grade J sign on the clinical outcomes. Among the 78 patients (81 knees), 47 patients (47 knees) met the inclusion criteria. The mean follow-up time was 26.1 ± 1.7 months. The mean preoperative and postoperative FAAs were 36.2°± 5.3° and 10.0°± 2.1°, respectively, with a mean correction angle of 26.2°± 5.9°. At the final follow-up, all patient-reported outcomes improved significantly, and subgroup analyses showed that the high-grade group had significantly lower Kujala scores (75.6 vs 85.3 for low-grade group 1 [ In a group of patients treated for RPD with a positive preoperative J sign and increased FAA (≥30°), patients with a preoperative high-grade J sign had inferior clinical outcomes, more MPFL residual graft laxity, and greater residual patellar maltracking.

Medial Meniscus Posterior Root Tear Treatment: A Matched Cohort Comparison of Nonoperative Management, Partial Meniscectomy, and Repair

01-01-2020 – Christopher D. Bernard,Nicholas I. Kennedy,Adam J. Tagliero,Christopher L. Camp,Daniel B.F. Saris,Bruce A. Levy,Michael J. Stuart,Aaron J. Krych

Journal Article

There are limited data comparing the outcomes of similarly matched patients with a medial meniscus posterior root tear (MMPRT) treated with nonoperative management, partial meniscectomy, or repair. The purpose was to compare treatment failure, clinical outcome scores, and radiographic findings for a matched cohort of patients who underwent either nonoperative management, partial meniscectomy, or transtibial pull-through repair for an MMPRT. We hypothesized that patients who underwent meniscus root repair will have lower rates of progression to arthroplasty than patients who were treated with nonoperative management or partial meniscectomy. Cohort study; Level of evidence, 3. Patients who underwent transtibial medial meniscus posterior horn root repair were matched by meniscal laterality, age, sex, and Kellgren-Lawrence (K-L) grades to patients treated nonoperatively or with a partial meniscectomy. Progression to arthroplasty rates, International Knee Documentation Committee and Tegner scores, and radiographic outcomes were analyzed between groups. Forty-five patients were included in this study (15 nonoperative, 15 partial meniscectomy, 15 root repair). Progression to arthroplasty demonstrated significant differences among treatment groups at a mean of 74 months (nonoperative, 4/15; partial meniscectomy, 9/15; meniscal repair, 0/15; Meniscus root repair leads to significantly less arthritis progression and subsequent knee arthroplasty compared with nonoperative management and partial meniscectomy in a matched cohort based on patient characteristics.

Minimum 10-Year Clinical and Radiological Outcomes of a Randomized Controlled Trial Evaluating 2 Different Approaches to Full Weightbearing After Matrix-Induced Autologous Chondrocyte Implantation

01-01-2020 – Jay R. Ebert,Michael Fallon,Timothy R. Ackland,Gregory C. Janes,David J. Wood

Journal Article

Longer term outcomes after matrix-induced autologous chondrocyte implantation (MACI) are lacking, while early postoperative weightbearing (WB) management has traditionally been conservative. To investigate the longer term clinical and radiological outcomes after an 8-week (vs 12-week) WB protocol after MACI. Randomized controlled trial; Level of evidence, 1. A randomized study design allocated 70 patients to an 8- (n = 34) or 12-week (n = 36) approach to full WB after MACI of the medial or lateral femoral condyle. Patients were evaluated preoperatively; at 3, 12, and 24 months after surgery; and at 5 and 10 years after surgery. At 10 years (range, 10.5-11.5 years), 60 patients (85.7%; 8 weeks: n = 29; 12 weeks: n = 31) were available for review. Clinical outcomes included patient-reported outcomes, maximal isokinetic knee extensor and flexor strength, and functional hop capacity. High-resolution magnetic resonance imaging (MRI) was undertaken to assess the quality and quantity of repair tissue per the MOCART (magnetic resonance observation of cartilage repair tissue) system. A combined MRI composite score was also evaluated. Clinical and MRI-based scores for the full cohort significantly improved ( MACI provided high satisfaction levels and tissue durability beyond 10 years. The outcomes of this randomized trial demonstrate a safe 8-week WB rehabilitation protocol without jeopardizing longer term outcomes.

Matrix Metalloproteinase Inhibition With Doxycycline Affects the Progression of Posttraumatic Osteoarthritis After Anterior Cruciate Ligament Rupture: Evaluation in a New Nonsurgical Murine ACL Rupture Model

01-01-2020 – Xueying Zhang,Xiang-Hua Deng,Zhe Song,Brett Croen,Camila B. Carballo,Zoe Album,Ying Zhang,Reyna Bhandari,Scott A. Rodeo

Journal Article

Doxycycline has broad-spectrum activity as a matrix metalloproteinase (MMP) inhibitor and thus could reduce the progression of posttraumatic osteoarthritis (PTOA) after anterior cruciate ligament (ACL) rupture. Doxycycline would inhibit progression of PTOA in a murine ACL rupture model. Controlled laboratory study. For the in vitro study, cadaveric C57BL/6 male mice knees (N = 108) were used for the development of a nonsurgical ACL rupture model. For the in vivo study, 24 C57BL/6 male mice then underwent ACL rupture with our manual procedure and were divided into 4 groups: untreated control; doxycycline, 10 mg/kg/d; doxycycline, 50 mg/kg/d; and doxycycline, 100 mg/kg/d. Doxycycline was administered in drinking water beginning immediately after ACL rupture. Radiographic imaging and paw prints were evaluated at 3, 7, 14, and 28 days. The foot length and toe spread were analyzed as measures of function. Histology and MMP-13 immunohistochemistry were done at 4 weeks. Radiographs demonstrated anterior tibial subluxation and meniscal extrusion after ACL rupture, confirming knee joint instability without fractures. Statistically significant differences in gait were found between the intact and experimental groups. Histologic examination demonstrated cartilage damage, meniscal tears, and mild osteoarthritis after ACL rupture, similar to what occurs in human patients. Hypertrophy of the posterior horn of the medial and lateral meniscus was found, and tears of the posterior horn of the menisci were common. All doxycycline groups had a lower score than the untreated control group, indicating less cartilage damage. The posterior tibia of the untreated group had the most cartilage damage as compared with the 3 doxycycline groups, with a significant difference between the untreated and 50-mg/kg/d doxycycline groups, suggesting that the latter dose may protect against proteoglycan loss and decrease the progression of osteoarthritis. The nondoxycycline group had the highest synovial inflammation score among all groups, indicating that doxycycline has an inhibitory effect on synovitis. There was significantly lower MMP-13 expression on the tibia in the doxycycline-treated groups, with a positive correlation between doxycycline concentration and MMP-13 inhibition. Modulation of MMP-13 activity by doxycycline treatment may offer a novel biological pathway to decrease the progression of PTOA after ACL rupture. Doxycycline is an approved, readily available drug with infrequent side effects of photosensitivity and gastrointestinal symptoms. Future clinical trials could evaluate doxycycline to reduce or prevent progressive cartilage damage after ACL rupture.

Arthroscopic Microfracture for Osteochondral Lesions of the Talus: Functional Outcomes at a Mean of 6.7 Years in 165 Consecutive Ankles

01-01-2020 – Seung-Won Choi,Gun-Woo Lee,Keun-Bae Lee

Journal Article

Arthroscopic microfracture for osteochondral lesions of the talus (OLT) has shown good functional outcomes. However, some studies have reported that functional outcomes deteriorate over time after surgery. To use various functional scoring systems to evaluate functional outcomes in a large sample of patients with OLT treated by arthroscopic microfracture. Case series; Level of evidence, 4. The study cohort consisted of 165 ankles (156 patients) that underwent arthroscopic microfracture for small to mid-sized OLT. The mean lesion size was 73 mm The mean FAOS significantly improved in regard to all subscores ( Arthroscopic microfracture showed good functional outcomes and improved quality of life with maintenance of satisfactory outcomes at a mean follow-up of 6.7 years. Therefore, arthroscopic microfracture seems to be reliable as a first-line treatment for OLT at an intermediate-term follow-up.

Comparing Outcomes of Competitive Athletes Versus Nonathletes Undergoing Hip Arthroscopy for Treatment of Femoroacetabular Impingement Syndrome

01-01-2020 – Ian M. Clapp,Benedict U. Nwachukwu,Edward C. Beck,Kyleen Jan,Anirudh K. Gowd,Shane J. Nho

Journal Article

A growing number of studies have examined return to sport in competitive athletes after undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS); however, few have evaluated the rate of achieving meaningful clinical outcomes in this group. To determine if competitive athletes (professional, semiprofessional, or collegiate) have better 2-year patient-reported outcomes and achieve the minimal clinically important difference (MCID) and substantial clinical benefit at higher rates when compared with nonathletes undergoing hip arthroscopy for the treatment of FAIS. Cohort study; Level of evidence, 3. The study was a retrospective analysis of all consecutive patients who identified as either a competitive athlete or a nonathlete and had undergone hip arthroscopy for FAIS by a single fellowship-trained surgeon between January 2012 and April 2017. Patients in the 2 groups were matched 1:2 by age, sex, and body mass index. Baseline and clinical outcomes, including the Hip Outcome Score-Activities of Daily Living, Hip Outcome Score-Sports Subscale (HOS-SS), modified Harris Hip Score, and international Hip Outcome Tool-12, were collected preoperatively and at 2 years postoperatively and compared between the groups. The MCID and substantial clinical benefit were calculated for each group separately and compared using chi-square analysis. A total of 59 competitive athletes and 118 nonathletes were included in the final analysis. Most of the competitive athletes were soccer players (23.7%), followed by softball players (10.2%) and runners (10.2%). Postoperative score comparison between competitive athletes and nonathletes demonstrated a statistically significant difference in the HOS-SS (mean ± SD, 84.5 ± 19.0 vs 76.1 ± 23.8; Hip arthroscopy for the treatment of FAIS in competitive athletes and nonathletes produced clinically meaningful outcomes in both patient groups. However, competitive athletes achieved the MCID on the HOS-SS at higher rates than nonathletes and had significantly higher scores at 2 years postoperatively on the HOS-SS.

Atypical Hip Pain in Femoroacetabular Impingement: A Comparison of Outcomes Based on Primary Hip Pain Location

01-01-2020 – Mathew J. Hamula,Michael K. Ryan,Samuel L. Baron,David A. Bloom,Thomas Youm

Journal Article

Patients with symptomatic femoroacetabular impingement (FAI) typically have anterior groin pain. However, a subset of these patients may have pain located laterally, posteriorly, or in a combination of locations around the hip. To report and compare outcomes of hip arthroscopy for patients with FAI and atypical hip pain versus classic anterior groin pain. Cohort study; Level of evidence, 2. Consecutive patients undergoing hip arthroscopy for FAI between August 2011 and March 2013 were identified. A total of 258 patients were identified as having symptomatic FAI based on clinical, radiographic, and advanced imaging diagnosis of FAI. Exclusion criteria included isolated thigh, knee, or low back pain. We also excluded patients with hip abductor pathology and trochanteric bursitis. Of the 226 patients ultimately included, 159 (70.4%) reported anterior groin pain, while 67 (29.6%) reported isolated lateral or posterior hip pain or a combination of locations. Patients were categorized into 4 groups: isolated anterior groin pain, lateral hip pain, posterior hip pain, and multiple primary hip pain locations (combined). These patients were followed prospectively with a minimum follow-up of 2 years. Patient characteristics, surgical characteristics, modified Harris Hip Score (m
HHS), Non-arthritic Hip Score (NAHS), revision hip arthroscopy, and conversions to total hip arthroplasty (THA) were recorded. All 226 patients were included at final follow-up. Hip arthroscopy was performed by a single sports medicine fellowship-trained orthopaedic surgeon. Preoperative patient characteristics and baseline functional outcome scores did not significantly differ among groups. All 4 groups showed statistically significant improvements in m
HHS and NAHS from baseline to final follow-up of a mean 2.63 years (range, 2.01-3.23 years). Functional outcome scores and rates of revision hip arthroscopy or conversion to THA did not significantly differ between groups. Hip arthroscopy can effectively improve patient outcomes in atypical hip pain. A careful history and physical examination should identify this clinically meaningful subset of patients with FAI who can benefit from surgical intervention while identifying patients with concomitant posterior extra-articular hip or spine pathology that should be addressed appropriately.

Radiographic and Demographic Factors Can Predict the Need for Primary Labral Reconstruction in Hip Arthroscopic Surgery: A Predictive Model Using 1398 Hips

01-01-2020 – David R. Maldonado,Jeffrey W. Chen,Rafael Walker-Santiago,Philip J. Rosinsky,Jacob Shapira,Ajay C. Lall,Cynthia Kyin,Benjamin G. Domb

Journal Article

Labral tears are the most common findings in patients with symptomatic femoroacetabular impingement (FAI). The restoration of labral function is critical, and labral reconstruction has been proposed as an alternative for irreparable tears. To compare preoperative radiographic measurements and demographics of patients who underwent primary arthroscopic labral reconstruction versus primary labral repair and to identify factors that are predictive of the need for reconstruction. Case-control study; Level of evidence, 3. Patients who underwent their index hip arthroscopic procedure between October 2010 and November 2018 and underwent either labral reconstruction or repair were included in the study. A total of 18 variables (14 radiographic and 4 demographic) were assessed in a bivariate comparison and analyzed in a multivariate logistic model. A total of 251 primary reconstruction and 1147 primary repair procedures were included. The logistic model selected age, body mass index (BMI), Tönnis grade, lateral center-edge angle (LCEA), and alpha angle. The odds of reconstruction were 2.52 times higher in patients with Tönnis grade 1 than 0 (odds ratio [OR], 2.52 [95% CI, 1.82-3.49]). Each additional degree in the LCEA was associated with a 6% increase in the odds of reconstruction (OR, 1.06 [95% CI, 1.04-1.09]) and 4% for each additional degree in the alpha angle (OR, 1.04 [95% CI, 1.03-1.05]). Higher age (per log 10 unit) and BMI also increased the likelihood of reconstruction (OR, 11.29 [95% CI, 4.23-30.10] and OR, 1.03 [95% CI, 1.00-1.06], respectively). In a multivariate analysis, factors identified as preoperative predictors for primary arthroscopic labral reconstruction in the setting of FAI and labral tears were Tönnis grade, LCEA, age, and BMI. These predictive factors may be useful for the clinician in determining the preoperative likelihood of primary labral reconstruction.

Spinopelvic Characteristics in Acetabular Retroversion: Does Pelvic Tilt Change After Periacetabular Osteotomy?

01-01-2020 – George Grammatopoulos,Saif Salih,Paul E. Beaule,Johan Witt

Journal Article

Acetabular retroversion may lead to impingement and pain, which can be treated with an anteverting periacetabular osteotomy (a
PAO). Pelvic tilt influences acetabular orientation; as pelvic tilt angle reduces, acetabular version reduces. Thus, acetabular retroversion may be a deformity secondary to abnormal pelvic tilt (functional retroversion) or an anatomic deformity of the acetabulum and the innominate bone (pelvic ring). To (1) measure the spinopelvic morphology in patients with acetabular retroversion and (2) assess whether pelvic tilt changes after successful anteverting PAO (a
PAO), thus testing whether preoperative pelvic tilt was compensatory. Case series; Level of evidence, 4. A consecutive cohort of 48 hips (42 patients; 30 ± 7 years [mean ± SD]) with acetabular retroversion that underwent successful a
PAO was studied. Spinopelvic morphology (pelvic tilt, pelvic incidence, anterior pelvic plane, and sacral slope) was measured from computed tomography scans including the sacral end plate in 21 patients, with adequate images. In addition, the change in pelvic tilt with a
PAO was measured via the sacrofemoral-pubic angle with supine pelvic radiographs at an interval of 2.5 ± 2 years. The spinopelvic characteristics included a pelvic tilt of 4° ± 4°, a sacral slope of 39° ± 9°, an anterior pelvic plane angle of 11° ± 5°, and a pelvic incidence of 42° ± 10°. Preoperative pelvic tilt was 4° ± 4° and did not change postoperatively (4° ± 4°) ( Pelvic tilt in acetabular retroversion was within normal parameters, illustrating “normal” sagittal pelvic balance and values similar to those reported in the literature in healthy subjects. In addition, it did not change after a
PAO. Thus, acetabular retroversion was not secondary to a maladaptive pelvic tilt (functional retroversion). Further work is required to assess whether retroversion is a reflection of a pelvic morphological abnormality rather than an isolated acetabular abnormality. Treatment of acetabular retroversion should focus on correcting the deformity rather than attempting to change the functional pelvic position.

Acetabular Morphologic Characteristics Predict Early Conversion to Arthroplasty After Isolated Hip Arthroscopy for Femoroacetabular Impingement

01-01-2020 – Brian D. Giordano,Benjamin D. Kuhns,Itay Perets,Leslie Yuen,Benjamin G. Domb

Journal Article

Hip arthroscopy in the setting of dysplasia and borderline dysplasia is controversial. Dysplasia severity is most often defined by the lateral center edge angle (LCEA) but can also be evaluated radiographically by the acetabular inclination (AI). The purpose was to determine the effect of AI on outcomes after isolated hip arthroscopy for femoroacetabular impingement (FAI). We hypothesized that patients with dysplasia would have higher rates of arthroplasty as well as inferior clinical and functional outcomes compared with patients who did not have dysplasia. Cohort study; Level of evidence, 3. A hip arthroscopy registry was reviewed for participants undergoing arthroscopic correction of FAI from February 28, 2008, to June 10, 2013. Participants required a clinical diagnosis and isolated arthroscopic correction of FAI with preoperative imaging and intraoperative cartilage status recorded. AI dysplasia was defined as an AI greater than 10°, LCEA dysplasia as LCEA less than 18°, and borderline LCEA dysplasia as LCEA 18° to 25°. Patients without an acetabular deformity (LCEA 25°-40°; AI <10°) served as a control population. Postoperative variables included patient-reported outcome surveys with conversion to arthroplasty as the primary endpoint. Minimum 5-year outcome scores were obtained for 337 of 419 patients (80.4%) with an average follow-up of 75.2 ± 12.7 months. This study included 419 patients: 9 (2%) with LCEA dysplasia, 42 (10%) with AI dysplasia, and 51 (12%) with borderline dysplasia. The AI but not LCEA was significantly correlated with lower outcome scores on the modified Harris Hip Score ( We found that an elevated AI, along with increasing age, Tönnis grade, and femoral Outerbridge grade significantly predict early conversion to arthroplasty after isolated hip arthroscopy. We recommend using the AI, in addition to the LCEA, in evaluating hip dysplasia before hip arthroscopy.

Differential Effects of Platelets Selectively Activated by Protease-Activated Receptors on Meniscal Cells

01-01-2020 – Hongyao Xu,Xiangjie Zou,Pengcheng Xia,Mohammad Ahmad Kamal Aboudi,Ran Chen,He Huang

Journal Article

Meniscal injury is very common, and injured meniscal tissue has a limited healing ability because of poor vascularity. Platelets contain both pro- and anti-angiogenic factors, which can be released by platelet selective activation. Platelets release a high level of vascular endothelial growth factor (VEGF) when they are activated by protease-activated receptor 1 (PAR1), whereas the platelets release endostatin when they are activated by protease-activated receptor 4 (PAR4). The PAR1-treated platelets enhance the proliferation of meniscal cells in vitro and promote in vivo healing of wounded meniscal tissue. Controlled laboratory study. Platelets were isolated from human blood and activated with different reagents. The released growth factors from the activated platelets were determined by immunostaining and enzyme-linked immunosorbent assay. The effects of the platelets with different treatments on meniscal cells were tested by an in vitro model of cell culture and an in vivo model of wounded meniscal healing. The results indicated that platelets contained both pro- and antiangiogenic factors including VEGF and endostatin. In unactivated platelets, VEGF and endostatin were contained inside of the platelets. Both VEGF and endostatin were released from the platelets when they were activated by thrombin. However, only VEGF was released from the platelets when they were activated by PAR1, and only endostatin was released from the platelets when they were activated by PAR4. The rat meniscal cells grew much faster in the medium that contained PAR1-activated platelets than in the medium that contained either PAR4-activated platelets or unactivated platelets. The wounds treated with PAR1-activated platelets healed faster than those treated with either PAR4-activated platelets or unactivated platelets. Many blood vessel-like structures were found in the wounded menisci treated with PAR1-activated platelets. The PAR1-activated platelets released high levels of VEGF, which increased the proliferation of rat meniscal cells in vitro, enhanced the vascularization of menisci in vivo, and promoted healing of wounded menisci. Our results suggested that selective activated platelets can be used clinically to enhance healing of wounded meniscal tissue.

Articular Joint-Simulating Mechanical Load Activates Endogenous TGF-β in a Highly Cellularized Bioadhesive Hydrogel for Cartilage Repair

01-01-2020 – Peter Behrendt,Yann Ladner,Martin James Stoddart,Sebastian Lippross,Mauro Alini,David Eglin,Angela Rita Armiento

Journal Article

The treatment of osteochondral defects (OCDs) constitutes a major problem for orthopaedic surgeons. The altered mechanics and the cell types, with associated soluble factors derived from the exposed subchondral bone, are likely responsible for the mechanically and structurally inferior articular cartilage subsequently obtained as a repair tissue. There is therefore an unmet clinical need for bioresponsive biomaterials that allow cell delivery, reduce cell infiltration from the bone marrow, and support chondrogenesis in the presence of joint mechanical loading. To develop a cell-laden injectable biomaterial, with bioadhesive properties, low cell invasion, and good mechanoresilience, in which simulated joint loading could induce tissue maturation through the production and activation of transforming growth factor beta 1 (TGF-β1). Controlled laboratory study. Human bone marrow-derived mesenchymal stromal/stem cells were encapsulated in tyramine-modified hyaluronic acid (HA-Tyr) hydrogels, with crosslinking initiated by the addition of horseradish peroxidase (HRP) and various concentrations of hydrogen peroxide (H The viscoelastic properties of the cell-laden HA-Tyr hydrogels, as crosslinked with different ratios of HRP and H HA-Tyr hydrogels can be mechanically conditioned to induce activation of endogenous TGF-b1 produced by the embedded cells. HA-Tyr hydrogels function as cell carriers supporting biomechanically induced production and activation of TGF-β1 and as bioadhesive materials with low cell invasion, suggesting that they hold promise as a novel biomaterial for OCD repair strategies. Leveraging physiological joint mechanics to support chondrogenic graft maturation in an optimized mechanosensitive hydrogel in the absence of exogenous growth factors is of highest interest for OCD repair.

High Prevalence of Connective Tissue Gene Variants in Professional Ballet

01-01-2020 – Angelina M. Vera,Leif E. Peterson,David Dong,Varan Haghshenas,Thomas R. Yetter,Domenica A. Delgado,Patrick C. McCulloch,Kevin E. Varner,Joshua D. Harris

Journal Article

There is a high prevalence of hypermobility spectrum disorder (HSD) in dancers. While there is no known genetic variant for HSD, hypermobile Ehlers-Danlos syndrome is a genetic disorder that exists within HSD. There are many connective tissue disorders (CTDs) with known (and unknown) genes associated with hypermobility. Hypermobility has distinct advantages for participation in flexibility sports, including ballet. To determine the prevalence of gene variants associated with hypermobility in a large professional ballet company. Cross-sectional study; Level of evidence, 3. In this cross-sectional investigation, 51 professional male and female dancers from a large metropolitan ballet company were eligible and offered participation after an oral and written informed consent process. Whole blood was obtained from peripheral venipuncture, and DNA was isolated. Isolated DNA was subsequently enriched for the coding exons of 60 genes associated with CTD that included hypermobility as a phenotype, including Ehlers-Danlos syndromes, osteogenesis imperfecta, Marfan syndrome, and others. Genes were targeted with hybrid capture technology. Prepared DNA libraries were then sequenced with next-generation sequencing technology. Genetic database search tools (Human Gene Mutation Database and e!Ensembl, ) were used to query specific variants. Descriptive statistics were calculated. Of 51 dancers, 32 (63%) agreed to participate in DNA analysis (mean ± SD age, 24.3 ± 4.4 years; 18 men, 14 women). Twenty-eight dancers had at least 1 variant in the 60 genes tested, for an 88% prevalence. A total of 80 variants were found. A variant in 26 of the 60 genes was found in at least 1 dancer. Among the 28 dancers with variants, 16 were found in the Genetic variants in CTD-associated genes are highly prevalent (88%) in professional ballet dancers. This may significantly account for the high degree of motion in this population.

Current Workload Recommendations in Baseball Pitchers: A Systematic Review

01-01-2020 – Neil K. Bakshi,Paul M. Inclan,Jacob M. Kirsch,Asheesh Bedi,Cristine Agresta,Michael T. Freehill

Journal Article

Several recommendations have been made regarding pitch counts and workload for baseball players of different levels, including Little League, high school, collegiate, and professional baseball. However, little consensus is found in the literature regarding the scientific basis for many of these recommendations. The primary purpose of this study was to summarize the evidence regarding immediate and long-term musculoskeletal responses to increasing pitching workload in baseball pitchers of all levels. A secondary purpose of this review was to evaluate the extent to which workload influences injury and/or performance in baseball pitchers. Systematic review. We performed a systematic search in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for studies addressing physiologic and/or pathologic musculoskeletal changes in response to a quantifiable pitching workload. We included studies examining the effects of pitching workload on performance, injury rate, and musculoskeletal changes in Little League, high school, collegiate, and professional baseball players. We identified 28 studies that met our inclusion and exclusion criteria: 16 studies regarding Little League and high school pitchers and 12 studies regarding collegiate and professional pitchers. The current evidence presented suggests that increased pitching workload may be associated with an increased risk of pain, injury, and arm fatigue in Little League and high school pitchers. However, little consensus was found in the literature regarding the association between pitching workload and physiologic or pathologic changes in collegiate and professional pitchers. Evidence, although limited, suggests the use of pitch counts to decrease injury rates and pain in Little League and high school baseball pitchers. However, further research must be performed to determine the appropriate number of pitches (or throws) for players of different ages. This systematic review reported conflicting evidence regarding the use of pitch counts in college and professional baseball. Future high-quality research is required to determine the role, if any, of pitch counts for collegiate and professional pitchers.

Cost-efficacy of Knee Cartilage Defect Treatments in the United States

01-01-2020 – Joshua S. Everhart,Andrew B. Campbell,Moneer M. Abouljoud,J. Caid Kirven,David C. Flanigan

Journal Article

Multiple knee cartilage defect treatments are available in the United States, although the cost-efficacy of these therapies in various clinical scenarios is not well understood. The purpose was to determine cost-efficacy of cartilage therapies in the United States with available mid- or long-term outcomes data. The authors hypothesized that cartilage treatment strategies currently approved for commercial use in the United States will be cost-effective, as defined by a cost 3 cm Currently employed treatments for knee cartilage defects in the United States are cost-effective in most clinically acceptable applications. Microfracture is not a cost-effective initial treatment of defects >3 cm

Return to Sport After Arthroscopic Rotator Cuff Repair: Is There a Difference Between the Recreational and the Competitive Athlete?

01-01-2020 – Burak Altintas,Nicole Anderson,Grant J. Dornan,Robert E. Boykin,Catherine Logan,Peter J. Millett

Journal Article

Return to sport (RTS) remains an important challenge and measure of success for athletes undergoing arthroscopic rotator cuff repair (RCR). To determine the rate of RTS after RCR and to analyze predictive factors associated with a lower rate of return. Systematic review and meta-analysis. 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, MEDLINE, Cochrane, and Google Scholar were used for the literature search. Study quality was evaluated according to the Coleman Methodology Score. Studies in English evaluating RTS after arthroscopic repair of partial- or full-thickness rotator cuff tears among athletes of all levels, ages, and sports were included. Random effects meta-analysis and metaregression were performed to investigate RTS activity rate after arthroscopic RCR and to explore study heterogeneity, respectively. Fifteen studies were reviewed, including 486 patients (499 shoulders) who were treated with arthroscopic RCR and who had a mean follow-up of 40.1 months (range, 18-74.4 months). Eighteen patients were lost to follow-up, leaving 468 patients with outcome data; 347 identified themselves as athletes (81 competitive, 266 recreational). The most commonly included sports were baseball (n = 45), golf (n = 38), football (n = 23), and tennis (n = 18). RTS specific to the type of athlete was reported for 299 of 347 athletes. According to the meta-analysis, the overall rate of RTS at a similar level of play or higher was 70.2%, with 73.3% of recreational athletes and 61.5% of competitive athletes able to return. A subset of 43 baseball and softball players across 4 studies yielded a 79% rate of RTS; however, only 38% returned to the same level of play or higher. Subgroup meta-analysis revealed no significant difference in the rate of RTS between competitive and recreational athletes. Metaregression analysis revealed that the mean follow-up time and mean age at surgery were not significantly associated with RTS rate. Most athletes (70.2%) were able to return to a preinjury level of play after arthroscopic RCR. While recreational sports participation (73.3%) was associated with higher return, competitive sports (61.5%) and overhead sports (38%) were associated with lower return. Exactly why all athletes do not return remains uncertain and likely multifactorial.

Society News

01-01-2020 –

No Evidence for Effective Prevention of Venous Thromboembolism With Low-Molecular-Weight Heparin After Anterior Cruciate Ligament Reconstruction: Letter to the Editor

01-01-2020 – Raymond A. van Adrichem,Banne Nemeth,Rob G.H.H. Nelissen,Suzanne C. Cannegieter


No Evidence for Effective Prevention of Venous Thromboembolism With Low-Molecular-Weight Heparin After Anterior Cruciate Ligament Reconstruction: Response

01-01-2020 – Jing Zhu,Ling Li,Hai Jiang,Zhonglan Chen,Jian Li,Xin Tang

Journal Article

Adaptation of Running Biomechanics to Repeated Barefoot Running: Letter to the Editor

01-01-2020 – Peter Francis,Catherine B. Tucker,Cassie Oddy,Mark I. Johnson


Adaptation of Running Biomechanics to Repeated Barefoot Running: Response

01-01-2020 – Karsten Hollander,Dominik Liebl,Stephanie Meining,Klaus Mattes,Steffen Willwacher,Astrid Zech

Journal Article

Efficacy of Platelet-Rich Plasma for the Treatment of Interstitial Supraspinatus Tears: Letter to the Editor

01-01-2020 – Gerard A. Malanga,Ken Mautner,Christopher J. Rodgers,Brian J. Shiple,Steven E. Sampson,Jay E. Bowen,Ivan J. Perez


Efficacy of Platelet-Rich Plasma for the Treatment of Interstitial Supraspinatus Tears: Response

01-01-2020 – Adrien J. Schwitzguebel,Frank C. Kolo,Jérôme Tirefort,Mo Saffarini,Alexandre Lädermann

Journal Article

Timing of Surgery: Can It Predict Outcome? Letter to the Editor

01-01-2020 – Mingjin Zhong,Kan Ouyang


Timing of Surgery: Can It Predict Outcome? Response

01-01-2020 – Kyle N. Kunze,Edward C. Beck,Benedict U. Nwachukwu,Junyoung Ahn,Shane J. Nho

Journal Article

Problem of Multiplicity in Clinical Studies and Inferences Made When It Is Present: Letter to the Editor

01-01-2020 – Aleksi Reito


Problem of Multiplicity in Clinical Studies and Inferences Made When It Is Present: Response

01-01-2020 – Joshua S. Everhart,David C. Flanigan

Journal Article

Problem of Multiplicity in Clinical Studies and Inferences Made When It Is Present: Response

01-01-2020 – Jonathan Stone,Matthew Salzler

Journal Article

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

27-12-2019 – 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.

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

27-12-2019 – 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 identifier).

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

25-12-2019 – 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.

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

24-12-2019 – 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.

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

20-12-2019 – 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.

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

19-12-2019 – 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.

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

17-12-2019 – 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.

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

14-12-2019 – 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.

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

13-12-2019 – 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 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).

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

12-12-2019 – 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 patients 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.

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

12-12-2019 – 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.

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

11-12-2019 – 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.

Predictors of Pain, Function, and Change in Patellofemoral Pain

11-12-2019 – 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 identifier).

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

11-12-2019 – 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.

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

06-12-2019 – 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.

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

05-12-2019 – 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.

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

05-12-2019 – 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.

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

05-12-2019 – 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.

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

05-12-2019 – 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.

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

28-11-2019 – 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

28-11-2019 – 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

27-11-2019 – 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

20-11-2019 – 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

15-11-2019 – 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

12-11-2019 – 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

09-11-2019 – 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

07-11-2019 – 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

22-10-2019 – 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

05-10-2019 – 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

21-09-2019 – 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

11-09-2019 – 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

31-08-2019 – 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

06-08-2019 – 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

18-07-2019 – 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

13-06-2019 – 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 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

06-06-2019 – 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

23-05-2019 – 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

16-05-2019 – 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.

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

08-05-2019 – 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 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.

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

01-05-2019 – 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.

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

01-05-2019 – 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.

Horizontal Instability of the Acromioclavicular Joint: A Systematic Review

24-04-2019 – Gianna M. Aliberti,Matthew J. Kraeutler,Jeffrey D. Trojan,Mary K. Mulcahey

Journal Article

Injuries to the acromioclavicular (AC) joint are common and should be suspected in patients who have shoulder pain in the region of the acromion and clavicle. Injuries to the AC ligament can cause horizontal instability and are often neglected or underdiagnosed, which can lead to poor patient outcomes. To perform a systematic review of the literature on the diagnosis and treatment of horizontal instability of the AC joint. Systematic review. The authors performed a systematic review using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. PubMed and EMBASE were searched for studies that investigated diagnosis, treatment, and failure of operative management of acute and chronic AC separations. Studies that did not specifically evaluate AC joint injuries, were not written in English, or were specific only to vertical instability of the AC joint were excluded. Overall, 23 articles met the inclusion criteria and were therefore included in this systematic review. Diagnosing horizontal AC instability is difficult using plain radiographs; dynamic views were shown in some cases to better detect horizontal instability than with static views. More than 60 procedures for treating AC joint injuries have been published, but many focus on vertical rather than horizontal instability. Modifications to current surgical procedures to incorporate reconstruction of the horizontal component showed improved patient outcomes. Such modifications included additional AC joint suture cord cerclage, combined AC and coracoclavicular ligament reconstruction, and the Twin Tail Tight
Rope triple button technique. Failure after surgical stabilization of AC joint separation has been reported to occur in 15% to 80% of cases. No consensus is available regarding the best practices for diagnosis, evaluation, and treatment of acute or chronic horizontal instability of the AC joint. Moreover, horizontal instability injuries are often neglected or poorly understood, making diagnosis difficult, which may lead to high complication rates and failure after surgical stabilization.