Medial Collateral Ligament Reconstruction of the Knee: The Modified Marx Technique With Adjustable-Loop Femoral Fixation and Posteromedial Corner Plication.

The medial collateral ligament serves as the primary stabilizer to valgus stress on the medial side of the knee and is the most commonly injured ligament in the knee. Medial collateral ligament reconstruction can provide improved stability and clinical outcomes for patients. Advancements in techniques, including the use of an adjustable-length-loop suspensory fixation device through a longitudinal incision, have been introduced in recent years. The purpose of this Technical Note and video is to provide a minimally invasive method for medial collateral ligament reconstruction with adjustable-loop femoral fixation and posteromedial corner plication.

Minimally Invasive Quadriceps Tendon Harvest for Anterior Cruciate Ligament Reconstruction Using the Quadriceps Tendon Harvest Guide (QUADTRAC) System and Repair Augmentation With a Bioinductive Implant.

Quadriceps tendon autografts are an increasingly popular choice for anterior cruciate ligament (ACL) reconstruction, with decreased donor-site morbidity alongside good patient outcomes. Although harvesting of the tendon can be done in a minimally invasive fashion, this introduces some difficulty with visualization and consistency of graft sizing. The purpose of this Technical Note and video is to provide a method of quadriceps tendon autograft harvesting using the Quadriceps Tendon Harvest Guide System (QUADTRAC) in a single-bundle ACL reconstruction.

Primary Hip Arthroscopy in Patients With Acetabular Dysplasia: A Systematic Review of Published Clinical Outcomes at Minimum 5-Year Follow-up.

BACKGROUND: Hip arthroscopy in patients with borderline hip dysplasia has satisfactory outcomes at short-term follow-up; however, the data on midterm outcomes are inconsistent, and failure rates are high in some studies, limiting understanding of the role and utility of hip arthroscopy in this patient cohort. PURPOSE: To provide an up-to-date, evidence-based review of the clinical outcomes of primary hip arthroscopy in patients with frank or borderline hip dysplasia at ≥5-year follow-up and report the failure rate and progression to total hip arthroplasty in this cohort. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: A comprehensive literature search was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies were included if they evaluated outcomes of primary hip arthroscopy in patients with lateral center-edge angle (LCEA) <25° at ≥5-year follow-up. Risk of bias assessment was performed using the methodological index for non-randomized studies scoring system. Level of evidence was determined using criteria from the Oxford Centre for Evidence-Based Medicine. RESULTS: Nine studies were included in this review. Patients with LCEA <25° demonstrated satisfactory clinical outcomes, high patient satisfaction, and significant postoperative improvements in patient-reported outcomes (PROs) at follow-up ranging from a ≥5 to 10 years. Studies comparing patients with dysplasia to those without did not demonstrate significant differences in preoperative, postoperative, or delta PROs or in failure, reoperation, or revision rates. There was no overall significant correlation between outcomes and LCEA stratification. CONCLUSION: Hip arthroscopy in carefully selected patients with LCEA <25° can be successful at mid- to long-term follow-up and may provide clinical outcomes and failure rates comparable with patients with normal LCEA, understanding that this is a singular, 2-dimensional radiographic measure that does not differentiate instability from impingement or combinations thereof, warranting future studies delineating these differences. These findings suggest that hip dysplasia may not be an absolute contraindication for isolated hip arthroscopy and may serve as a viable intervention with consideration of staged future periacetabular osteotomy (PAO). Importantly, this review does not suggest that hip arthroscopy alters the natural history of dysplasia; therefore, patients with dysplasia should be counseled on the potential utility of PAO by appropriate hip preservation specialists.

Long-term Outcomes After Surgical Reconstruction of Multiligamentous Knee Injuries: Results at Minimum 10-Year Follow-up.

Background: Multiligamentous knee injuries (MLKIs) are devastating injuries with concomitant injuries that complicate treatment and recovery. Short-term studies have shown satisfactory patient outcomes after surgical treatment; however, evaluations of long-term outcomes remain scarce. Purpose: To evaluate long-term outcomes after surgically reconstructed MLKIs and further investigate the relationship between patient age on clinical outcomes. Study Design: Case series; Level of evidence, 4. Methods: A total of 55 knees (age, 36 ± 11 years; 24% female subjects) who underwent surgical reconstruction for MLKI between 1992 and 2013 met the study inclusion criteria and were evaluated with postoperative patient-reported outcomes (PROs) including International Knee Documentation Committee (IKDC) score, Lysholm score, visual analog scale (VAS) for pain, Forgotten Joint Score, subjective improvement ratings and surgery satisfaction, and Tegner activity scores. PRO scores, revision, and conversion to arthroplasty were analyzed using descriptive statistics, linear regression, Wilcoxon rank-sum, and Fisher exact tests. Results: At final follow-up (mean, 15 ± 5 years; range, 10-31 years), 67% of the cohort reported subjective improvement in their knee, and 82% reported satisfaction with their surgery. Compared with preoperative scores, there were significant improvements in postoperative VAS pain at rest in the full cohort, age ≤30-year cohort, and age >30-year cohort (4 ± 1 vs 2 ± 2; 4 ± 1 vs 2 ± 3; 4 ± 1 vs 1 ± 2, respectively; P≤ .029 for all) but significant reductions in Tegner scores (6 ± 3 vs 4 ± 2; 7 ± 2 vs 5 ± 2; 5 ± 2 vs 3 ± 1; P≤ .003 for all). Younger patients had higher postoperative Tegner scores than older patients (5 ± 2 vs 3 ± 1, respectively; P = .003), but no other differences in PROs were observed based on age. At a mean 15-year follow-up, 3.6% of the cohort underwent revision ligament surgery and 10.9% required arthroplasty. Conclusion: The majority of the cohort reported modest subjective improvement and were satisfied with their surgery. Gradual but expected age-related decreases in Tegner scores were observed, and some patients demonstrated continued symptomatic and functional limitations, but mean PRO scores remained satisfactory. Revision surgery and conversion to arthroplasty were not commonly required.

Interval Throwing Programs for Baseball Players: Methodological Assessment of the Quality and Construct of Publicly Available Programs.

CONTEXT: The quality and interprogram variability of publicly available throwing programs have not been assessed. OBJECTIVE: To (1) identify publicly available interval throwing programs, (2) describe their components and structure, and (3) evaluate their quality, variability, and completeness. DATA SOURCES: Google, Bing, Yahoo; keyword: "interval throwing program." STUDY SELECTION: Baseball-specific publicly available programs. STUDY DESIGN: Systematic review. LEVEL OF EVIDENCE: Level 4. DATA EXTRACTION: Independent evaluation by 2 authors using a novel 21-item Quality Assessment Rubric (QAR). RESULTS: Of the 99 included programs, 54% were designed for return from injury/surgery; 42% explicitly stated no expected timeline for completion, and approximately 40% did not provide criteria to initiate the program. Program construction was highly variable. There were broad-ranging shortest (mean: 40±8 ft, range: 20-45 ft) and longest (mean: 150±33 ft, range: 90-250 ft) long toss distances, and variable maximum numbers of mound pitches thrown before returning to game play (range: 40-120, mean: 85). Only 63% of programs provided guidelines for handling setbacks, and standardized warm-ups, arm care, and concomitant training were absent in 32%, 63%, and 47% of programs, respectively. Mean QAR completion rate and QAR item response rate were low (62 ± 4% [range, 24-91%], 62 ± 24% [range, 7-99%], respectively). Finally, only 20 (20%) programs provided at least 1 peer-reviewed reference, most of which were published >10 years ago. CONCLUSION: Publicly available interval throwing programs are readily available but demonstrate significant interprogram heterogeneity across multiple areas including target audience, program construction, progression, and execution. The quality and consistency of publicly available interval throwing programs is poor at this time, which may limit their utility and effectiveness for baseball players attempting to return to competition. This work identifies a multitude of deficiencies in currently available throwing programs that should be targets of future improvement efforts.

Long-term Outcomes of Primary Hip Arthroscopy: Multicenter Analysis at Minimum 10-Year Follow-up With Attention to Labral and Capsular Management.

BACKGROUND: Hip arthroscopy is rapidly advancing, with positive published outcomes at short- and midterm follow-up; however, available long-term data remain limited. PURPOSE: To evaluate outcomes of primary hip arthroscopy at a minimum 10-year follow-up at 2 academic centers by describing patient-reported outcomes and determining reoperation and total hip arthroplasty (THA) rates. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Patients with primary hip arthroscopy performed between January 1988 and April 2013 at 2 academic centers were evaluated for postoperative patient-reported outcomes-including the visual analog scale, Tegner Activity Scale score, Hip Outcome Score Activities of Daily Living and Sport Specific subscales, modified Harris Hip Score, Nonarthritic Hip Score, 12-item International Hip Outcome Tool, surgery satisfaction, and reoperations. RESULTS: A total of 294 patients undergoing primary hip arthroscopy (age, 40 ± 14 years; 66% women; body mass index, 27 ± 6) were followed for 12 ± 3 years (range, 10-24 years) postoperatively. Labral debridement and repair were performed in 41% and 59% of patients, respectively. Of all patients who underwent interportal capsulotomy, 2% were extended to a T-capsulotomy, and 11% underwent capsular repair. At final follow-up, patients reported a mean visual analog scale at rest of 2 ± 2 and with use of 3 ± 3, a 12-item International Hip Outcome Tool of 68 ± 27, a Nonarthritic Hip Score of 81 ± 18, a modified Harris Hip Score of 79 ± 17, and a Hip Outcome Score Activities of Daily Living of 82 ± 19 and Sport Specific subscale of 74 ± 25. The mean surgical satisfaction was 8.4 ± 2.4 on a 10-point scale, with 10 representing the highest level of satisfaction. In total, 96 hips (33%) underwent reoperation-including 65 hips (22%) converting to THA. THA risk factors included older age, higher body mass index, lower lateral center-edge angle, larger alpha angle, higher preoperative Tönnis grade, as well as labral debridement and capsular nonrepair (P≤ .039). Patients undergoing combined labral and capsular repair demonstrated a THA conversion rate of 3% compared with 31% for patients undergoing combined labral debridement and capsular nonrepair (P = .006). Labral repair trended toward increased 10-year THA-free survival (84% vs 77%; P = .085), while capsular repair demonstrated significantly increased 10-year THA-free survival (97% vs 79%; P = .033). CONCLUSION: At a minimum 10-year follow-up, patients undergoing primary hip arthroscopy demonstrated high satisfaction and acceptable outcome scores. In total, 33% of patients underwent reoperation-including 22% who underwent THA. Conversion to THA was associated with patient factors including older age, higher Tönnis grade, and potentially modifiable surgical factors such as labral debridement and capsular nonrepair.

Minimally Invasive Quadriceps Tendon Anterior Cruciate Ligament Reconstruction Using the Quadriceps Tendon Harvest Guide System.

Anterior cruciate ligament (ACL) reconstruction using the quadriceps tendon (QT) autograft is an increasingly utilized technique that confers less donor site morbidity and comparable outcomes to other historically used graft options. The graft harvest and implantation process present vast variability-particularly regarding the achievement of adequate graft site visualization, consistently attaining a uniform and appropriately sized graft, and subsequent reconstruction of the ACL with the all-soft tissue graft. The purpose of this Technical Note and video is to describe and demonstrate minimally invasive quadriceps tendon autograft harvesting using the Quadriceps Tendon Harvest Guide System (QUADTRAC), and its subsequent implantation within a single-bundle ACL reconstruction with suspensory fixation.

Early Surgery for Partial Tears of the Ulnar Collateral Ligament May Be More Cost-Effective and Result in Longer Playing Careers Than Nonoperative Management for High-Level Baseball Pitchers: A Decision-Analytic Markov Model-Based Analysis.

BACKGROUND: Nonoperative management versus early reconstruction for partial tears of the medial ulnar collateral ligament (MUCL) remains controversial, with the most common treatment options for partial tears consisting of rest, rehabilitation, platelet-rich plasma (PRP), and/or surgical intervention. However, whether the improved outcomes reported for treatments such as MUCL reconstruction (UCLR) or nonoperative management with a series of PRP injections justifies their increased upfront costs remains unknown. PURPOSE: To compare the cost-effectiveness of an initial trial of physical therapy alone, an initial trial of physical therapy plus a series of PRP injections, and early UCLR to determine the preferred cost-effective treatment strategy for young, high-level baseball pitchers with partial tears of the MUCL and with aspirations to continue play at the next level (ie, collegiate and/or professional). STUDY DESIGN: Economic and decision analysis; Level of evidence, 2. METHODS: A Markov chain Monte Carlo probabilistic model was developed to evaluate the outcomes and costs of 1000 young, high-level, simulated pitchers undergoing nonoperative management with and without PRP versus early UCLR for partial MUCL tears. Utility values, return to play rates, and transition probabilities were derived from the published literature. Costs were determined based on the typical patient undergoing each treatment strategy at the authors' institution. Outcome measures included costs, acquired playing years (PYs), and the incremental cost-effectiveness ratio (ICER). RESULTS: The mean total costs resulting from nonoperative management without PRP, nonoperative management with PRP, and early UCLR were $22,520, $24,800, and $43,992, respectively. On average, early UCLR produced an additional 4.0 PYs over the 10-year time horizon relative to nonoperative management, resulting in an ICER of $5395/PY, which falls well below the $50,000 willingness-to-pay threshold. Overall, early UCLR was determined to be the preferred cost-effective strategy in 77.5% of pitchers included in the microsimulation model, with nonoperative management with PRP determined to be the preferred strategy in 15% of pitchers and nonoperative management alone in 7.5% of pitchers. CONCLUSION: Despite increased upfront costs, UCLR is a more cost-effective treatment option for partial tears of the MUCL than an initial trial of nonoperative management for most high-level baseball pitchers.