Meniscal Comma Sign Responds to Partial Meniscectomy Despite Increased Levels of Arthritis.

Purpose: To compare the outcomes of patients undergoing partial meniscectomy preoperatively identified with the "meniscal comma sign" with those undergoing meniscectomy with other tear patterns. Methods: Patients with meniscal "comma sign," as indicated by a query of magnetic resonance imaging reports, were screened using the search terms "meniscotibial recess," "meniscus perched over the medial tibial margin," or other search terms by radiologists between January 2008 and November 2019. Patients were matched and chart review was done for demographics, revision surgery, and progression to total knee arthroplasty. Radiographs were used for osteoarthritis grading using the Kellgren-Lawrence (KL) scoring system. Preoperative and postoperative International Knee Documentation Committee, Knee Injury and Osteoarthritis Outcome Score, Lysholm, and Short Form 12-item Survey scores were collected. Results: A total of 406 patients met inclusion (comma sign = 197; control group = 209). The control group had an increased duration of symptoms at the initial visit (P = .001). More patients with the meniscal comma sign received corticosteroid knee injections before surgery (P = .011), and they also had greater mean KL scores (P = .001) as well as greater KL categorical scores (P = .002), indicating more advanced levels or arthritis. There were no differences in those receiving physical therapy (PT) before surgery (P = .966) or those receiving injections or PT after surgery (P = .631, P = .37, respectively). International Knee Documentation Committee, Knee Injury and Osteoarthritis Outcome Score, Lysholm, and Short Form 12-Item Survey Physical scores improved preoperatively to postoperatively in both groups (P < .05), and there was no difference between the case and control group (P > .05). No significant difference was found in revisions or progression to total knee arthroplasty between cohorts. (P = .676 and P = .424). Conclusions: Patients presenting with preoperative findings of meniscal comma sign fare similarly to those that do not. Patients with this meniscal injury tend to have more advanced grading of osteoarthritic changes in the knee at presentation and seek care earlier than those without. Arthroscopic meniscectomy is a good treatment option for patients with a meniscal fragment in the meniscotibial recess and shows outcomes comparable with those with other tear patterns. Level of Evidence: Level III, retrospective cohort.

Arthroscopic Measurements Predict Knee Chondral Lesion Size More Accurately Than Magnetic Resonance Imaging, and Mechanism of Injury Influences Ability of Either Technique to Predict Graft Size.

Purpose: To compare osteochondral defect size measurements and characteristics across magnetic resonance imaging (MRI) and arthroscopy and at the time of osteochondral allograft (OCA) transplantation or autologous chondrocyte implantation (ACI). Methods: Patients who underwent ACI and OCA transplantation at a single institution between 2015 and 2019 were retrospectively identified. Patients were excluded if they had severe osteoarthritis, MRI scans were not available for review, surgical records did not include defect sizing necessary for analysis, or operative reports were not available. Osteochondral lesion characteristics including size were collected preoperatively by MRI and arthroscopy and at the time of definitive open surgical intervention. Subgroup analysis was performed comparing measurement techniques depending on the corrective surgical approach used, as well as depending on the mechanism of chondral injury, to determine whether these factors had any effect on the ability of arthroscopy or MRI to predict graft size. Results: Overall, 136 chondral lesions were addressed, with restoration procedures in 117 patients (mean age, 32.5 years). The average difference between the final graft size and the lesion area measured with index arthroscopy was 116 mm2, whereas the average difference between the final graft size and the lesion size measured with preoperative MRI was 182 mm2 (P < .001). Depending on surgical technique, measurements with MRI were more similar to the final graft size when a patient underwent OCA transplantation versus ACI (P = .007). Depending on the mechanism of injury, MRI measurements of lesions were closer to the graft area when lesions resulted from trauma (P = .047). Conclusions: Chondral lesion size as determined by preoperative MRI is less accurate than arthroscopic measurement. The mechanism of injury leading to chondral damage and degree of damage may influence the ability of MRI and arthroscopy to accurately measure chondral lesions and predict the final graft size used in surgical correction. Level of Evidence: Level III, retrospective cohort study.

Most Patients Older Than 40 Years of Age Who Underwent Meniscal Root Repair Presented With an Effusion, a Positive McMurray Test, and a Positive Hyperflexion Test.

Purpose: To analyze the presenting symptoms and clinical examination findings of patients undergoing meniscal root repairs to aid physicians in diagnosing this injury. Methods: All patients undergoing isolated arthroscopic meniscal root repair from January 1, 2016, to September 1, 2021, were identified. Patients younger than the age of 40 years were excluded. Clinical notes were reviewed for presenting symptoms and physical examination findings. Preoperative radiographs were graded using the Kellgren-Lawrence (KL) scale for osteoarthritis. Root tears were graded using the radiographic criteria of Chung et al. and articular cartilage injury was graded using a validated system, AMADEUS (mean total Area Measurement And Depth & Underlying Structures). Results: In total, 221 patients met inclusion criteria; 65.6% of patients reported that their pain began after an acute injury, with 39.4% of patients reporting a "pop." On examination, an effusion was present in 71% of knees. McMurray test was reported positive in 85.5% and a positive hyperflexion test in 53.8% of knees. In total, 49.5% of knees were graded KL 1. 154 had medial root tears, 10 had lateral root tears, and 24 suffered both root tears. In total, 44.1% of tears occurred at the midsubstance of the root, with 28.0% occurring at the enthesis and 28.0% occurring at the root-posterior horn junction. The mean AMADEUS score was 94.4 ± 11.4. Conclusions: Although most patients reported pain began after acute injury, less than one-half reported hearing a "pop." When patients were evaluated, an effusion, positive McMurray test, and positive hyperflexion test were present in most meniscal root tears. Level of Evidence: Level IV, diagnostic case series.

Effects of Melatonin on Sleep Quality and Patient-Reported Outcomes After Arthroscopic Rotator Cuff Surgery: A Prospective Randomized Controlled Trial.

BACKGROUND: Sleep disturbance is a significant symptom associated with both rotator cuff tears and arthroscopic rotator cuff repair. Melatonin has been shown to be safe and effective in managing multiple sleep disorders, including secondary sleep disorders, with relatively minor adverse effects and lack of addictive potential. PURPOSE: To investigate the effects of oral melatonin on postoperative sleep quality after arthroscopic rotator cuff repair. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: This was a prospective randomized clinical trial evaluating patients undergoing arthroscopic rotator cuff repair. Exclusion criteria included history of alcohol abuse, current antidepressant or sedative use, revision rotator cuff repair, severe glenohumeral arthritis, and concurrent adhesive capsulitis. Patients were randomly assigned in a 1:1 ratio to 1 of 2 groups: 5-mg dose of melatonin 1 hour before bedtime or standard sleep hygiene (≥6 hours per night, avoiding caffeine and naps in the evening). Patients in the melatonin group took their assigned melatonin dose for 6 weeks beginning the day of surgery. Patient-reported outcome assessments, including the Pittsburgh Sleep Quality Index (PSQI), the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), and the Single Assessment Numeric Evaluation (SANE), and pain medication charts were collected preoperatively as well as at 2 weeks, 6 weeks, 3 months, 4 months, and 6 months postoperatively. Numeric variables were analyzed using paired and unpaired t tests, with significance set at P < .05. RESULTS: Eighty patients were included for final analysis (40 in the control group, 40 in the melatonin group). Patient characteristics such as age, sex, race, body mass index, and laterality did not differ significantly (P≥ .05). Preoperative ASES, SANE, and PSQI scores did not differ between groups (P≥ .055). PSQI scores were significantly lower (better quality sleep) in the melatonin group at the 6-week postoperative period (P = .036). There was a positive correlation between how patients rated the intensity of their pain and the PSQI at the 6-week postoperative period (0.566). The PSQI question regarding sleep quality was found to be significantly lower in the melatonin group at the 3-month, 4-month, and 6-month postoperative periods (P = .015, P = .041, and P≤ .05, respectively). SANE scores were significantly lower in the melatonin group (P = .011) at 6 weeks and then higher in the melatonin group (P = .017) at 6 months. ASES scores were significantly higher in the melatonin group at 4 and 6 months (P = .022 and P = .020, respectively). Lastly, patients who were randomized into the melatonin group were found to use significantly less narcotic medication at the 4-month postoperative period (P = .046). CONCLUSION: Melatonin use after arthroscopic rotator cuff repair led to improved sleep quality (PSQI) in the early postoperative period as well as improved functional outcomes (ASES and SANE scores) and decreased narcotic use in the later postoperative period. Patients with significant sleep disturbances associated with rotator cuff repairs may benefit from the use of melatonin. REGISTRATION: NCT04278677 (ClinicalTrials.gov identifier).

Comparable Outcomes Between Autologous Chondrocyte Implantation and Osteochondral Allograft Transplantation in the Setting of Patellar Realignment.

PURPOSE: To determine clinical and functional outcomes in patients treated with autologous chondrocyte implantation (ACI) or osteochondral allograft (OCA) transplantation for chondral defects secondary to patellar instability with concomitant medial patellofemoral ligament (MPFL) reconstruction and tibial tubercle osteotomy (TTO) for patellar realignment. METHODS: A retrospective review identified patients who underwent ACI or OCA transplantation with concomitant MPFL reconstruction and TTO. Patients were excluded if they did not have concomitant MPFL reconstruction and TTO, had the presence of other intra-articular pathologies, or failed to complete postoperative subjective outcome evaluations at a minimum of 2 years following surgery. Subjective outcome measures included the Knee injury and Osteoarthritis Outcome Score for Joint Replacement, International Knee Documentation Committee evaluation, and 12-item Short Form Health Survey physical scores, collected a minimum of 2 years after surgery. Defect location, size, complications, and rate of subsequent surgery were determined. RESULTS: Eighteen total patients were included in this study. The ACI cohort included 11 patients with 13 total defects that were treated with ACI. The OCA cohort included 7 patients with 10 total defects that were treated with OCA. This was due to a number of patients in either group having multiple cartilage defects. Twenty-three total chondral defects were compared to analyze clinical and functional outcomes following surgical correction (ACI: n = 13, OCA: n = 10). Five defects were noted on the femoral condyle and 18 on the patellar facets/central ridge. Defects were comparable between groups, including size measured during index arthroscopy (ACI = 3.34 cm2 [95% CI, 2.3-4.4 cm2] vs OCA = 4.03 cm2 [95% CI, 3.1-5.0 cm2]; P = .351), Outerbridge classification (ACI = 54.8% grade 4 vs OCA = 60.0% grade 4; P ≥ .999), and Area Measurement and Depth Underlying Structures score (ACI = 47.1 vs OCA = 58.6; P = .298). Postoperative outcomes were comparable, including revision rate (ACI = 15.4% vs OCA = 10.0%; P ≥ .999) and 2-year International Knee Documentation Committee scores (ACI = 74.2 [95% CI, 65.2-83.2] vs OCA = 51.2 [95% CI, 30.3-72.1]; P = .077). ACI did have significantly higher 2-year Knee injury and Osteoarthritis Outcome Score for Joint Replacement (85.1 [95% CI, 76.9-93.3] vs 63.7 [95% CI, 49.1-78.3]; P = .031) and 12-item Short Form Health Survey scores (54.1 [95% CI, 52.0-56.2] vs 42.6 [95% CI, 35.8-49.4]; P = .007) compared to OCA. CONCLUSIONS: ACI or OCA transplantation for chondral defects with concomitant MPFL reconstruction and TTO can be safely performed in an outpatient setting with functional and clinical outcomes being comparable. LEVEL OF EVIDENCE: Level III, retrospective case series study.

Evaluating Return to Sports After Surgical Treatment of Unstable Osteochondritis Dissecans of the Knee: A Systematic Review.

Background: Although the incidence of osteochondritis dissecans (OCD) of the knee may be low, an overview and comparison of sports-related outcomes with current surgical management techniques are needed. Purpose: To summarize the available evidence regarding outcomes for different surgical treatment options for unstable OCD of the knee in both skeletally mature and immature patients by calculating the return to sports (RTS) rate, the mean RTS time, and other sports-related postoperative outcome measures. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review of studies on RTS after surgical correction of unstable OCD within the knee was conducted utilizing PubMed, Embase, and the Cochrane databases. Included were studies discussing the treatment of unstable OCD with minimum 1-year follow-up outcomes. Multivariate analysis was used to compare studies grouped together based on RTS and skeletal maturity. Results: Of 2229 articles, 6 studies (197 patients; 198 knees) met the inclusion criteria and were included in our analysis. The percentage of patients who returned to the previous level of sport ranged from 52% to 100%; those returning to any level of sport ranged from 87% to 100%. Clinical outcomes did not differ between patients with open versus closed physes. Osteochondral Autograft Transfer System (OATS) procedures had a 100% RTS rate across several studies with skeletally mature and mixed cohorts, and microfracture had the lowest overall RTS rate (52%). For skeletally immature patients, all examined studies that utilized either open or arthroscopic reduction and internal fixation, 77% and 78%, respectively, had acceptable RTS rates. Arthroscopic fixation had a higher rate of revision surgery in both skeletally mature and immature patients. Conclusion: Our analysis indicated that the treatment of unstable OCD lesions using the OATS technique demonstrated high RTS rates across several studies, while microfracture alone exhibited the lowest RTS rate. Both arthroscopic and open internal fixation utilizing bioabsorbable screws yielded satisfactory RTS rates for juvenile patients with OCD.

Different anatomic patterns of the indirect tendon of the rectus femoris.

PURPOSE: The rectus femoris forms the anterior portion of the quadriceps muscle. It has a proximal tendinous complex, which is constituted by a direct tendon, an indirect tendon, and a variable third tendon. Direct and indirect tendons converge into a common tendon. The purposes of this study are to add anatomical knowledge about the proximal tendinous complex and describe anatomical variants of the indirect tendon and, on these basis, categorize different anatomical patterns. METHOD: In this study, 48 hemipelvis from bodies donated to the Universitat Autònoma de Barcelona have been dissected to examine the proximal tendinous complex of the rectus femoris. RESULTS: The following anatomical variants of the indirect tendon were described: inferior aponeurotic expansion in 23/48 cases (47.9%); superior aponeurotic expansion in 21/48 cases (43.7%); and an unusual origin of the myotendinous junction of the rectus femoris in the free portion of the indirect tendon in 19/48 cases (39.6%). On the basis of the aponeurotic expansions, the following anatomical patterns of the indirect tendon were defined: standard (19/48 cases, 39.6%), superior and inferior complex (15/48 cases, 31.2%), inferior complex (8/48 cases, 16.7%), and superior complex (6/48 cases, 12.5%). CONCLUSION: We can categorize four different anatomical patterns of the indirect tendon, three of which are complex. We suggest that complex patterns can cause an increased stiffness of the indirect tendon and so be considered non-modifiable risk factors for rectus femoris injuries. Finally, it would be useful to identify complex patterns and perform injury prevention actions through specific physical preparation programs.

Patients' under 25 subjective readiness to return to sport after ACL reconstruction with bone-patellar-bone grafts: Autograft vs. allograft.

Purpose: To assess the difference in perceived readiness to return to sport (RTS) within the first year postoperative period between individuals undergoing anterior cruciate ligament (ACL) reconstruction with bone-patellar tendon-bone (BTB) autografts or allografts. Methods: This was a prospective cohort study of patients undergoing primary ACL reconstruction done either with BTB autograft or allograft from 2010 to 2018. Skeletally mature patients aged 14 to 25 were eligible for inclusion. Patients completed the Marx Activity Rating Scale (MARS) questionnaire postoperatively evaluating perceived ability to perform various activities to compare subjective ability to RTS. Those patients who were outside outlined cohort age, failed to complete a single post-operative survey, underwent revision procedures, or underwent simultaneous or staged additional ligament surgery were excluded. Results: Fifty-nine patients (20.1 ± 3.19 years, 57.6 % Male) were included in the study. Sixteen patients underwent ACL reconstruction with allograft (19.8 ± 3.43 years) while 43 patients received autograft (20.2 ± 3.13). At 3 months autograft recipients reported higher perceived ability to cut (P = .003). At 6-months, allograft recipients reported higher perceived ability to run (P = .033), cut (P = .048), and decelerate (P = .008) as well as a higher overall perceived ability to RTS (P = .032). At all other times, there was no significant difference between cohorts' subjective readiness to perform activities. Conclusion: The results of this study indicate that at times within the first year of recovery following ACL reconstruction, patients who receive allografts and autografts may have significantly different perceived ability to perform activities or RTS. However, while present at various times throughout the first year of recovery, any difference in perceived ability to perform activities or in overall RTS is no longer present at 12 months. Level of evidence: Level II, Prospective cohort study.

A systematic review of the biomechanical properties of suture materials used in orthopaedics.

Background: Soft tissue injuries are frequently repaired using various suture material. The ideal suture should have the biomechanical properties of low displacement, high maximum load to failure, and high stiffness to avoid deformation. Since tendon healing occurs over a period of months, it is important for the surgeon to select the proper suture with certain biomechanical properties. Therefore, the purpose of this study is to qualitative summarize the published literature on biomechanical properties of different suture materials used in orthopaedic procedures. Methods: Following PRISMA guidelines, PubMed and Cochrane databases were queried for original articles containing "biomechanic(s)" and "suture" keywords. Following screening for inclusion and exclusion, final articles were reviewed for relevant data and collected for qualitative analysis. Data collected from each study included the tissue type repaired, suture material, and biomechanical properties, such as elongation, maximum load to failure, stiffness, and method of failure. Results: 17 articles met final inclusion criteria. Two studies found No.2 Fiberwire™ to have the lowest elongation and 4 studies found No. 2 Ultrabraid™ to have the greatest. 12 studies reported Maximum load to failure was highest in No. 2 Fiberwire™, No. 2 Ultrabraid™, and FiberTape™ while No. 2 Ethibond ™ had the lowest in 5 studies. 3 of the 5 studies that evaluated No. 2 Fiberwire™ found it to have the highest stiffness. No. 2 Ethibond™, No. 2 Orthocord™, and No. 2 PDS™ were reported as the least stiff sutures in 2 studies each. Conclusion: Fiberwire™, FiberTape™, and Ultrabraid™ demonstrated the highest load to failure while Ethibond™ consistently was the weakest. Fiberwire™ was found to have the lowest elongation while Ultrabraid™ had the highest. Fiberwire™ was also noted to be the stiffest while PDS, Ethibond™, and Orthocord™ were found to be the least stiff. Final treatment decisions on which suture to utilize to optimize repair integrity and healing are complex, and rarely solely dependent upon the biomechanical properties of the materials used. Level of evidence: Systematic Review, Level IV.

Analysis of reasons for failure to return to sport after Latarjet surgery: a systematic review.

BACKGROUND: The purpose of this study was to perform a systematic review of the literature to identify Shoulder Instability Return to Sport after Injury (SIRSI) scores in athletes who underwent open Latarjet surgery, determine the reasons why athletes failed to return to play (RTP) after Latarjet surgery, and compare SIRSI scores of those who did vs. did not RTP. METHODS: According to PRISMA guidelines, the PubMed, SportDiscus, and Ovid MEDLINE databases were queried to identify studies evaluating return to sport after Latarjet surgery. Study quality was assessed using the MINORS criteria. Studies were included if RTP after Latarjet surgery and a psychological factor were evaluated, with potential psychological factors including readiness to RTP and reasons for failure to RTP. RESULTS: Fourteen studies, 10 of level III evidence and 4 of level IV evidence, with 1034 patients were included. A total of 978 athletes were eligible to RTP. Of these, 792 (79%) successfully returned to play and 447 (56.4%) returned to play at their previous level of play. Mean RTP time was 6.2 months. Postoperative SIRSI scores averaged 71.2 ± 8.8 at a mean of 21 months' follow-up. Postoperative SIRSI scores for those able to RTP was 73.2, whereas athletes unable to RTP scored an average of 41.5. Mean postoperative SIRSI scores for those in contact sports was 71.4, whereas those in noncontact sports was 86.5. There were 31 athletes with a documented reason why they did not RTP, with postoperative shoulder injury being the most common reason (54.5%). Fear of reinjury and feeling "not psychologically confident" each represented 6.5% of the total. CONCLUSION: Athletes who RTP have higher average SIRSI scores than those who are unable to RTP. Of the athletes who documented why they did not RTP, more than half cited a shoulder injury as their reason for not returning to play, whereas fear of reinjury and lack of psychological readiness were other common reasons.

Patients With First-Time or Recurrent Patellar Dislocation Have a Similar High Rate and Extent of Articular Cartilage Injury Observed on Magnetic Resonance Imaging.

Purpose: To use magnetic resonance imaging (MRI) scans to compare the prevalence of articular cartilage damage in patients with a single patellar dislocation versus those with multiple dislocations and to compare the locations and severity of chondral injury between the groups. Methods: Patients with patellar dislocation between January 2017 and July 2021 were retrospectively identified. Patients with a documented history of patellar dislocation and an MRI scan of the affected knee were included. Patients with articular cartilage injury prior to the dislocation event were excluded. Articular cartilage injury was graded using a validated system: AMADEUS (Mean Total Area Measurement and Depth & Underlying Structures). Caton-Deschamps Index (CDI) scores and Dejour classifications of trochlear dysplasia were also collected. Data were calculated by performing t tests, Mann-Whitney tests, and χ2 or Fisher Exact tests to calculate P values for categorical data. Results: In total, 233 patients were included: 117 with primary dislocations and 116 with recurrent dislocations. Articular cartilage injuries were present in 51 patients with primary dislocations (43.6%) and 68 patients with recurrent dislocations (58.6%, P = .026). On comparison of the groups, the recurrent group contained a significantly larger proportion of female patients (65.5% vs 46.2%, P = .004). There was no difference in lesion size, subchondral bone defect, presence of bone edema, or total AMADEUS score between groups (P = .231). Caton-Deschamps Index scores were not significant when comparing between groups; however, the Dejour classifications showed higher grades in the recurrent group (P = .013 for A-D grading scale and P = .005 for high/low grading scale). Subgroup analysis revealed that when cartilage damage was present, patients from the primary group had significantly more full-thickness lesions (P < .001) and lower AMADEUS scores (P = .016). Conclusions: There was a similarly high prevalence of cartilage injury seen on MRI after both a primary patellar dislocation and a recurrent patellar dislocation. Chondral injury primarily affected the medial and lateral patellar facets and the lateral femoral condyle in both the primary and recurrent dislocation groups. However, the primary group showed an increased number of full-thickness lesions. There was no difference in lesion size, subchondral bone defect, presence of bone edema, or total AMADEUS score between the primary and recurrent groups. Level of Evidence: Level III, retrospective comparative prognostic investigation.

Does central sensitization correlate with two-year postoperative functional outcome scores following hip arthroscopy?

Background: Central sensitization (CS) involves amplified central nervous system (CNS) signaling and several biochemical changes which lead to pain hypersensitivity. Data on the effects of CS are limited in orthopaedics and has been associated with reported levels of postoperative pain after hip arthroscopy. Methods: Patients over the age of 18 who underwent hip arthroscopy with preoperative as well as 2-year postoperative functional outcome scores were identified through the Multicenter Arthroscopic Study of the Hip (MASH) database. Patient demographics, procedure information, as well as patient reported outcome measures (PROMs) were collected along with CS index scores. Results: 34 patients met inclusion criteria for our study. Preop MCS and iHOT as well as Postop MCS, showed moderate to strong negative correlations with CSI scores (-0.607, -0.573, and -0.756, respectively). VAS, PCS and MSC scores were significantly different preoperatively to postoperatively, ensuring alleviation of pain after hip arthroscopy. Subgroup analysis by stratifying CSI scores into 1 SD below the mean, within 1 SD of the mean, and above 1 SD showed significant differences across all 3 groups for preoperative MCS (p < 0.001), postoperative MCS (p = 0.001), and PSEQ2 (p = 0.015). Postoperative VAS pain approached significance but did not meet criteria of p < 0.05 (p = 0.062). Conclusion: Increased postoperative CSI scores directly correlated with decreased preoperative and postoperative MCS scores and worse preoperative resilience. Recognizing the influence of CS on pain perception and resilience on coping with adversity in the recovery period may guide orthopaedic surgeons in developing comprehensive treatment plans to continue to improve surgical outcomes in hip arthroscopy. Level of evidence: IV.

Outcomes of Osteochondral Allograft Transplantation: A Comparative Study of BioUni and Snowman Techniques for Ovoid Lesions.

BACKGROUND: Treatment of large articular cartilage lesions of the knee includes surgical options one of which includes cartilage replacement therapies. Among these therapies include osteochondral allograft (OCA) transplantation, which can be performed utilizing a BioUni® (Arthrex BioUni® Instrumentation System; Arthrex, Naples, FL) replacement and a 'snowman' technique of repair. HYPOTHESIS/PURPOSE: To compare clinical and radiographic outcomes in patients who have undergone multiplug OCA transplantations utilizing a BioUni® replacement and a 'snowman' technique of repair. METHODS: Patients who underwent OCA transplantation utilizing a snowman technique or BioUni® replacement between January 1st, 2012 and December 31st, 2018, and who had a minimum 1-year follow-up at the same institution were identified for inclusion in this study via current procedural terminology (CPT) codes. Charts of included patients were reviewed for injury and treatment details as well as demographic information. Imaging studies and operative reports were reviewed and pre and postoperative subjective and objective outcome measures were recorded. RESULTS: Twenty-eight patients underwent OCA transplantation with either BioUni® replacement (n=5) or with snowman technique repair (n=23). Defects in both groups had similar characteristics including size, area, location, and classifications. Patient-reported outcomes using the Knee Injury and Osteoarthritis Outcome Score-Joint Replacement (KOOS-JR), International Knee Documentation Committee (IKDC), and Physical Health Composite Score (PCS-12) were similar at baseline and increased post-operatively for both groups with no significant differences between techniques after a mean follow-up of 2.77 ± 0.83. Although it did not reach significance, the snowman group had higher rates of knee-related complications (13%) and need for revision surgery (22%) when compared to BioUni® (0% and 0%, respectively). CONCLUSION: The use of both BioUni® and snowman techniques for large, unicondylar articular cartilage lesions of the femoral condyle demonstrate improved patient-reported outcomes at short-term follow-up. The use of the snowman technique presents relatively higher rates of revision similar to previous studies with no statistical difference in patient-reported outcomes when compared to those of a single plug OCA using a BioUni® system.

Anatomic greater tuberosity healing does not influence the functional outcomes of reverse shoulder arthroplasty for acute proximal humerus fractures.

Background: To investigate the functional outcomes of reverse shoulder arthroplasty (RSA) in acute complex proximal humerus fractures (PHF) in patients with an anatomic greater tuberosity union in comparison to patients with a displaced or resorbed tuberosity. Method: It is a retrospective study with prospective data collection including 32 consecutive PHF with a minimum two-year follow-up treated with RSA. A radiological study and a CT scan were performed specifically for the study. Two shoulder surgeons and a musculoskeletal radiologist assessed the position and union of the greater tuberosity. The functional outcomes were assessed with the Constant-Murley, DASH, ASES and ADLER scores. Results: The mean overall CS was 59.55. In 17 cases, the greater tuberosity healed in an anatomical position. In 15 cases, it was non-anatomical. In 53% of patients, greater tuberosity union was obtained. The CS was 62.76 in the anatomic union group and 55.9 in the non-anatomic union group. No significant differences were observed. No differences were observed in the ASES, DASH and ADLER scores. Conclusion: After RSA for PHF, anatomic greater tuberosity healing was obtained in 53% of patients. The influence of the position and union of the greater tuberosity on the functional results could not be evidenced.

Similar Outcomes Are Found Between Quadriceps Tendon Repair With Transosseous Tunnels and Suture Anchors: A Systematic Review and Meta-Analysis.

Purpose: To evaluate the clinical outcomes and biomechanical performance of transosseous tunnels compared with suture anchors for quadriceps tendon repair. Methods: In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic search was performed in April 2021 in the following databases: Cochrane Database of Systematic Reviews, PubMed (1980-2021), MEDLINE (1980-2021), Embase (1980-2021), and CINAHL (1980-2021). Level I-IV studies were included if they provided outcome data for surgical repair of the quadriceps tendon using transosseous tunnels or suture anchors with minimum 1-year follow-up. Biomechanical studies comparing transosseous tunnels and suture anchors were separately analyzed. Results: The systematic search yielded 1,837 citations, 23 of which met inclusion criteria (18 clinical, 5 biomechanical). In total, 13 studies reported results for transosseous repair and 7 studies reported results for repair with suture anchors. There were results for 508 patients from clinical studies. The average postoperative Lysholm score ranged from 88 to 92 for suture anchor repairs and 72.8 to 94 for transosseous repairs with range of motion ranging from 117° to 138° and 116° to 135°, respectively. Synthesis of the biomechanical data revealed the mean difference in load to failure was not significant between constructs (137.21; 95% confidence interval -10.14 to 284.57 N; P = .068). Conclusions: Transosseous and suture anchor techniques for quadriceps tendon repair result in similar biomechanical and postoperative outcomes. No difference between techniques in regard to ultimate load to failure among comparative biomechanical studies were observed. Level of Evidence: Level IV, systematic review level III-IV studies.

Effects of the Covid-19 Pandemic on the Orthopaedic Surgery Residency Application Match Patterns.

Background: The COVID-19 pandemic and its effects on the orthopaedic match process are yet to be fully understood and should be explored. We hypothesize that the cancellation of away rotations due to the COVID-19 pandemic would decrease the variability of where students matched into orthopaedic residency compared to pre-pandemic years. Methods: Accredited orthopaedic programs were collected from the Accreditation Council for Graduate Medical Education (ACGME) database. Rosters of orthopaedic residency classes for the years 2019, 2020, and 2021 were compiled across all orthopaedic programs in the United States. Data collection for the incoming 2021 orthopaedic surgery residents was carried out by reviewing each program's website, Instagram, and Twitter. Results: Data for the incoming orthopaedic surgery residents from the 2021 National Residency Match Program (NRMP) were collected. 25.7% of incoming residents matched at their home institution. Data collection for the 2020 and 2019 orthopaedic residency classes yielded 19.2% and 19.5% home institution match rates, respectively. When examining likelihood to match into an orthopaedic residency program in ones own's state, we found that in the 2021 match cycle, 39.3% of applicants matched within their state, while 34.3% and 33.4% of incoming residents matched in 2020 and 2019, respectively. Conclusion: To keep our patients and staff safe, visiting externship rotations were suspended in the 2021 Match cycle. As we continue to navigate the shifting waters of the COVID-19 pandemic, it is important to understand how our choices affect the dynamics of applying into residency training and beyond. This study demonstrates that a higher percentage of applicants that matched into orthopaedic residency remained at their home program compared to the previous two years before the pandemic. This indicates that programs tended to rank their home applicants, and that applicants tended to rank their home programs, higher than those that were less familiar. Level of Evidence: IV.

Is the Position and Union of the Tuberosities Assessable by Means of the Simple Radiograph After Reverse Shoulder Arthroplasty for Complex Proximal Humerus Fractures?

Background: The assessment of tuberosity position and union in reverse shoulder arthroplasty (RSA) for complex proximal humerus fractures (PHF) has been carried out by means of routine simple radiographs. To evaluate the interobserver agreement and intraobserver reproducibility of the simple radiograph in comparison to the CT scan. Methods: The position and consolidation of the tuberosities in 2 radiographic projections and in a CT scan of 32 consecutive patients operated on a RSA for PHF was assessed by 5 observers. Interobserver agreement and intraobserver reproducibility in both imaging tests were also assessed. Results: The interobserver agreement for the greater tuberosity position was 0.52 in the simple radiograph and 0.45 in the CT scan. For the greater tuberosity union, agreement was moderate in the simple radiograph (0.52), but fair in the CT scan (0.35). For the lesser tuberosity position and union, the agreement was fair in the radiograph and poor in the CT scan. Conclusion: Only moderate agreement was observed in the assessment of the position and union of the tuberosities in the RSA for PHF in the simple radiograph and no improvement in it was seen for the 2D CT scan.

[Translated article] Sagittal imbalance influences outcome of vertebroplasty in patients with osteoporotic vertebral compression fracture.

BACKGROUND AND OBJECTIVES: The correlation between sagittal balance of the spine and clinical outcome after vertebroplasty (VP) in patients with osteoporotic vertebral compression fractures (OVCF) is poorly investigated. We analysed the clinical outcome of patients with OVCF undergoing VP taking into account sagittal balance. METHODS: The primary endpoint was the change in axial back pain; disability and health-related quality of life using VAS, ODI and SF-36 respectively in correlation to the parameters that define sagittal balance (SVA). Radiographic assessment included full spine standing lateral films. Imaging and clinical data were collected pre and post procedure at 1, 3 and 12 months. RESULTS: Fifty-one patients were included presenting a total of 113 OVCF. Thirty patients (60.7%) had multiple OVCF. Comparing the evolution of VAS and ODI throughout the follow-up it does not seem that there are significant differences in their behaviour between the SVA>50mm and the SVA<50mm groups (p>0.05). On the contrary, preVP SF-36 scores showed worst results in the SVA>50mm group in the physical functioning section (PF) (p<0.05) and in the physical component score (PCS) (p<0.05). These differences were maintained until 3 months of follow-up in the case of the PCS and until the end of follow-up in the case of the PF (p<0.05). CONCLUSIONS: Patients with a SVA>50mm showed a slower recovery of their quality of life after VP for OVCF, but without significant differences with respect to pain or disability, when compared with patients with SVA<50mm.

A newly discovered membrane at the origin of the proximal tendinous complex of the rectus femoris.

PURPOSE: The rectus femoris (RF) forms the anterior portion of the quadriceps muscle group. It has a proximal tendinous complex (PTC) which is constituted by a direct tendon (DT), an indirect tendon (IT), and a variable third head. Direct and indirect tendons finally converge into a common tendon (CT). All the PTC shows a medially sloping in its proximal insertion.We investigated several anatomical specimens and discovered a new component: a membrane connecting the CT with the anterior superior iliac spine. Such membrane constitutes a new origin of the PTC. The aim of this study was to clarify whether this membrane was an anatomical variation of the PTC or a constant structure and to describe its morphology and trajectory. MATERIAL AND METHODS: We dissected 42 cadaveric lower limbs and examined the architecture of the PTC. We paid special attention to the morphology and interaction patterns between the tendons and the membrane. RESULTS: We demonstrated that the membrane is a constant component of the PTC. It has a lateral to medial trajectory and is in relation to the common tendon, the DT, and IT, which present a medial slope. This suggests that the membrane has an stabilizer role for the PTC, acting as a corrector of the inclined vector of the complex. CONCLUSION: The RF injuries are frequent in football. The newly discovered membrane is a constant component of the PTC and its integrity should be included in the algorithm to diagnose injuries.

Sagittal imbalance influences outcome of vertebroplasty in patients with osteoporotic vertebral compression fracture. / Influencia del desequilibrio sagital en el resultado clínico de la vertebroplastia en pacientes con fractura por compresión vertebral osteoporótica.

BACKGROUND AND OBJECTIVES: The correlation between sagittal balance of the spine and clinical outcome after vertebroplasty (VP) in patients with osteoporotic vertebral compression fractures (OVCF) is poorly investigated. We analysed the clinical outcome of patients with OVCF undergoing VP taking into account sagittal balance. MATERIAL AND METHOD: The primary endpoint was the change in axial back pain, disability and health-related quality-of-life using Visual Analogue Scale (VAS), Oswestry Disability Index (ODI) and SF-36, respectively, in correlation to the parameters that define sagittal balance (SVA). Radiographic assessment included full spine standing lateral films. Imaging and clinical data were collected pre- and post-procedure at 1, 3 and 12 months. RESULTS: 51 patients were included presenting a total of 113 OVCF. 30 patients (60.7%) had multiple OVCF. Comparing the evolution of VAS and ODI throughout the follow-up it does not seem that there are significant differences in their behaviour between the SVA>50mm and the SVA<50mm groups (p>0.05). On the contrary, pre-VP SF-36 scores showed worst results in the SVA>50mm group in the physical functioning (PF) section (p<0.05) and in the physical component score (PCS) (p<0.05). These differences were maintained until 3 months of follow-up in the case of the PCS and until the end of follow-up in the case of the PF (p<0.05). CONCLUSIONS: Patients with a SVA>50mm showed a slower recovery of their quality-of-life after VP for OVCF, but without significant differences with respect to pain or disability, when compared patients with SVA<50mm.