Arthroscopic suture bridge fixation for acute bony Bankart with anterior glenohumeral instability: a case report and narrative review.

Background and Objective: Anterior shoulder dislocations can result in acute glenoid rim fractures that compromise the bony stability of the glenohumeral joint. Adequate fixation of these fractures is required to restore stability, decrease shoulder pain, and facilitate return to activity. The double-row suture bridge is a relatively novel fixation technique, first described in 2009, that accomplishes internal fixation with sufficient stability using an all-arthroscopic technique to restore the glenoid footprint. A 40-year-old female with recurrent anterior shoulder instability in the setting of seizure disorder was found to have a bony Bankart lesion of 25% to 30% with a concomitant superior labral tear. The patient was treated with a double-row bony Bankart bridge and labral repair. At six months follow-up, she has progressed to a full recovery with no recurrence. Methods: A search was conducted in May 2023 in PubMed, EMBASE, and CINAHL with the search terms bony Bankart, bone Bankart, osseous Bankart, acute, bridge, suture bridge, double row. Key Content and Findings: Double-row suture bridge repairs result in improvement in shoulder function as determined by ASES (93.5), QuickDASH (4.5), SANE (95.9), and SF-12 (55.6). The overall recurrence rate of anterior instability after a bony Bankart bridge repair is 8%. When examining the return to prior level of function, 81.4% of patients were able to do so with only 7.9% of patients reporting significant modifications to their activity level. In mid-term results, double row suture bridge demonstrates similar outcomes to other all-arthroscopic fixation methods of bony Bankart injuries. Importantly, bony Bankart bridge remains a viable option for critical glenoid lesions over the 20% cutoff used in other all arthroscopic techniques. Biomechanically, the double-row suture bridge offers distinct benefits over its single-row counterpart including increased compression, reduced displacement, and reduced step-off. Conclusions: Although there is limited data, the studies discussed and the demonstrative case show the potential benefit of all-arthroscopic double-row suture bridge fixation including increased compression, decreased displacement, and a lower complication rate in patients with large bony Bankart lesions traditionally requiring bony augmentation. However, more robust studies are necessary to determine the long-term success of the double-row suture bridge.

Knotless Re-tensionable Direct Fixation of Medial Meniscus Posterior Root Tears.

Over the past decade, there has been an increased awareness of the recognition and treatment of medial meniscus posterior root tears. Recent systematic reviews and meta-analyses have shown that surgical repair of medial meniscus posterior root tears is effective in improving patient-reported outcome measures and decreasing the progression of osteoarthritis when compared with nonoperative treatment or meniscectomy. The available techniques currently consist of transosseous suture fixation and direct suture anchor fixation, with transosseous repairs being the most frequently performed. Transosseous fixation relies on indirect fixation on the anterior tibial cortex, which may predispose to gap formation at the repair site. On the other hand, suture anchor fixation is technically demanding with arthroscopic placement of the anchor perpendicular to the tibial plateau at the posterior medial root insertion. Furthermore, re-tensioning of the construct is not possible with the current techniques. In this technical note, we present a knotless re-tensionable direct fixation technique using an anterior tibial tunnel, which has the advantages of direct fixation, a rip-stop suture configuration, a reproducible surgical technique, and the possibility of re-tensioning of the repaired meniscal root.

Osteochodral Autograft and Allograft Show Favorable Outcomes For High Grade Hip Femoral Cartilage Lesions but Caution Is Required for Impaction Injuries and Osteonecrosis.

Articular cartilage defects of the hip pose therapeutic challenges. Among patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS), over 20% may have partial or full thickness chondral damage, and patients with high grade (ICRS Grade 3 or 4) damage who undergo arthroscopic treatment of FAIS have higher rates of re-operation at ten-year follow up. Arthroscopic and open techniques have been developed to translate cartilage restoration options initially developed in the knee for use in the hip. Arthroscopic options include chondroplasty, microfracture, biologic cartilage scaffolds, autologous chondrocyte implantation, and minced cartilage autograft (albeit more commonly in the acetabulum than the femoral head). Open techniques include autologous chondrocyte grafting, osteochondral autograft transfer (including mosaicplasty), osteochondral allograft transplantation, and arthroplasty. Open osteochondral allograft and autograft transplantation show improved patient reported outcomes and forestall arthroplasty in young patients with high grade cartilage defects of the femoral head. A recent review shows survivorship of 70 to 87.5% for allograft, and 61.5 to 96% for autograft. At the same time, outcomes are not universally positive, particularly for patients with post-traumatic impaction injuries and high-grade osteonecrosis. Until further data better clarifies the indications and contra-indications, widespread adoption of open cartilage transplantation to the femoral head should be approached with caution, especially for older patients where the gold standard of total hip arthroplasty has excellent survivorship at long term follow up.

Batter's Shoulder: All-Knotless Posterior Labral Repair With Retensionable Anchors for Treatment of Batter's Shoulder.

Batter's Shoulder is a unique injury that may be associated with recurrent microtrauma followed by acute subluxation of the humeral head on the posterior glenoid edge, leading to posterior labral tears. Early identification of this injury is critical, as it may be treated with conservative nonsurgical treatments prior to labral tear onset. If conservative treatment fails and pain persists, surgical options include arthroscopic fixation to reapproximate the posterior labrum to the glenoid and restore capsular tension. Previous studies have shown the benefit of using knotless suture anchors in arthroscopic shoulder fixation. This technical note demonstrates that Batter's Shoulder is a unique injury associated with posterior labral tears of the shoulder and provides a contemporary method of arthroscopic fixation of a posterior labral tear using retensionable knotless all-suture anchors.

Bioactive and Bioinductive Implants Are Increasingly Used in Orthopaedic Sports Medicine but Adequately Controlled Studies Are Needed: A Scoping Review.

PURPOSE: To describe the currently available literature reporting clinical outcomes for bioactive and bioinductive implants in sports medicine. METHODS: In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic search of 4 databases was completed to identify eligible studies. Inclusion criteria were studies using bioactive or bioinductive implants in human clinical studies for sports medicine procedures. Data were extracted and reported in narrative form, along with study characteristics. RESULTS: In total, 145 studies were included involving 6,043 patients. The majority of included studies were level IV evidence (65.5%), and only 36 included a control group (24.8%). Bioactive materials are defined as any materials that stimulate an advantageous response from the body upon implantation, whereas bioinductive materials provide a favorable environment for a biological response initiated by the host. Bioactivity can speed healing and improve clinical outcome by improving vascularization, osteointegration, osteoinduction, tendon healing, and soft-tissue regeneration or inducing immunosuppression or preventing infection. The most common implants reported were for knee (67.6%, primarily cartilage [most commonly osteochondral defects], anterior cruciate ligament, and meniscus), shoulder (16.6%, primarily rotator cuff), or ankle (11.7%, primarily Achilles repair). The most common type of implant was synthetic (44.1%), followed by autograft (30.3%), xenograft (16.6%), and allograft (9.0%). In total, 69% of implants were standalone treatments and 31% were augmentation. CONCLUSIONS: The existing bioactive and bioinductive implant literature in sports medicine is largely composed of small, low-level-of-evidence studies lacking a control group. CLINICAL RELEVANCE: Before bioactive implants can be adapted as a new standard of care, larger, comparative clinical outcome studies with long-term follow-up are essential.

Editorial Commentary: Early Clinical Results Are Promising for Meniscus Centralization as an Augment to Medial Meniscus Root Repair.

Meniscal root tears remain a common problem, with devastating biomechanical and clinical consequences. Thankfully, numerous techniques have been developed to repair the symptomatic meniscal root tear. However, rates of conversion to arthroplasty are reported to be 21% to 33% at 10 years, and persistent extrusion of the meniscus at follow-up is a known limitation of current root repair techniques. There is also growing evidence that some medial meniscal root tears may be an effect of meniscal extrusion, rather than the cause of it. In that vein, failure to correct extrusion may be a key mechanism of clinical and radiographic failure despite successful meniscus root repair. Techniques that "centralize" the meniscus (such as centralization with anchors at the tibial rim, meniscotibial ligament repair, deep medial collateral ligament repair, or circumferential suture augmentation of the meniscus) may improve patient outcomes by better correcting meniscal extrusion. Indications could be extrusion greater than 3 mm and documented extrusion before the root tear.

An Expedited Sling Immobilization Protocol After Isolated Biceps Tenodesis Results in Clinical and Patient-Reported Postoperative Outcomes Equivalent to a Standard Rehabilitation Protocol.

Purpose: To characterize clinical and patient-reported outcomes for patients after isolated biceps tenodesis (BT) who underwent either standard or expedited sling immobilization protocols following surgery. Methods: This retrospective cohort study compared patients who were assigned to use a sling for either 4 to 6 weeks (standard) or 0 to 2 weeks (expedited) following an isolated BT. Primary endpoint included rate of re-rupture, surgical revision, loss of fixation, and Popeye deformity. Secondary endpoints included shoulder range of motion (ROM) as well as pre- and postoperative patient-reported outcomes (PROs) of pain and function. Missing data were managed via multiple imputation with chained equations. Complication prevalence 95% confidence intervals were calculated using the Clopper Pearson method and a series of hierarchical mixed effects linear regressions were performed to assess differences between sling interventions in PROs and ROM. Results: The average age of the standard cohort (n = 66) was 49 years (±14 years), and the average age of the expedited cohort (n = 69) was 47 years (±14 years). The expedited and standardized cohorts demonstrated 0.4 and 0.3 complications per 10,000 exposure days, respectively, with no significant difference between groups (1.4 [95% confidence interval 0.2-10.0], P = .727). There was no demonstrated difference in forward flexion, abduction, or external ROM. The expedited group had less improvement in visual analog scale for pain scores that was not clinically significant and there were no differences in PROs of function. Conclusions: No statistically significant difference in the rate of re-rupture, surgical revision, loss of fixation, or Popeye deformity was noted between protocols after isolated BT. Furthermore, there were no clinically significant differences in ROM or PROs identified between protocols after isolated BT. This study suggests that patients who have undergone isolated BT may safely discontinue sling use within 2 weeks after surgery. Level of Evidence: Level III, retrospective comparative study.

Early Anterior Cruciate Ligament Treatment Might Be Crucial for Acute Combined Anterior Cruciate Ligament and Medial Collateral Ligament Injuries: A Systematic Review of the Various Treatment Strategies.

PURPOSE: To assess the outcomes of acute, combined, complete anterior cruciate ligament (ACL) and medial collateral ligament (MCL) injuries in the literature. METHODS: A literature search using PubMed, Embase, Scopus, and Cochrane Reviews was performed following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. The inclusion criteria were studies reporting outcomes of complete ACL-MCL injuries at a minimum of 12 months' follow-up. Data were presented as ranges. RESULTS: Twenty-seven studies with 821 patients were included (mean age, 29 years; 61% male patients; mean follow-up period, 27 months). There were 4 randomized trials, 10 Level III studies, and 13 Level IV studies. Nine different strategies were noted, of which nonoperative MCL treatment with acute ACL reconstruction and acute MCL repair with acute ACL reconstruction were most commonly performed. Nonoperative MCL-ACL treatment and acute MCL repair with nonoperative ACL treatment led to low rates of valgus stability at 30° of flexion (27%-68% and 36%-77%, respectively) compared with acute ACL reconstruction with either nonoperative MCL treatment (80%-100%), acute MCL repair (65%-100%), or acute MCL reconstruction (81%-100%). Lysholm scores were not different between the strategies. CONCLUSIONS: Outcomes in this systematic review suggest that ACL stabilization in the acute setting might result in the lowest rates of residual valgus laxity, whereas there is no clear difference between the different MCL treatments along with acute ACL reconstruction. Nonoperative MCL treatment with either nonoperative or delayed ACL reconstruction, as well as acute MCL repair with either nonoperative or delayed ACL reconstruction, leads to higher rates of valgus laxity. LEVEL OF EVIDENCE: Level IV, systematic review of Level I to IV studies.

Editorial Commentary: Meniscal Allograft Transplantation Is Effective for Adolescents With Meniscal Insufficiency, Although Outcomes May Decline Over Time.

Over the last several years, there has been a shift from arthroscopic partial meniscectomy to meniscal repair, especially in the younger patient. In case of a necessary partial meniscectomy, some patients have unremittent symptoms of pain and effusion corresponding to the postmeniscectomy syndrome. In these patients without large coronal malalignment, meniscal allograft transplantation is a valuable option to restore contact pressures, promote a chondroprotective microenvironment, and potentially delay secondary surgical interventions symptoms. In the adolescent population, meniscal allograft transplantation has been shown to effectively improve patient-reported outcomes with a low conversion to arthroplasty. However, these treatments are far from ideal, and prevention is certainly better than the cure: timely diagnosis of meniscus injuries, appropriate treatment with meniscus repair rather than partial meniscectomy, even in the complex tear patterns, and consideration of corrective osteotomy for milder cases of malalignment.

Predictive factors influencing internal rotation following reverse total shoulder arthroplasty.

BACKGROUND: Reverse total shoulder arthroplasty (RTSA) is increasingly used as a treatment modality for various pathologies. The purpose of this review is to identify preoperative risk factors associated with loss of internal rotation (IR) after RTSA. METHODS: A systematic review was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Ovid MEDLINE, Ovid Embase, and Scopus were queried. The inclusion criteria were as follows: articles in English language, minimum 1-year follow-up postoperatively, study published after 2012, a minimum of 10 patients in a series, RTSA surgery for any indication, and explicitly reported IR. The exclusion criteria were as follows: articles whose full text was unavailable or that were unable to be translated to English language, a follow-up of less than 1 year, case reports or series of less than 10 cases, review articles, studies in which tendon transfers were performed at the time of surgery, procedures that were not RTSA, and studies in which the range of motion in IR was not reported. RESULTS: The search yielded 3792 titles, and 1497 duplicate records were removed before screening. Ultimately, 16 studies met the inclusion criteria with a total of 5124 patients who underwent RTSA. Three studies found that poor preoperative functional IR served as a significant risk factor for poor postoperative IR. Eight studies addressed the impact of subscapularis, with 4 reporting no difference in IR based on subscapularis repair and 4 reporting significant improvements with subscapularis repair. Among studies with sufficient power, BMI was found to be inversely correlated with degree of IR after RTSA. Preoperative opioid use was found to negatively affect IR. Other studies showed that glenoid retroversion, component lateralization, and individualized component positioning affected postoperative IR. CONCLUSIONS: This study found that preoperative IR, individualized implant version, preoperative opioid use, increased body mass index and increased glenoid lateralization were all found to have a significant impact on IR after RTSA. Studies that analyzed the impact of subscapularis repair reported conflicting results.

Baseball Pitchers who Suffer Latissimus Dorsi and Teres Major Tendon Injuries Have a High Return to Play Rate After Either Operative or Nonoperative Treatment.

Purpose: To provide a concise overview of the prevalence, diagnostic workup, management options, surgical techniques, and reported outcomes in the treatment of latissimus dorsi (LD) and teres major (TM) injuries in professional baseball pitchers. Methods: A systematic review of studies reporting on professional baseball players who sustained LD or TM injuries was performed. Data were collected including patient presentation, injury management strategies, return-to-play (RTP) rates, time to RTP, patient-reported outcome measures, player performance after RTP, preinjury factors associated with injury, and complications. Results: Nine studies with 159 professional baseball players with a LD or TM injury were identified. All studies (2 retrospective cohort studies with high risk of bias and 7 case series) reported shoulder pain after pitching, and magnetic resonance imaging was performed in all cases to confirm diagnosis. Twenty-three patients underwent surgical treatment, whereas 136 patients underwent nonsurgical treatment. Overall RTP rates and performance between surgical and nonsurgical groups were similar (75% to 100% vs 75% to 93%), although the largest study reported improved performance with surgery. Two studies described a surgical technique with a posterior axillary approach and endosteal button fixation of the LD tendon. All studies reported a progressive strengthening and throwing program prior to returning to sport. Conclusion: Professional baseball players who suffer a LD or TM injury have predictable clinical presentations and imaging findings. There is a high RTP rate and performance with both surgical and nonsurgical management. The heterogeneity and low level of evidence of available literature precludes comparative conclusions between treatment approaches. Level of Evidence: IV systematic review of Level III and IV studies.

Knee Extensor Mechanism Complications After Autograft Harvest in ACL Reconstruction: A Systematic Review and Meta-analysis.

Background: Existing systematic reviews have sought to characterize the relative donor-site morbidity of bone-patellar tendon-bone (BTB) and quadriceps tendon (QT) grafts after anterior cruciate ligament reconstruction (ACLR). However, no studies have reported the pooled proportions of patellar fractures and donor tendon ruptures across the body of literature. Purpose: To estimate the proportion of patellar fractures, patellar tendon ruptures, and QT ruptures associated with BTB or QT autograft harvest during ACLR using published data. Study Design: Systematic review; Level of evidence, 4. Methods: A meta-analysis was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using 3 online databases (PubMed, Scopus, and Web of Science). A total of 800 manuscripts were included in the initial research of peer-reviewed articles in English that reported extensor mechanism complications associated with graft harvest in patients after ACLR. Pooled proportions of patellar fractures, patellar tendon ruptures, and QT ruptures were calculated for each graft type (BTB, QT) using a random-effects model for meta-analysis. Results: A total of 28 studies were analyzed. The pooled proportion of patellar fractures was 0.57% (95% CI, 0.34%-0.91%) for the BTB harvest and 2.03% (95% CI, 0.78%-3.89%) for the QT harvest. The proportion of patellar tendon ruptures was 0.22% (95% CI, 0.14%-0.33%) after the BTB harvest, and the proportion of QT ruptures was 0.52% (95% CI, 0.06%-1.91%) after the QT harvest. The majority of included studies (16/28 [57.1%]) had an evidence level of 4. Conclusion: Based on the current literature, the proportion of extensor mechanism complications after ACLR using either a BTB or a QT autograft is low, indicating that the extensor mechanism harvest remains a safe option. A higher proportion of patellar fractures was noted for QT grafts and a higher proportion of donor tendon ruptures was noted for QT grafts compared with BTB grafts.

In-Season Management of Shoulder Instability: How to Evaluate, Treat, and Safely Return to Sport.

PURPOSE OF REVIEW: Anterior glenohumeral instability is a common injury in contact and collision athletes, and in-season management remains a controversial topic. RECENT FINDINGS: Several recent studies have examined non-operative and operative management of in-season athletes after instability events. Non-operative treatment is associated with faster return to play and higher rates of recurrent instability. Dislocations and subluxations have similar rates of recurrent instability but non-operatively treated subluxations have a quicker return to play than dislocations. Operative treatment is often a season ending decision but is associated with high rates of return to sport and significantly lower rates of recurrent instability. Indications for in-season operative intervention may include critical glenoid bone loss (>15%), an off-track Hill-Sachs lesion, an acutely reparable bony Bankart lesion, high-risk soft tissue injures such as a humeral avulsion of the glenohumeral ligament or displaced anterior labral periosteal sleeve avulsion, recurrent instability, insufficient time remaining in season to rehabilitate from injury, and inability to successfully return to sport with rehabilitation. It is the role of the team physician to appropriately educate athletes on risks and benefits of operative and non-operative treatment strategies and guide athletes through the shared decision-making process that balances these risks against their long-term health and athletic career goals.

Optimizing Outcomes After Reverse Total Shoulder Arthroplasty: Rehabilitation, Expected Outcomes, and Maximizing Return to Activities.

PURPOSE OF REVIEW: Given the touted clinical and patient-reported outcomes of reverse shoulder arthroplasty (RTSA) in improving pain and restoring function, shoulder surgeons are rapidly expanding the indications and utilization of RTSA. Despite its increasing use, the ideal post-operative management ensuring the best patient outcomes is still debated. This review synthesizes the current literature regarding the impact of post-operative immobilization and rehabilitation on clinical outcomes following RTSA including return to sport. RECENT FINDINGS: Literature regarding the various facets of post-operative rehabilitation is heterogeneous in both methodology and quality. While most surgeons recommend 4-6 weeks of immobilization post-operatively, two recent prospective studies have shown that early motion following RTSA is both safe and effective with low complication rates and significant improvements in patient-reported outcome scores. Furthermore, no studies currently exist assessing the use of home-based therapy following RTSA. However, there is an ongoing prospective, randomized control trial assessing patient-reported and clinical outcomes which will help shed light on the clinical and economic value of home therapy. Finally, surgeons have varying opinions regarding return to higher level activities following RTSA. Despite no clear consensus, there is growing evidence that elderly patients are able to return to sport (e.g., golf, tennis) safely, though caution must be taken with younger or more high-functioning patients. While post-operative rehabilitation is believed to be essential to maximize outcomes following RTSA, there is a paucity of high-quality evidence that guides current rehabilitation protocols. There is no consensus regarding type of immobilization, timing of rehabilitation, or need for formal therapist-directed rehabilitation versus physician-guided home exercise. Additionally, surgeons have varied opinions regarding return to higher level activities and sports following RTSA. There is burgeoning evidence that elderly patients can return to sport safely, though caution must be taken with younger patients. Further research is needed to clarify the optimal rehabilitation protocols and return to sport guidelines.

Suture Anchor-Based Quadriceps Tendon Repair May Result in Improved Patient-Reported Outcomes but Similar Failure Rates Compared to the Transosseous Tunnel Technique.

PURPOSE: The purpose of this study was to compare failure rates and patient-reported outcomes between transosseus (TO) suture and suture anchor (SA) quadriceps tendon repairs. METHODS: Following institutional review board approval, patients who underwent primary repair for quadriceps tendon rupture with TO or SA techniques between January 2009 and August 2018 were identified from an institutional database and retrospectively reviewed. Patients were contacted for satisfaction (1-10 scale), current function (0-100 scale), failure (retear), and revision surgeries; International Knee Documentation Committee (IKDC) score and Knee Injury and Osteoarthritis Outcomes Score (KOOS) were also collected to achieve a minimum of 2-year follow-up. RESULTS: Sixty-four patients (34 SA, 30 TO) were available by phone or e-mail at a mean of 4.81 ± 2.60 years postoperatively. There were 10 failures, for an overall failure rate of 15.6%. Failure incidence did not significantly differ between treatment groups (P = .83). Twenty-seven patients (47% of nonfailed patients) had completed patient-reported outcomes. The SA group reported higher subjective function (SA: 90 [85-100] vs TO: 85 [60-93], 95% CI of difference: -19.9 to -2.1 × 10-5, P = .042), final IKDC (79.6 [50.0-93.6] vs 62.1 [44.3-65.5], 95% CI of difference: -33.0 to -0.48, P = .048), KOOS Pain (97.2 [84.7-97.2] vs 73.6 [50.7-88.2], 95% CI of difference: -36.1 to -3.6 × 10-5, P = .037), Quality of Life (81.3 [56.3-93.8] vs 50.0 [23.4-56.3], 95% CI of difference: -50.0 to -6.2, P = .026), and Sport (75.0 [52.5-90.0] vs 47.5 [31.3-67.5], 95% CI of the difference: -45.0 to -4.1 × 10-5, P = .048). CONCLUSIONS: There is no significant difference in failure rate between transosseus and suture anchor repairs for quadriceps tendon ruptures (P = .83). Most failures occur secondary to a traumatic reinjury within the first year postoperatively. Despite the lack of difference in failure rates, at final follow-up, patients who undergo suture anchor repair may report significantly greater subjective function and final IKDC, KOOS Pain, Quality of Life, and Sport scores. LEVEL OF EVIDENCE: III, retrospective cohort study.

Factors That Affect the Magnitude of Tibial Tubercle-Trochlear Groove Distance in Patients With Patellar Instability.

BACKGROUND: Tibial tubercle-trochlear groove (TT-TG) distance is a risk factor for recurrent patellar dislocation and is often included in algorithmic treatment of instability. The underlying factors that determine TT-TG have yet to be clearly described in orthopaedic literature. PURPOSE/HYPOTHESIS: The purpose of our study was to determine the underlying anatomic factors contributing to TT-TG distance. We hypothesized that degree of tubercle lateralization and knee rotation angle may substantially predict TT-TG. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: All patients evaluated for patellar instability at a single institution between 2013 and 2021 were included. Patients with previous knee osseous procedures were excluded. TT-TG and its anatomic relationship to patellofemoral measures, including dysplasia, femoral anteversion, tibial tubercle lateralization, knee rotation angle, and tibial torsion, were measured and subsequently quantified using univariate and multivariable analysis. RESULTS: In total, 76 patients met the inclusion criteria (46 female, 30 male; mean ± SD age, 20.6 ± 8.6 years) and were evaluated. Mean TT-TG was 16.2 ± 5.4 mm. On univariate analysis, increasing knee rotation angle (P < .01), tibial tubercle lateralization (P = .02), and tibial torsion (P = .01) were associated with increased TT-TG. In dysplastic cases, patients without medial hypoplasia (Dejour A or B) demonstrated significantly increased TT-TG (18.1 ± 5.4 mm) as compared with those with medial hypoplasia (Dejour C or D; TT-TG: 14.9 ± 5.2 mm; P = .02). Multivariable analysis revealed that increased knee rotation angle (+0.43-mm TT-TG per degree; P < .01) and tubercle lateralization (+0.19-mm TT-TG per percentage lateralization; P < .01) were statistically significant determinants of increased TT-TG distance. Upon accounting for these factors, tibial torsion, trochlear width, and medial hypoplasia were no longer significant components in predicting TT-TG (P≥ .54). Of note, all patients with TT-TG ≥20 mm had tibial tubercle lateralization ≥68%, a knee rotation angle ≥5.8°, or both factors concurrently. CONCLUSION: TT-TG distance is most influenced by knee rotation angle and tibial tubercle lateralization.

Landmarks Used in Medial Patellofemoral Ligament Reconstruction Have Variable Topography.

Purpose: To describe the morphology of the adductor tubercle (AT), medial epicondyle (ME), and gastrocnemius tubercle (GT); to quantify their relationships to the medial patellofemoral ligament (MPFL) footprint location; and to classify the reliability of each landmark based on measurement variability. Methods: Eight cadaveric specimens were dissected to expose the following landmarks on the femur: MPFL footprint, AT, ME, and GT. Using the MicroScribe 3D digitizer, each landmark was projected into a 3-dimensional coordinate system and reconstructed into a complex, closed polygon. For each specimen tubercle, the base surface area, volume, height, base:height ratio, sulcus point, and distance from the MPFL footprint center were calculated. Levene's test was performed to evaluate differences in variance of the morphologic parameters between the three osseous structures. Results: The ME had significantly greater variance in volume than the GT (P = .032), and the AT (17.5 ± 3.9) and GT (19.5 ± 3.6) were significantly less variable in base:height ratio than the ME (95.3 ± 19.2; P < .001). The GT was the closest to the MPFL footprint center (7.1 ± 3.1 mm) compared with the AT (13.4 ± 3.6 mm, P = .002) and ME (13.2 ± 2.7 mm, P = .003). However, the tubercles were equally variable in terms of distance to the MPFL footprint center (P = .86). Lastly, the sulcus point was estimated to be on average 1.9 ± 2.9 mm distal and 2.0 ± 2.0 mm posterior to the MPFL center point. Conclusions: The 3 major osseous landmarks of the medial femur have significantly different variances in volume and base:height ratio. Specifically, the variability and elongated morphology of the ME differentiated this landmark from the AT and GT, which demonstrated the most consistent morphology. Clinical Relevance: The results of this study may be useful to accurately locate landmarks for femoral tunnel placement and determine the isometric MPFL point during reconstruction.

After Chondroplasty, Patient Election to Proceed With Cartilage Transplantation Is Closely and Additively Associated With Preoperative AMADEUS (Area Measurement And DEpth Underlying Structure) Grade, Condylar Involvement, Knee Injury and Osteoarthritis Outcome Score Pain Score, and Veterans Rand 12-Item Health Survey Physical Score.

Purpose: To identify risk factors for patient election to proceed with cartilage transplant after staging chondroplasty. Methods: This study retrospective reviewed patients prospectively enrolled at the time of staging chondroplasty, with early election defined as patient decision to proceed to cartilage transplantation within 6 months of chondroplasty. Cox proportional hazards analysis was used to determine univariate predictors of conversion, and a predictive calculator, the Cartilage Early Return for Transplant score, was formulated using stepwise regression employing the Akaike information criterion. Receiver operator curves and the area under the curve were used to evaluate the predictive ability of the final model on the studied patient population. Results: Sixty-five knees (63 patients) were evaluated, with an overall transplant election rate of 27.7% within 6 months after chondroplasty. Based on multivariate results, the final Akaike information criterion-driven Cartilage Early Return for Transplant score employed preoperative Knee Injury and Osteoarthritis Outcome Score Pain Score, Veterans Rand 12-Item Health Survey Physical Score, condylar involvement, and AMADEUS (Area Measurement And DEpth Underlying Structure) score to generate a 0- to 7-point risk-stratification system with a 3% early election to proceed to transplant risk in the 0- to 2-point score group, 33% risk in the 3- to 4-point group, and 79% risk in the 5+-point group (P < .01) and an overall AUC of 0.906 (P < .01). Conclusions: Risk of early patient election to pursue cartilage transplantation after chondroplasty is closely and additively associated with preoperative AMADEUS grade, condylar involvement, Knee Injury and Osteoarthritis Outcome Score Pain Score, and Veterans Rand 12-Item Health Survey Physical Score. Clinical Relevance: Understanding risk factors for conversion to cartilage transplantation may improve preoperative planning and counseling prior to staging chondroplasty.

Open Access Articles Garner Increased Social Media Attention and Citation Rates Compared With Subscription Access Research Articles: An Altmetrics-Based Analysis.

BACKGROUND: To better understand the research impact on social media, alternative web-based metrics (Altmetrics) were developed. Open access (OA) publishing, which allows for widespread distribution of scientific content, has become increasingly common in the medical literature. However, the relationship between OA publishing and social media impact remains unclear. PURPOSE: To compare social media attention and citation rates between OA and subscription access (SA) research articles within the orthopaedic and sports medicine literature. STUDY DESIGN: Cross-sectional study. METHODS: Articles published as either OA or SA in 5 high-impact hybrid orthopaedic journals between January 2019 and December 2019 were analyzed. The primary outcome was the Altmetric Attention Score (AAS), a validated measure of social media attention. Secondary outcomes included citation rates, article characteristics, and the number of shares on social media. Independent t tests and chi-square analyses were used to compare outcomes between OA and SA articles. A multivariable linear regression analysis was performed to determine the association between article type and AAS while controlling for bibliometric characteristics. RESULTS: A total of 2143 articles (246 OA articles, 11.5%; 1897 SA articles, 88.5%) were included. The mean AAS among all OA articles was 62.4 ± 184.6 (range, 0-2032), whereas the mean AAS among all SA articles was 18.4 ± 109.8 (range, 0-3425), representing a statistically significant difference (P < .001). The mean citation rate among OA articles was significantly higher (17.0 ± 22.5; range, 0-139) than that of SA articles (8.6 ± 13.4; range, 0-169) (P < .001). Multivariable linear regression analysis demonstrated that OA status (ß = 15.15; P = .044), number of institutions (ß = 2.13; P = .023), studies classified as epidemiological investigations (ß = 107.40; P < .001), and disclosure of a conflict of interest (ß = -11.18; P = .032) were significantly associated with a higher AAS. CONCLUSION: OA articles resulted in significantly greater AAS and citations in comparison with SA articles. Articles published through the OA option in hybrid journals as well as those with a higher number of institutions, those that disclosed a conflict of interest, and those classified as epidemiological investigations were positively associated with greater AAS in addition to a greater number of citations. The potential for more extensive research dissemination inherent in the OA option may therefore translate into greater reach and social media attention.

Anatomic Factors Associated With Osteochondral Allograft Matching for Trochlear Cartilage Defects: A Computer-Simulation Study.

BACKGROUND: Articular step-off between the donor and recipient in osteochondral allograft transplant has been shown to alter contact pressures. Currently, commercial allograft donor selection is primarily based on simple anatomic parameters such as trochlear length, trochlear width, and tibial width. PURPOSE: To identify anatomic factors associated with optimal graft matching by using a 3-dimensional simulation model. STUDY DESIGN: Descriptive laboratory study. METHODS: Computed tomography images of 10 cadaveric trochlear specimens were obtained to generate 3-dimensional models. Circular defects were created virtually in the recipient trochleae at both superolateral (18.0 mm and 22.5 mm) and central (18.0 mm, 22.5 mm, 30.0 mm) locations. The donor models were virtually projected onto the defect models, and the most optimal graft from any location of the donor specimen was selected. Cartilage incongruity, subchondral bone incongruity, and peripheral articular step-off were calculated for each graft-defect combination. Linear regression models were generated to identify predictors of incongruity, step-off, and the effect of sulcus and sagittal angle mismatch. Akaike information criterion-driven stepwise regression models were generated to identify multivariate predictors. RESULTS: Ideal matches were found for 100% of superolateral defects but for only 15% to 53% of central defects, depending on the defect size. Multivariate stepwise regression identified laterality (odds ratio [OR], 0.54; P = .081), sulcus angle (OR, 0.79; P < .001), sagittal angle (OR, 0.83; P = .001), lateral radius of curvature (OR, 0.81; P < .001), and medial facet width (OR, 0.86; P = .155) as predictors of ideal graft matching. In central defects with proud grafts, increasing sagittal angle and sulcus angle resulted in significantly (P < .001) increased articular step-off, which became sequentially larger with defect size. CONCLUSION: Sagittal angle, sulcus angle, and lateral radius of curvature mismatch should be used to determine optimal donor allografts, especially in the setting of large (30-mm) central defects. Increasing sulcus angle and sagittal angle mismatch correlated with increasing step-off in proud grafts, whereas sulcus angle and sagittal angle inconsistently correlated with step-off in recessed grafts. CLINICAL RELEVANCE: Additional descriptive trochlear measurements should be incorporated into the algorithm for donor selection. These findings can be used to identify acceptable mismatch parameters.