Inside-Out Repair of Medial Meniscal Ramp Lesions in Patients Undergoing Anterior Cruciate Ligament Reconstruction.

Background: Medial meniscal ramp lesions are disruptions at the meniscocapsular junction and/or meniscotibial attachment of the posterior horn of the medial meniscus, and occur in up to 42% of all acute anterior cruciate ligament (ACL) tears1,3-5. Ramp lesions are frequently missed because of the limited diagnostic sensitivity of magnetic resonance imaging (MRI), physical examination, and standard anterior compartment arthroscopic exploration4,6,7. Arthroscopic evaluation of ramp lesions often requires a modified Gillquist maneuver and/or a posteromedial accessory portal for adequate assessment of the posteromedial "blind spot."4,8-10 Clinically, ramp lesions are associated with increased preoperative anterior knee instability, which may increase the risk of ACL graft failure if left untreated6,13. Although long-term comparative data on ramp-repair techniques are limited, proper arthroscopic assessment and treatment is recommended for all patients with ramp lesions at the time of ACL reconstruction (ACLR)1-5. In the present video article, we demonstrate a systematic approach for the identification and assessment of ramp lesions and describe a mini-open inside-out arthroscopically assisted repair technique for unstable ramp lesions at the time of ACLR. Description: (1) The patient is placed in the supine position, and a contralateral leg holder is utilized to create more working room on the medial side. (2) Standard diagnostic arthroscopy is performed through anteromedial and anterolateral portals. (3) Next, with the arthroscope in the anterolateral portal, the scope is advanced through the intercondylar notch with the knee in 30° of flexion in order to inspect the posterior horn of the medial meniscus. Probing is directed both over the superior aspect of the posterior horn to assess for tears, separation, and/or displacement of the meniscocapsular junction, and under the inferior aspect of the posterior horn to assess the integrity of the meniscotibial attachment. (4) After confirmation of a ramp tear, an open dissection is carried out through the sartorial fascia, with blunt dissection performed anterior to the medial gastrocnemius and above the semimembranosus to create the posteromedial surgical site. (5) A suture-shuttling device is utilized, and the corresponding cannula is placed into the anterolateral portal and directed toward the tear under arthroscopic visualization from the anteromedial portal. (6) Next, the first needle is passed through the meniscus, and the second is delivered through the adjacent capsule to create a vertical or oblique suture pattern. The needles are retrieved from the posteromedial surgical site and promptly cut, and the sutures are tied. (7) Multiple sutures, both above (femoral) and below (tibial) the meniscus, are placed 3 to 5 mm apart in a similar fashion. (8) On completion of the repair, the meniscocapsular junction is probed in order to confirm adequate stability with minimal translation of the medial meniscus. Alternatives: In the setting of an ACL tear, surgical options for concomitant repair of an unstable ramp lesion include all-inside, inside-out, or hybrid techniques (i.e., outside-in, inside-in, and/or all-inside). Rationale: Repair of ramp lesions using an inside-out technique restores preoperative excessive knee instability, which may decrease the risk of ACL graft failure. In addition, an inside-out ramp repair has a reported low secondary meniscectomy rate (2%), offers flexibility regarding the number and placement of the sutures, and creates a potentially stronger repair; however, this procedure is more technically challenging compared with other repair techniques6,10. All-inside ramp repairs have been reported to have higher secondary meniscectomy rates, ranging from 11% to 31%, because of the inability to repair the meniscotibial ligament from the anterior portals13,14. Suture hook repair using a posteromedial portal is becoming more popular and reportedly has a significantly lower secondary meniscectomy rate compared with all-inside techniques (19% compared with 30.6%)15. Expected Outcomes: At a minimum of 2 years of follow-up, DePhillipo et al. reported similar clinical outcomes and return to sports for patients who underwent combined ACLR plus inside-out repair of ramp lesions (n = 50) compared with a matched cohort who underwent isolated ACLR (n = 50). Although the ACLR plus ramp lesion repair group had had significantly greater preoperative knee instability compared with the isolated ACLR group, there was no difference in postoperative instability between groups at an average of 2.8 years (range, 2 to 8 years) of follow-up6. Important Tips: The exterior posteromedial incision should be facilitated by inside-out transillumination of the medial compartment and by palpation using an intra-articular probe at the medial aspect of the joint in order to avoid saphenous vein injury10.Two-thirds of the posteromedial incision should be distal to the joint line, with one-third proximal, because the suture needles often angle downwards as they exit the capsule10.The pes anserinus tendons should be retracted during the posteromedial dissection in order to avoid injury to the saphenous nerve (which lies posteromedial to the tendons)10.70° to 90° of flexion relaxes the hamstring and gastrocnemius, which improves visualization and aids in retrieval of the suture needles as they exit the posterior capsule10.Entering the anterolateral portal with the suture-delivery device decreases the risk of neurovascular damage and optimizes the direction of the needle10.After placement of the first needle, keep slight tension on the first suture to avoid inadvertent suture damage during advancement of the second needle10.Recent reports have suggested that ramp lesions can occur in isolation without ACL injury or accompanying isolated or combined posterior cruciate ligament (PCL) tears. Do not forget to assess for ramp lesions in these scenarios16. Acronyms: ACL = anterior cruciate ligamentPCL = posterior cruciate ligamentMMBH = medial meniscus bucket-handleMRI = magnetic resonance imagingMFC = medial femoral condyleMTP = medial tibial plateauPMC = posteromedial capsuleMM = medial meniscusAT = adductor tuberclesMCL = superficial medial collateral ligamentSM = semimembranosusMGT = medial head of gastrocnemius tendonACLR = anterior cruciate ligament reconstructionPROMs = patient-reported outcome measuresMTL = meniscotibial ligament.

Rates of Subjective Failure After Both Isolated and Combined Posterior Cruciate Ligament Reconstruction: A Study From the Norwegian Knee Ligament Registry 2004-2021.

BACKGROUND: Outcomes after posterior cruciate ligament (PCL) reconstruction (PCLR) have been reported to be inferior to those of anterior cruciate ligament reconstruction. Furthermore, combined ligament injuries have been reported to have inferior outcomes compared with isolated PCLR. PURPOSE/HYPOTHESIS: The purpose of this study was to report on PCLR outcomes and failure rates and compare these outcomes between isolated PCLR and multiligament knee surgery involving the PCL. The hypothesis was that combined PCL injury reconstruction would have higher rates of subjective failure and revision relative to isolated PCLR. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Patients with primary PCLR with or without concomitant ligament injuries registered in the Norwegian Knee Ligament Registry between 2004 and 2021 were included. Knee injury and Osteoarthritis Outcome Score (KOOS) totals were collected preoperatively and at 2 years and 5 years postoperatively. The primary outcome measure was failure, defined as either a revision surgery or a KOOS Quality of Life (QoL) subscale score <44. RESULTS: The sample included 631 primary PCLR procedures, with 185 (29%) isolated PCLR procedures and 446 (71%) combined reconstructions, with a median follow-up time of 7.3 and 7.9 years, respectively. The majority of patients had poor preoperative knee function as defined by a KOOS QoL score <44 (90.1% isolated PCLR, 85.7% combined PCL injuries; P = .24). Subjective outcomes improved significantly at 2- and 5-year follow-up compared with preoperative assessments in both groups (P < .001); however, at 2 years, 49.5% and 46.5% had subjective failure (KOOS QoL <44) for isolated PCLR and combined PCLR, respectively (P = .61). At 5 years, the subjective failure rates of isolated and combined PCLR were 46.7% and 34.2%, respectively (P = .04). No significant difference was found in revision rates between the groups at 5 years (1.9% and 4.6%, respectively; P = .07). CONCLUSION: Patients who underwent PCLR had improved KOOS QoL scores relative to their preoperative state. However, the subjective failure rate was high for both isolated and multiligament PCLR. Within the first 2 years after surgery, patients who undergo isolated PCLR can be expected to have similar failure rates to patients who undergo combined ligament reconstructions.

Editorial Commentary: Meniscal Extrusion.

With the improved recognition of meniscal root tears over the past decade, it has become clear that root repairs are necessary in most patients indicated for a repair to prevent the further progression of osteoarthritis. Root repairs are cost beneficial to and prevent the early need for a total knee arthroplasty. As further postoperative follow-up occurs for root repairs, we have found that most patients have significantly improved patient-reported outcomes, while it is still clear that further clinical outcome study as well as further refinement of surgical technique is necessary. The next thing that we have to investigate is how to prevent recurrent meniscal extrusion after a root repair. Nonanatomic repair significantly alters tibiofemoral biomechanics and results in notably increased meniscal extrusion. In contrast, biomechanical studies show anatomic repair of the meniscus attachment within 1 cm of the meniscus attachment site restores joint loading close to normal.

Combined Rip-Stop and Transtibial Pull-out Technique for Lateral Meniscus Radial Repairs.

Radial tears of the meniscus disrupt circumferential fibers that allow for the dispersion of axial tibiofemoral forces. Both nonoperative treatment and meniscectomy carry increased risk of early-onset degeneration of the joint because of decreased contact surface area and increased point-loading of the chondral surfaces. Radial type tears are also notable for the relatively high failure rate associated with repair. The purpose of this technical note is to demonstrate our surgical technique for a radial lateral meniscus repair construct that allows for good apposition and anatomic reduction of the meniscus with less risk of residual postoperative extrusion through use of a combination inside-out rip-stop and transtibial pull-out suturing repair.

Concurrent Repair of Medial Meniscal Ramp Lesions and Lateral Meniscus Root Tears in Patients Undergoing Anterior Cruciate Ligament Reconstruction: The "New Terrible Triad".

Recent studies have suggested that up to 8% of patients with anterior cruciate ligament (ACL) tears can present with a combined medial meniscal ramp lesion (MMRL) and lateral meniscus root tear (LMRT). MMRLs and LMRTs often are missed preoperatively and can increase the risk of ACL graft failure if left untreated. Given the potential synergistic biomechanical consequences and challenging repair techniques used for treatment, our group commonly refers to this presentation (MMRL-LMRT-ACL) as the "new terrible triad" of ACL pathology. This Technical Note aims to describe a systematic approach for arthroscopic assessment and our preferred inside-out and transtibial pull-out repair techniques to efficiently diagnose and treat a combined MMRL and LMRT at the time of ACL reconstruction surgery.

Natural history of intraosseous low-grade chondroid lesions of the proximal humerus.

Introduction: Enchondromas and grade 1 chondrosarcomas are commonly encountered low-grade chondroid tumors in the proximal humerus. While there is a concern for malignant transformation, few studies have evaluated the natural history of these lesions. The purpose of this study is to evaluate the natural history of proximal humerus low-grade chondroid lesions managed both conservatively and surgically, and to define management criteria using clinical and radiographic findings for these low-grade chondroid lesions. Methods: The patient population included 90 patients intended for conservative treatment and 22 patients proceeding directly to surgery. Data collection was based on a combination of chart review and patient imaging and descriptive statistics were calculated for each group. Results: No malignant transformations were noted amongst any group. In the conservative treatment group, 7 of 64 (11%) progressed to surgery after an average of 20.3 months of conservative treatment due to persistent pain unexplained by other shoulder pathology. Importantly, 71% experienced continued pain at a mean of 53.1 months post-operatively. The group that went directly to surgery also demonstrated pain in 41% at an average follow-up of 57.3 months. Discussion: Low-grade cartilaginous lesions of the proximal humerus without concerning imaging findings can be managed with conservative treatment and the risk of malignant transformation is very low. Patients with a clear source of their shoulder pain unrelated to their tumor and without concerning characteristics on imaging can be managed with serial annual radiographic imaging. Patients undergoing surgery for these indolent tumors are likely to experience persistent pain even after surgery.

Treatment of a Failed Posterior Cruciate Ligament Avulsion Fracture Fixation in a Skeletally Immature Patient: A Case Report.

CASE: A 12-year-old skeletally immature girl presented with 1 year of persistent instability after an open reduction and internal fixation (ORIF) for a posterior cruciate ligament (PCL) avulsion fracture. With a period of nonoperative management, her PCL stress radiographic measurements significantly decreased and her posterior tibial slope increased because the primary ORIF effectively led to growth arrest with an early fusion of the posterior tibial physis. At age 13 years when she was skeletally mature, revision PCL and fibular collateral ligament (FCL) reconstructions were performed. Promising clinical outcomes were observed at age 17 years. CONCLUSION: Pediatric patients with a failed PCL ORIF can successfully be managed with a period of nonoperative bracing and a revision PCL reconstruction once skeletally mature.

Combined Repair of Medial Meniscal Ramp Lesions and Posterior Root Tears of the Lateral Meniscus During Anterior Cruciate Ligament Reconstruction: A Case Report.

CASE: This case report describes the clinical outcomes for 2 patients who underwent a primary or revision anterior cruciate ligament (ACL) reconstruction with a combined inside-out and transtibial pullout repair for a medial meniscal ramp lesion (MMRL) and a lateral meniscus root tear (LMRT), respectively. Promising short-term outcomes were seen at the one-year follow-up for both patients. CONCLUSIONS: Utilization of these repair techniques can successfully treat a combined MMRL and LMRT injury at the time of primary or revision ACL reconstruction.

Using Advanced Data to Analyze the Impact of Injury on Performance of Major League Baseball Pitchers: A Narrative Review.

Major league baseball (MLB) pitchers are at risk of numerous injuries during play, and there is an increasing focus on evaluating their performance in the context of injury. Historically, performance after return to play (RTP) from injury has focused on general descriptive statistics, such as innings or games played, or rate statistics with inherent variability (eg, earned run average, walks and hits per inning pitched, strikeouts per 9 innings, or walks per 9 innings). However, in recent years, MLB has incorporated advanced technology and tracking systems in every stadium, allowing for more in-depth analysis of pitcher-specific data that are captured with every pitch of every game. This technology allows for the ability to delve into the pitching performance on a basis that is more specific to each pitcher and allows for more in-depth analysis of different aspects of pitching performance. The purpose of this narrative review was to illustrate the current state of injury recording for professional baseball pitchers, highlight recent technological advances in MLB, and describe the advanced data available for analysis. We used advanced data in the literature to review the current state of performance analysis after RTP in MLB pitchers after injury. Finally, we strived to provide a framework for future studies to more meticulously assess RTP performance given the current available resources for analysis.

Ulnar Collateral Ligament Reconstruction Does Not Decrease Spin Rate or Performance in Major League Pitchers.

BACKGROUND: Ulnar collateral ligament reconstruction (UCLR) is commonly performed in Major League Baseball (MLB) pitchers, with variable reported effects on velocity and traditional rate statistics. Currently, no studies have evaluated spin rate in the context of return to play (RTP) after injury. Greater spin rate has become increasingly sought after in the baseball community, as it is believed to be a vital aspect of pitch effectiveness. PURPOSE/HYPOTHESIS: The purpose was to evaluate the effect of primary UCLR on fastballs (FB) and sliders (SL) of MLB pitchers in terms of spin rate, velocity, hard-hit rate, and whiff rate. It hypothesized that the post-UCLR FB and SL spin rates, velocity, and whiff rate would be significantly decreased versus their pre-UCLR levels, while the FB and SL hard-hit rates would be higher in comparison with pre-UCLR levels. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: In total, 42 pitchers who underwent UCLR and returned to MLB play were identified from public records from 2016 to 2019. The Statcast system was used to collect spin rate, velocity, hard-hit rate, and whiff rate for 4-seam FB (4FB), 2-seam FB (2FB), and SL for pitchers in the preinjury year as well as the 2 years after return from UCLR. Data were analyzed using the appropriate statistical tests. RESULTS: A total of 36 pitchers met the inclusion criteria, and 31 of the eligible 36 players (86.1%) were able to return to MLB pitching (RTP). There were no significant decreases for 4FB, 2FB, or SL in spin rate, measured in revolutions per minute (rpm), when comparing preinjury levels with the first and second seasons after return. There was a significant decrease in velocity for the 2FB in the first season (92.9 vs 93.7 miles per hour [mph]; P = .045) but not the second season (93 mph; P = .629) after RTP in comparison with pre-UCLR levels. For the 2FB, there was a significant increase in spin rate between preinjury and RTP season 2 (2173.5 vs 2253 rpm; P = .022). For the SL, there was a significant increase in spin rate between preinjury and RTP season 2 (2245.1 vs 2406 rpm; P = .016). CONCLUSION: A cohort of MLB pitchers who underwent UCLR and returned to the MLB level demonstrated no significant decreases in the spin rate, velocity, whiff rate, or hard-hit rate of 4FB, 2FB, or SL at 2 years after UCLR.

The Spectrum of Anterior Cruciate Ligament Reconstruction Options for the Pediatric and Adolescent Patient: A Narrative Review.

As youth sports participation has increased in recent years, injuries to the anterior cruciate ligament (ACL) have become increasingly common in pediatric patients. Historically, ACL reconstruction was delayed in pediatric patients to avoid physeal damage with the potential for leg-length discrepancy or angular deformity. Current research shows that delaying reconstruction or choosing nonoperative management is associated with increased rates of meniscal and chondral injuries, persistent knee instability, and low rates of return to previous activity. Early ACL reconstruction using techniques to avoid physeal growth disturbance is now widely accepted among physicians. The purpose of this review was to describe the pediatric ACL in terms of the relevant anatomy and biomechanics, physical examination, and diagnostic imaging. In addition, the importance of skeletal age and possible physeal injury is discussed in the context of ACL reconstruction options by skeletal age and remaining growth potential.

Revision ulnar collateral ligament reconstruction in Major League Baseball pitchers: effects of fastball velocity and usage.

BACKGROUND: Ulnar collateral ligament (UCL) tears are prevalent in Major League Baseball (MLB) pitchers and can cause significant loss of time with varying reports of impact on performance. Revision UCL reconstruction (UCLR) is becoming increasingly common, with little known about the effects on fastball (FB) velocity and usage (FB%) in this setting. HYPOTHESIS/PURPOSE: The purpose was to evaluate the effect of revision UCLR on MLB pitchers with respect to postoperative FB velocity and FB% at 1 and 2 years after return to play. The hypothesis was postoperative FB velocity and FB% would significantly decrease vs. prerevision levels, and that revision UCLRs would result in significantly decreased FB velocity and FB% in comparison to a matched group of MLB pitchers after primary UCLR. METHODS: Twenty-one pitchers who underwent revision UCLR and returned to MLB play were identified from public records from 2008-2021. The PITCHf(x) system collected FB velocity for 4-seam (4FB) and 2-seam (2FB) fastballs and total FB% for pitchers in the prerevision year as well as the 2 years after return. A matched control group of pitchers who underwent primary UCLR was used for comparison. RESULTS: There were no significant differences in FB velocity between prerevision levels (4FB 92.9 mph, 2FB 91.4 mph) and years 1 (4FB 92.5 mph, 2FB 91.2 mph) and 2 (4FB 93.4 mph, 2FB 91.1 mph) after revision UCLR. FB% decreased from the prerevision season (60.1) and the first (56.2, P = .036) and second years (52.5, P = .002) after return. There were no significant differences between FB velocity and FB% or between the revision and primary UCLR groups. CONCLUSION: Pitchers returning to the MLB level after revision UCLR can expect similar FB velocity to their prerevision FB velocity and to pitchers undergoing primary UCLR; however, they do demonstrate a decrease in FB%, which may suggest less confidence in their FB after RTP.

Return-to-play and performance after operative treatment of Achilles tendon rupture in elite male athletes: a scoping review.

OBJECTIVE: To examine the current evidence regarding return-to-play (RTP) and performance after Achilles tendon rupture in elite athletes treated with operative intervention. DESIGN: Scoping review. DATA SOURCES: Published sources identified through a PubMed search of elite athletes, defined as professional or division one collegiate athletes in baseball, basketball, American football or soccer. METHODS: Our search yielded a total of 2402 studies, with 13 studies fulfilling the study criteria of reporting elite athletes with objective measures of their athletic performance. A total of 709 elite athletes were included from the NBA, NFL, Major League Baseball (MLB), National Collegiate Athletic Association (NCAA) football and professional soccer. RESULTS AND DISCUSSION: Overall, 61%-100% of elite male athletes RTP after Achilles tendon rupture and operative repair. NBA players had inferior performance compared with their preoperative status as well as controls of non-injured players. Studies did not show significantly different performance after Achilles injury for MLB players. Professional soccer, NFL and NCAA football studies reported varying performance after injury. CONCLUSIONS: Evidence suggests that sports with explosive plantarflexion demands, such as basketball, may be associated with a greater decrease in performance despite operative intervention after Achilles rupture.

Hip Dislocation and Subluxation in Athletes: A Systematic Review.

BACKGROUND: Hip dislocation is a rare occurrence during sports but carries serious implications for athletes. PURPOSE: To systematically review treatment strategies and outcomes for hip dislocation in athletes, with the ultimate goal of providing sports medicine physicians with the information necessary to appropriately treat and counsel patients sustaining this injury. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: PubMed, MEDLINE, and Embase were searched for studies relating to hip instability and athletics from January 1, 1989 to October 1, 2019. Abstracts and articles were evaluated on the basis of predefined inclusion and exclusion criteria. Inclusion criteria were the following: (1) data from ≥1 patients, (2) native hip dislocation or subluxation occurring during sports, (3) patients aged at least 10 years, and (4) written in English. Exclusion criteria were (1) patients younger than 10 years; (2) nonnative or postoperative hip dislocation or subluxation; (3) a native hip injury without dislocation or subluxation; (4) patients with dislocation or subluxation secondary to neuromuscular, developmental, or syndromic causes; (5) dislocation or subluxation not occurring during sports; (6) patients with physeal fractures; or (7) review articles or meta-analyses. Data were recorded on patient demographics, injury mechanism, treatment strategies, and clinical and radiographic outcomes. Where possible, pooled analysis was performed. Studies were grouped based on reported outcomes. Meta-analysis was then performed on these pooled subsets. RESULTS: A total of 602 articles were initially identified, and after screening by 2 reviewers, 27 articles reporting on 145 patients were included in the final review. There were 2 studies that identified morphological differences between patients with posterior dislocation and controls, including decreased acetabular anteversion (P = .015 and .068, respectively), increased prevalence of a cam deformity (P < .0035), higher alpha angles (P≤ .0213), and decreased posterior acetabular coverage (P < .001). No differences were identified for the lateral center edge angle or Tonnis angle. Protected postreduction weightbearing was most commonly prescribed for 2 to 6 weeks, with 65% of reporting authors recommending touchdown, toe-touch, or crutch-assisted weightbearing. Recurrence was reported in 3% of cases. Overall, 4 studies reported on findings at hip arthroscopic surgery, including a 100% incidence of labral tears (n = 27; 4 studies), 92% incidence of chondral injuries, 20% incidence of capsular tears, and 84% incidence of ligamentum teres tears (n = 25; 2 studies). At final follow-up, 86% of patients reported no pain (n = 14; 12 studies), 87% reported a successful return to play (n = 39; 10 studies), and 11% had radiographic evidence of osteonecrosis (n = 38; 10 studies). CONCLUSION: Various treatment strategies have been described in the literature, and multiple methods have yielded promising clinical and radiographic outcomes in patients with native hip dislocation sustained during sporting activity. Data support nonoperative treatment with protected weightbearing for hips with concentric reduction and without significant fractures and an operative intervention to obtain concentric reduction if unachievable by closed means alone. Imaging for osteonecrosis is recommended, with evidence suggesting 4- to 6-week magnetic resonance imaging and follow-up at 3 months for those with suspicious findings in the femoral head.

ICD-10 codes do not accurately reflect ankle fracture injury patterns.

OBJECTIVE: To determine the accuracy of International Classification of Disease Version 10 (ICD-10) coding for ankle fracture injury patterns. DESIGN: Retrospective cohort study PATIENTS: 97 adult patients with fractures about the ankle (rotational ankle fracture or distal tibia fracture) from 2016 to 2020, selected by stratified random sampling. INTERVENTION: Assignment of an ICD-10 code representative of a rotational ankle fracture, pilon fracture, or unspecified fracture of the lower leg. OUTCOME MEASUREMENTS: Injury radiographs were reviewed by three authors to determine the correct code. Agreement between the correct code and the electronic medical record (EMR) assigned code was determined using kappa's statistic in the aggregate as well as percent agreement, sensitivity, specificity, and positive predictive value (PPV) between individual codes. RESULTS: 59 of 97 cases (60.8%) demonstrated discordance between the existing EMR and surgeon-assigned codes. Aggregate agreement between all codes was fair (K = 0.26). Lateral malleolus fracture codes demonstrated the highest PPV (0.91, 95% CI 0.72-0.99), while the lowest PPV was found for "other fractures of the lower leg" (0.05, 95% CI 0.0-0.24) and "other fracture of the fibula" (0.0, 95% CI 0.0-0.15). Generalized "other fracture" codes comprised 45% of EMR codes compared to only 6% of assigned codes (p < 0.001). EMR codes were specific but not sensitive. CONCLUSION: There is substantial discordance between existing EMR and surgeon-assigned ICD-10 codes for ankle fractures. Database research that relies on ICD-10 coding as a surrogate for primary clinical data should be interpreted with caution and institutions should make efforts to increase the accuracy of their coding.

Medial Patellofemoral Ligament Repair or Medial Advancement: Is There a Role?

Patellar instability is one of the most prevalent knee disorders, with dislocations occurring in 5 to 43 cases per 10,000 annually. Traumatic patellar dislocation can result in significant morbidity and is associated with patellofemoral chondral injuries and fractures, medial soft tissue disruption, pain, and reduced function, and can lead to patellofemoral osteoarthritis. Chronic and recurrent instability can lead to deformation and incompetence of the medial soft tissue stabilizers. Despite recent gains in understanding the pathoanatomy of this disorder, the management of patients with this condition is complex and remains enigmatic.

Biologic Augmentation for the Operative Treatment of Osteochondral Defects of the Knee: A Systematic Review.

BACKGROUND: Various surgical treatment options exist for repairing, replacing, or regenerating tissue to fill osteochondral defects. Biologic augmentation has been increasingly studied as an adjunct in the surgical treatment of osteochondral defects of the knee in animal and human models. PURPOSE/HYPOTHESIS: The purpose of the study was to systematically review use of platelet-rich plasma (PRP) and bone marrow concentrate (BMC) augmentation in the surgical treatment of osteochondral knee defects and to describe the outcomes. It was hypothesized that both PRP and BMC augmentation will result in improved outcomes in osteochondral knee surgery in both animal and human models. STUDY DESIGN: Systematic review. METHODS: PubMed, MEDLINE, and Embase were searched for studies relating to PRP or BMC and treatment of osteochondral defects of the knee, from database inception to February 1, 2020. Included were articles that (1) studied PRP or BMC augmentation; (2) used osteochondral autograft, allograft, or biologic scaffold; and (3) treated osteochondral defects in the knee. Data on use of PRP or BMC, outcomes assessed, and results were recorded for each publication. RESULTS: Of the 541 articles identified initially, 17 were included in the final review. Five articles studied osteochondral grafts in animals, 5 studied biologic scaffolds in animals, and 7 studied scaffolds or allografts in humans; the combined sample size was 202 patients. Of 4 histologic scaffold studies, 3 PRP-augmented scaffold studies identified histologic improvements in regenerated cartilage in animal models, while 1 BMC study demonstrated similar improvement in histologic scores of BMC-augmented scaffolds compared with controls. Three studies associated greater collagen type 2 and glycosaminoglycan content with PRP treatment. Comparative studies found that both augments increase osteogenic proteins, including bone morphogenetic protein-2 and osteoprotegerin. Two of 3 studies on BMC-augmented osteochondral allografts reported no difference in radiographic features postoperatively. Long-term improvement in clinical and radiographic outcomes of PRP-augmented scaffolds was demonstrated in 1 human study. CONCLUSION: Animal studies suggest that biologics possess potential as adjuncts to surgical treatment of osteochondral knee defects; however, clinical data remain limited.

An Overview of Clinically Relevant Biomechanics of the Anterolateral Structures of the Knee.

Residual anterolateral rotatory laxity following injury and reconstruction of the anterior cruciate ligament (ACL) has become a popular topic and has generated interest in characterizing the relative contribution from the anterolateral structures of the knee. Studies have reported on the anatomic and biomechanical features of the anterolateral ligament (ALL), revealing a role in restraining internal tibial rotation in both ACL-intact and ACL-deficient knees. The Kaplan fibers of the iliotibial band have also been reported to provide significant restraint to internal tibial rotation. The ACL is the primary restraint to anterior tibial translation, and both the proximal and distal bundles of the iliotibial band, with a divergent orientation, also provide significant static restraint against internal tibial rotation, and each bundle may have a distinct individual role. In the setting of ACL deficiency, subsequent sectioning of the ALL and Kaplan fibers led to further increases in anterior tibial translation. Residual rotatory laxity that may be seen clinically following ACL reconstruction may be attributable to an associated anterolateral structure injury even in the setting of an anatomic ACLR, leading to consideration for a concomitant anterolateral structure reconstruction. Studies evaluating the kinematic influence of anatomic ALL reconstruction or lateral extra-articular tenodesis have focused on internal rotation, axial plane translation, and anterior tibial translation, with variable results having been reported. Further, despite the long history of anterolateral structure reconstruction, most commonly with a lateral extra-articular tenodesis, the clinical use of these combined techniques is still in its relative infancy, and long-term patient outcomes have yet to be published for relative comparisons.

Biomechanical Comparison of Screw Fixation Versus a Cortical Button and Self-tensioning Suture for the Latarjet Procedure.

BACKGROUND: Metal screws are traditionally used to fix the coracoid process to the glenoid. Despite stable fixation, metal screws have been associated with hardware complications. Therefore, some studies have advocated for suture button fixation during the Latarjet procedure to reduce the complications associated with screw fixation. PURPOSE: To biomechanically evaluate the ultimate failure load of a cortical button and self-tensioning suture versus metal screws for coracoid graft fixation during the Latarjet procedure. STUDY DESIGN: Controlled laboratory study. METHODS: Eight matched pairs of fresh-frozen, male cadaveric shoulders (N = 16) underwent the Latarjet procedure. The shoulders of each pair were randomly assigned to 1 of 2 groups: fixation using two 3.75-mm cannulated, fully threaded metal screws or fixation using a double suture button construct. Specimens were secured in a dynamic testing machine and cyclically preconditioned from 2 to 10 N at 0.1 Hz for 10 cycles. After preconditioning, specimens were pulled to failure at a normalized displacement rate of 400% of the measured gauge length per minute. The ultimate failure load and mechanism of failure were recorded for each specimen. RESULTS: The mean ultimate load to failure for screw fixation (226 ± 114 N; 95% CI, 147-305 N) was not significantly different from that for suture button fixation (266 ± 73 N; 95% CI, 216-317 N) (P = .257). The mean strain at failure for screw fixation (63% ± 21%; 95% CI, 48%-77%) was not significantly different from that for suture button fixation (86% ± 26%; 95% CI, 69%-104%) (P = .060). The most common mechanism of failure for the screw fixation method was at the bone block drill holes, while an intramuscular rupture at the clamp-muscle interface occurred for the suture button construct. CONCLUSION: The screw and suture button fixation techniques exhibited comparable biomechanical strength for coracoid bone block fixation of the Latarjet procedure. CLINICAL RELEVANCE: Metal screws have been reported to be a large contributor to intraoperative and postoperative complications. Therefore, given the results of the current study, a suture button construct may be an alternative to metal screw fixation during the Latarjet procedure. However, further clinical studies are warranted.

Changes in the Neurovascular Anatomy of the Shoulder After an Open Latarjet Procedure: Defining a Surgical Safe Zone.

BACKGROUND: Although previous literature has described the relevant anatomy for an open anterior Bankart approach of the shoulder, there is little known regarding the anatomic relationship changes in the neurovascular structures after an open Latarjet procedure. PURPOSE: To define the neurovascular anatomy of the native shoulder in relation to the coracoid and to define the anatomy after the Latarjet procedure in relation to the glenoid to determine distances to these neurovascular structures with and without neurolysis of the musculocutaneous nerve (MCN) from the conjoint tendon. STUDY DESIGN: Descriptive laboratory study. METHODS: Fourteen fresh-frozen male cadaveric shoulders (7 matched pairs) were utilized. The distances of 7 neurovascular structures (the main trunk of the MCN at its insertion into the conjoint tendon, the MCN at its closest location to the coracoid process, the lateral cord of the plexus, the split of the lateral cord and MCN, the posterior cord of the plexus, the axillary nerve, and the axillary artery) to pertinent landmarks were first measured in the native state in relation to the coracoid. After the Latarjet procedure, these landmarks were measured in relation to the glenoid. In addition, measurements of the MCN distances were performed both with and without neurolysis of the MCN from the conjoint tendon. All measurements were performed using digital calipers and reported as medians with ranges. RESULTS: The median MCN entry into the conjoint tendon was 56.5 mm (range, 43.0-82.2 mm) and 57.1 mm (range, 23.5-92.9 mm) from the tip of the coracoid in the neurolysis group and nonneurolysis group, respectively ( P = .32). After the Latarjet procedure, the median MCN entry into the conjoint tendon was 43.8 mm (range, 20.2-58.3 mm) and 35.6 mm (range, 27.3-84.5 mm) from the 3-o'clock position of the glenoid in the neurolysis and nonneurolysis groups, respectively ( P = .83). The median MCN entry into the conjoint tendon was 35.6 mm (range, 25.1-58.0 mm) and 36.3 mm (range, 24.4-77.9 mm) from the 6-o'clock position in the neurolysis group and nonneurolysis group, respectively ( P = .99). After the Latarjet procedure, the closest neurovascular structures in relation to both the 3-o'clock and 6-o'clock positions to the coracoid were the axillary nerve at a median 27.4 mm (range, 19.8-40.0 mm) and 27.7 mm (range, 23.2-36.1 mm), respectively. CONCLUSION: This study identified a minimum distance medial to the glenoid after the Latarjet procedure to be approximately 19.8 mm for the axillary nerve, 23.6 mm for the posterior cord, and 24.4 mm and 20.2 mm for the MCN without and with neurolysis, respectively. Neurolysis of the MCN did not significantly change the distance of the nerve from pertinent landmarks compared with no neurolysis, and routine neurolysis may not be indicated. However, the authors still advise that there may be clinical benefit to performing neurolysis during surgery, especially given that the short length of the MCN puts it at risk for traction injuries during the Latarjet procedure. CLINICAL RELEVANCE: The findings of this study provide an improved understanding of the position of the neurovascular structures after the Latarjet procedure. Knowledge of these minimum distances will help avoid iatrogenic damage of the neurovascular structures when performing procedures involving transfer of the coracoid process.