Comparable clinical outcomes using knotless and knot-tying anchors for arthroscopic capsulolabral repair in recurrent anterior glenohumeral instability at mean 5-year follow-up.

PURPOSE: To compare rates of recurrent instability, revision surgery and functional outcomes following arthroscopic anterior capsulolabral repair for recurrent anterior instability using knot-tying versus knotless suture anchor techniques. METHODS:  Patients who had undergone arthroscopic anterior labrum and capsular repair for recurrent anterior glenohumeral instability using knotless anchors were identified. Those with minimum 2-year follow-up were matched (1:2) to knot-tying anchor repair patients. Rates of failure and recurrent instability were compared, as well as Visual Analog Scale (VAS), Single Assessment Numeric Evaluation (SANE), Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), University of California Los Angeles (UCLA) and Rowe scores. RESULTS: One hundred and two patients (89 males, 13 females) with a mean age of 24.3 ± 9.6 were included. Repair was performed with knotless anchors in 34 and knot-tying anchors in 68 shoulders. At mean follow-up of 4.8 ± 2.5 years, re-dislocation rates between groups were not significantly different (knotless anchor: 9% versus knot-tying group: 15%, n.s.), but the knot-tying group showed a higher re-subluxation rate (p = 0.039). 12 (18%) revisions were performed in the knot-tying group at a mean 2.9 years after surgery and 1 (3%) revision in the knotless anchors group at 1.4 years (n.s.). There was no difference in mean VAS with use (1.3 ± 1.9 versus 0.8 ± 1.5, n.s.), SANE scores (91.8 ± 12.7 versus 92.0 ± 11.0, n.s.), QuickDASH scores (4.1 ± 5.5 versus 3.0 ± 6.5, n.s.), UCLA Shoulder Score (32.5 ± 3.6 versus 33.2 ± 3.1, n.s.), or Rowe scores (90.5 ± 18.5 versus 92.2 ± 16.6, n.s.) between knotless and knot-tying groups, respectively. VAS at rest was higher in the knotless group (0.7 ± 1.5 vs 0.1 ± 0.4, p = 0.021). CONCLUSIONS: Knotless anchors demonstrated similar rates of re-dislocation and revision surgery, and lower rates of recurrent subluxation, compared to knot-tying anchors. Patients achieved good-to-excellent functional outcomes. This supports the efficacy of knotless anchors as an alternative to knot-tying anchors for arthroscopic anterior labral repair of recurrent anterior shoulder dislocation. LEVEL OF EVIDENCE: III.

Smoking, unemployment, female sex, obesity, and medication use yield worse outcomes in patellofemoral arthroplasty.

PURPOSE: The purpose of this study was to identify effects of psychosocial and demographic factors on patellofemoral arthroplasty (PFA) outcomes. METHODS: Patients who underwent PFA by a single surgeon between 2002 and 2013 (min. 2 year follow-up) were included. Knee Society scores (KSS), UCLA, and Tegner Scores were prospectively collected in a designated arthroplasty registry. Patient records were retrospectively reviewed and univariate and multivariate statistical analyses were performed to assess the effect of psychosocial factors and demographic variables including patient sex, BMI, smoking and medication use, psychiatric history, and employment status on improvement between pre- and post-operative scores. RESULTS: Seventy-four knees in 55 patients (88% female) with a mean age of 51.8 (SD 8.8) and mean follow-up of 46.5 (SD 26.9) months were included. Patients showed significant improvement in all functional outcomes (p < 0.001). Mean improvement in KSS-F scores and median improvement in Tegner scores was greater in males compared to females (37.8 vs 16.1, p = 0.007; 3.0 vs 2.0, p = 0.07, respectively). Smokers showed less improvement in KSS-P compared to non-smokers (17.2 vs 30.0, p = 0.028). Retired or employed patients had a greater mean improvement in KSS-F and median improvement in Tegner Scores compared to those were unemployed or on work disability (p = 0.022, p = 0.01). Patients who reported using opioids and/or anti-depressants pre-operatively showed less improvement in UCLA scores (p = 0.006). Obese patients showed less improvement in both KSS-F and Tegner score compared to non-obese patients (p = 0.009, p = 0.004). CONCLUSION: Psychosocial factors influence the degree of improvement following PFA. Although patients showed overall improvement compared to their baseline scores, obese patients, smokers, unemployed/work disabled, and pre-operative use of opioids and/or anti-depressants were risk factors for decreased improvement… The consideration of psychosocial variables are clinically important when assessing a patient's candidacy for PFA and improve pre-operative patient selection and counselling. LEVEL OF EVIDENCE: Level IV.

Increasing Numbers of Shoulder Corticosteroid Injections Within a Year Preoperatively May Be Associated With a Higher Rate of Subsequent Revision Rotator Cuff Surgery.

PURPOSE: To identify any dose-dependent association between the use of subacromial corticosteroid injections within a year before rotator cuff repair (RCR) and subsequent need for revision rotator cuff surgery. METHODS: Two large administrative databases were queried for patients undergoing arthroscopic RCR. A minimum of 1 year of preoperative database exposure and 2 years of postoperative database follow-up were required for inclusion. Patients were stratified into groups that received 0 (control), 1, 2, or 3 or more ipsilateral corticosteroid shoulder injections within the year prior to RCR. The outcome of interest was ipsilateral revision arthroscopic or open RCR or arthroscopic debridement for a diagnosis of rotator cuff tear within 2 years of the index surgery. Revision rates were compared between groups using a multivariate logistic regression analysis controlling for demographic and comorbidity confounders. RESULTS: A total of 110,567 patients from the Medicare database and 12,892 patients from the private insurance database were included. There was no association between a single injection within the year prior to RCR and revision surgery in either cohort. The use of 2 or more injections was associated with a significant increase in the risk of requiring revision surgery in both the Medicare (odds ratio [OR], 2.76-3.26; P < .0001) and private insurance (OR, 2.53-2.87; P < .0001) populations. CONCLUSIONS: A single shoulder injection within a year prior to arthroscopic RCR was not associated with any increased risk of revision surgery; however, the administration of 2 or more injections was associated with a substantially increased risk of subsequent revision rotator cuff surgery (OR, 2.53-3.26). Although causality cannot be established on the basis of this database review, caution is recommended when considering more than 1 shoulder corticosteroid injection in patients with potentially repairable rotator cuff tears. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Systematic Review of Medial Patellofemoral Ligament Reconstruction Techniques: Comparison of Patellar Bone Socket and Cortical Surface Fixation Techniques.

PURPOSE: To compare patellar bone socket and cortical surface fixation techniques for isolated medial patellofemoral ligament (MPFL) reconstruction and determine whether there was a difference in (1) complication rates, including fracture of the patella; (2) redislocation rates; or (3) patient-reported outcomes. METHODS: A literature search was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We included patients who underwent isolated MPFL reconstruction for recurrent patellar instability. Patients with confirmed concomitant or prior ipsilateral knee procedures, multiligament injury, or less than 3 months of follow-up were excluded. Risk-of-bias assessment was performed using the Methodological Index for Non-randomized Studies (MINORS) system. Studies were classified by surgical technique (patellar bone socket group [group S] vs cortical fixation group [group F]), and complications, redislocations, and patient-reported outcomes were collected. RESULTS: A total of 29 studies yielded 981 patients with MPFL reconstruction for inclusion. Of the patients, 620 underwent a patellar bone socket technique and 361 underwent a cortical fixation technique. Patients ranged in age from 11 to 68 years. Patellar fracture rates ranged from 0% to 17% in group S and were 0% in all group F studies. Mean Kujala scores ranged from 83.5 to 93.6 in group S and from 84.4 to 94.5 in group F. Mean Lysholm scores ranged from 84.6 to 91.7 in group S and from 83.5 to 95 in group F. Redislocation rates ranged from 0% to 21% in group S and from 0% to 13% in group F. Although heterogeneous in nature, complication rates ranged from 0% to 28% in group S and from 0% to 4% in group F. CONCLUSIONS: MPFL reconstruction techniques with patellar bone sockets showed a larger range of complication rates than cortical fixation techniques, although overall, complications remained uncommon. Clinically, the bone socket group had comparable postoperative redislocation rates and patient outcomes to the group treated with cortical fixation techniques. LEVEL OF EVIDENCE: Level IV, systematic review of Level I through IV studies.

Incidence of posterior shoulder instability and trends in surgical reconstruction: a 22-year population-based study.

BACKGROUND: The incidence of posterior shoulder instability (PSI) in the general population is not well defined. This study aimed to define the population-based incidence of PSI and describe trends in incidence and surgery rates. METHODS: The study population included 143 patients (16 females, 127 males) diagnosed with new-onset PSI between January 1, 1994, and December 31, 2015. Medical records were reviewed to extract patient data. Age- and sex-specific incidence rates were calculated and adjusted to the 2010 United States population. Poisson regression was performed to examine trends by timeline, sex, and age. RESULTS: Age- and sex- adjusted annual incidence of PSI was 4.64 per 100,000 person-years, and posterior dislocation was 1.30 per 100,000 person-years. Peak PSI incidence for males and females was at 14 to 19 years (31.82 and 5.23 per 100,000 person-years). PSI incidence was higher in males than females (8.86 vs. 1.07 per 100,000 person-years, P < .001). The 5-year cumulative risk of surgery for patients with PSI was 53.1% between 1996 and 2002, 59.9% between 2003 and 2008, and 87.5% between 2009 and 2015. Patients with PSI between 2009 and 2015 had a significantly increased rate of surgery (hazard ratio, 2.2; 95% confidence interval, 1.4-3.6; P = .001) compared with those between 1996 and 2002. CONCLUSION: The age- and sex- adjusted incidence of PSI in the general population was 4.64 per 100,000 person-years. There is a significantly greater incidence of PSI in males than females, with both sexes peaking at 14 to 19 years and incidence rates remaining elevated throughout the third and fourth decades of life. The incidence of PSI remained stable over time; however, the rate of surgical intervention increased significantly, from 53.1% of patients between 1996 and 2002 to 87.5% of patients between 2009 and 2015.

The lateral collateral ligament complex of the elbow: quantitative anatomic analysis of the lateral ulnar collateral, radial collateral, and annular ligaments.

BACKGROUND: Injury to the lateral ulnar collateral ligament (LUCL) complex of the elbow often results in posterolateral rotatory instability. Although surgical reconstruction of the LUCL is often required, gaps in our understanding of the LUCL complex remain. The purpose of this study was to provide a robust and accurate characterization of the lateral elbow ligamentous complex. METHODS: The LUCLs, radial collateral ligaments, and annular ligaments in 10 cadaveric elbows were 3-dimensionally digitized and reconstructed using computed tomography. Surface areas, origin and insertion footprint areas, distances between perceived footprint centers and geometric footprint centroids, distances to key landmarks, and ligament isometry were measured. RESULTS: The mean surface area of the LUCL was 229.3 mm2. The mean origin and insertion footprint areas were 26.0 mm2 and 22.9 mm2, respectively. The mean distance between the apparent centers and the geometric centroids of the footprints was 1 mm. The center of the LUCL origin was 10.7 mm distal to the lateral epicondyle and 8.2 mm from the capitellar articular margin. The center of the LUCL insertion was 3.3 mm distal to the apex of the supinator crest. The LUCL showed anisometric properties as elbow flexion increased (P < .001). CONCLUSIONS: The LUCL origin center was 10.7 mm from the lateral epicondyle, whereas the insertion center was 3.3 mm from the apex of the supinator crest. The visually estimated footprint centers were generally within 1 mm of the geometric centroid. These geometries and distances to key landmarks will be informative for surgeons seeking to perform anatomic ligament reconstruction procedures.

Arthroscopic Management of SLAP Lesions With Concomitant Spinoglenoid Notch Ganglion Cysts: A Systematic Review Comparing Repair Alone to Repair With Decompression.

PURPOSE: To determine if cyst management is necessary in the setting of SLAP lesions with concomitant paralabral ganglion cysts. METHODS: We performed a systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, including all studies that met inclusion criteria from January 1975 to July 2015. We included patients with a SLAP II-VII lesion and a concomitant paralabral ganglion cyst who underwent arthroscopic labral repair with or without cyst decompression. Patients with follow-up of less than 3 months, a SLAP I lesion, or who underwent concomitant cuff repair were excluded. The Methodological Index for Non-randomized Studies (MINORS) scoring system was used to quantify the potential bias in each study. Outcome measures reported were provided in a table format and a subjective analysis was performed. RESULTS: Nineteen studies were included yielding a total of 160 patients: 66 patients treated with repair alone [R] and 94 patients with additional cyst decompression or excision [R+D]. The VAS, Rowe, and Constant scores were excellent and similar in both groups. The mean VAS was 0.6 in [R] and ranged between 0 and 2 in [R+D] (0.5, 0, 2, 0.2). The mean Rowe scores were 94 and 98 in [R] and 95 in [R+D]. The mean Constant scores were 97 in [R] and ranged between 87 and 98 in [R+D] (98, 87, 92, 94). In total, 5 of 90 patients were unable to return to work and 2 of 45 were unable to return to sport. All 15 patients who had follow-up electromyographies displayed resolution, and in the 115 patients with follow-up MRIs, 12 did not have complete resolution of the cyst. CONCLUSIONS: Despite the lack of high-quality evidence, the studies subjectively analyzed in this review suggest that both groups have excellent results. The results do not show any advantages from performing decompression. LEVEL OF EVIDENCE: Level IV, systematic review of Level II and Level IV studies.

An Unusual Presentation of Myositis Ossificans in a Pediatric Patient.

BACKGROUND: Myositis ossificans (MO) is a rare, non-neoplastic lesion characterized by heterotopic ossification of soft tissue. The condition is predominantly seen in young adults and adolescents and is most commonly secondary to trauma. Although the exact etiology remains unclear, patients typically present with pain and restricted range of motion following trauma or overuse. MO rarely presents in the popliteal fossa of adult patients and has not been previously reported in that of a pediatric patient. METHODS: We present a 12-year-old patient with no history of direct trauma with MO in the right popliteal fossa, a highly unusual location. Initial x-rays failed to show the lesion; however, later radiographs showed an ossified mass. At peak dimensions, the ossification measured 3.8 cm anteroposterior×2.5 cm transverse×3.2 cm craniocaudal. After 14 months of observation and conservative therapy, the mass was excised. RESULTS: The patient was ultimately able to return to full activity. Radiographs taken 14 months after the excision showed no signs of recurrence of the lesion. CONCLUSIONS: To our knowledge, this is the first reported case of MO excised from the popliteal fossa of a pediatric patient and followed for >1 year. LEVEL OF EVIDENCE: Level IV-case report.

Downsizing human, bacterial, and viral proteins to short water-stable alpha helices that maintain biological potency.

Recombinant proteins are important therapeutics due to potent, highly specific, and nontoxic actions in vivo. However, they are expensive medicines to manufacture, chemically unstable, and difficult to administer with low patient uptake and compliance. Small molecule drugs are cheaper and more bioavailable, but less target-specific in vivo and often have associated side effects. Here we combine some advantages of proteins and small molecules by taking short amino acid sequences that confer potency and selectivity to proteins, and fixing them as small constrained molecules that are chemically and structurally stable and easy to make. Proteins often use short alpha-helices of just 1-4 helical turns (4-15 amino acids) to interact with biological targets, but peptides this short usually have negligible alpha-helicity in water. Here we show that short peptides, corresponding to helical epitopes from viral, bacterial, or human proteins, can be strategically fixed in highly alpha-helical structures in water. These helix-constrained compounds have similar biological potencies as proteins that bear the same helical sequences. Examples are (i) a picomolar inhibitor of Respiratory Syncytial Virus F protein mediated fusion with host cells, (ii) a nanomolar inhibitor of RNA binding to the transporter protein HIV-Rev, (iii) a submicromolar inhibitor of Streptococcus pneumoniae growth induced by quorum sensing pheromone Competence Stimulating Peptide, and (iv) a picomolar agonist of the GPCR pain receptor opioid receptor like receptor ORL-1. This approach can be generally applicable to downsizing helical regions of proteins with broad applications to biology and medicine.

Epidemiology and Impact of Hand and Wrist Injuries in Major and Minor League Baseball.

Background: Professional baseball players are at risk of acute and chronic injuries to their upper extremities. Methods: Major League Baseball's Health and Injury Tracking System, a prospective injury surveillance system, was used to identify and characterize all hand and wrist injuries sustained by all Major League Baseball (MLB) and Minor League Baseball (MiLB) players during the pre-, regular, and postseason throughout 2011-2016. Injuries were included if they resulted in at least 1 day out of play and were sustained during standard baseball activities. Days missed were defined as the time between injury and the first time in which a player was cleared to return to play. Results: During the study period, there were 4478 hand and 1748 wrist injuries throughout MLB and MiLB, which resulted in a total of 105 246 days out of play. This was equivalent to the length of 575 individual MLB player seasons, and the mean days missed per injury was 17 days. Most injuries were traumatic in nature, with 43% (n = 2672) of players injured after being hit by a baseball that mainly occurred during batting (n = 2521; 40%). Injuries that most frequently required surgical intervention were hook of hamate fractures (72%) and scaphoid fractures (60%). Conclusions: Understanding the epidemiology and impact of hand and wrist injuries in MLB and MiLB players may lead to improved management of these injuries and reduce time away from play. Most importantly, preventive measures and/or enhanced protective gear may be developed to minimize these types of injuries in MLB and MiLB.

Understanding the Implications of the Meniscal Ossicle: Patient Presentation, Treatment, and Outcomes.

The meniscal ossicle is observed in clinical practice, yet there currently is limited information on its potential clinical significance. The purpose of this study was to assess the clinical presentation, imaging findings, and clinical treatment and outcomes of a series of patients identified as having a meniscal ossicle. An institutional database was reviewed to identify knees with a meniscal ossicle. Clinical presentation, magnetic resonance imaging (MRI), treatment, and outcomes were analyzed. Radiographs were graded using Kellgren-Lawrence (KL) scores. MRIs were reviewed for the presence and location of meniscal ossicles and additional knee pathology. Knee arthroplasty rates were recorded with the remaining patients contacted to obtain final International Knee Documentation Committee (IKDC) and Tegner's scores. Failure was defined as conversion to arthroplasty or failing IKDC score (< 75.4). Forty-five meniscal ossicles in 45 patients (26 males and 19 females) with a mean age of 51 years (standard deviation [SD] = 19.0) were included. Pain was the most common presenting symptom (89%). Forty-two patients (93%) had an associated meniscus root tear on MRI. Eighteen percent of patients that did not have an ossicle on initial imaging subsequently developed an ossicle. Mean KL grades progressed significantly from baseline of 1.84 (SD = 1.0) to 2.55 (SD = 0.93 p < 0.01) on final follow-up. Thirty-nine percent of baseline radiographs showed KL grades of less than 2 compared with only 15% of follow-up radiographs (p = 0.04). Mean IKDC score obtained for patients ≤ 60 at an average follow-up of 3.1 years (SD = 3.2) was 65.2 (SD = 19.0). Eight out of 45 patients (18%) had progressed to total knee arthroplasty (TKA) by latest available follow-up. Sixty-two percent of patients met failure criteria at latest available follow-up. The meniscal ossicle is most commonly found in the posterior horn or root of the medial meniscus and is highly suggestive to be sequelae of a posterior root tear. Therefore, the presence of a meniscal ossicle should alert the orthopaedic surgeon to the high likelihood of the patient having a meniscus root tear. These patients have shown to have poor clinical outcomes and worsening arthritis.

Osteochondritis Dissecans of the Knee: Short-Term Outcomes of a Hybrid Technique to Restore a Partially Salvageable Progeny Fragment.

OBJECTIVE: This retrospective case series describes a hybrid fixation technique and determines the clinical outcomes, knee function, and activity level of patients at short-term follow-up. DESIGN: Seventeen patients (18 knees) with unstable osteochondritis dissecans (OCD) lesions involving the knee were treated with a hybrid fixation technique in which the salvageable fragment was fixed and osteochondral autograft transplantation system (OATS) was used for the unsalvageable fragment. Thirteen lesions involved the medial femoral condyle, 4 involved the lateral femoral condyle, and 1 involved the patella. Mean patient age was 17 years (range 12-28 years). All lesions were International Cartilage Repair Society (ICRS) grade III or IV. The patients were prospectively followed postoperatively. Outcome measures included the International Knee Documentation Committee (IKDC) score, Knee injury and Osteoarthritis Outcome Score (KOOS), and the Tegner activity scale. RESULTS: At mean follow-up of 36 months (range 24-67.2 months), the mean postoperative KOOS scores, given as mean (SD), were as follows: Quality of Life (QoL) 91.1 (17.0), Activities of Daily Living (ADL) 99.5 (1.5), Sport 94.5 (11.2), Pain 97.4 (5.8), and Symptoms 95.9 (6.5). Mean IKDC score was 96.2 (7.0). There was no significant difference between mean preinjury (7.95, SD = 1.1) and mean postoperative (7.45, SD = 1.5) Tegner scores (P = 0.363). The mean Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score was 87.5 at a mean 7.8 months (range 3-18 months) postoperation. There were no reported complications. CONCLUSION: The results of this case series suggest that patients with partially salvageable OCD lesions involving the knee can have positive short-term outcomes and can expect a low complication rate when treated with a hybrid technique of fixation with osteochondral autograft transfer.

Midterm Outcomes following Acute Repair of Grade III Distal MCL Avulsions in Multiligamentous Knee Injuries.

There is limited evidence guiding management of medial collateral ligament (MCL) avulsions or functional disruptions distal to the medial joint line. This study aims to determine outcomes of a series of patients with grade III distal MCL injuries managed with acute surgical repair. Patients with grade III, distal MCL injuries, with or without multiligament involvement were identified. Demographic, clinical examination, and midterm patient-reported outcomes (PRO) data were collected. Clinical follow-up included physical examination and ligamentous stress testing at a minimum of 6 months. PROs included Lysholm's knee scoring scale, Tegner's activity score, and subjective International Knee Documentation Committee (IKDC) scores at minimum of 2 years follow-up. Of the 24 eligible patients, outcomes data were available for 20 (83%). Of the 20 included patients, 16 had a concomitant anterior cruciate ligament (ACL) injury, 3 had ACL and posterior cruciate ligament (PCL) injuries, and 1 had an isolated MCL injury. Mean time from injury to surgery was 5 weeks. At mean clinical follow-up of 20.3 months, all patients showed valgus stability and satisfactory range of motion (ROM). Anteroposterior stability was normal in all but one patient who demonstrated a 2+ posterior drawer but with firm end points. At a mean follow-up of 5.7 years for PROs, mean Lysholm's score was 91.5 (standard deviation [SD] = 12.2), median Tegner's activity score was 7 (range, 4-9), and mean subjective IKDC score was 88.8 (SD: 9.9). The surgical repair of grade III distal MCL injuries delivered satisfactory clinical and functional outcomes. Future comparative studies with larger patient samples are needed.

Osteomeniscal Impact Edema (OMIE): Description of a Distinct MRI Finding in Displaced Flap Tears of the Medial Meniscus, with Comparison to Posterior Root Tears.

Bone marrow edema (BME) can be a late finding in osteoarthritis or a sign of subchondral insufficiency. The purpose of this study was to describe the magnetic resonance imaging (MRI) finding we refer to as "osteomeniscal impact edema" (OMIE), or reactive BME adjacent to a displaced meniscus flap tear. In addition, this edema pattern is compared with a control group of medial meniscus posterior root tears (MMPRT) with subchondral insufficiency edema. MRI records from 2000 to 2017 were retrospectively reviewed for studies that showed the presence of a medial meniscus displaced flap tear and an adjacent area of BME. The selected MRIs were matched to an equal number of MMPRT MRI studies. All MRI studies were assessed for cartilage surface grade using the modified Outerbridge classification system and for the extent of accompanying structural abnormalities using the whole-organ magnetic resonance imaging score. Descriptive statistics and hypothesis testing were utilized to compare the MRI findings between groups. Twenty-two flap tear (OMIE group) patients with a mean age of 57 (SD: 15) and 22 root tear (MMPRT) group patients with a mean age of 61 (SD: 10) were included. MRIs in the OMIE group showed a distinctive pattern of focal, peripheral edema adjacent to the meniscus flap tear, compared with more diffuse, central edema in the MMPRT group. Quantitatively, MRIs of the MMPRT group showed significantly worse mean femoral Outerbridge scores (3.72 vs. 2.68, p < 0.0001), more severe central (1.63 vs. 0.5, p = 0.0007) and posterior (0.31 vs. 0.0, p = 0.04) subchondral edema grades, and a higher incidence of tibial subchondral fractures (3 vs. 0, p = 0.036). Meniscus flap tears may present with a distinct MRI pattern of focal, adjacent, peripheral edema, which we refer to as OMIE. Patients with meniscus flap tears showed significantly less arthritic change, lower subchondral edema grades, and a lower incidence of insufficiency fractures and subchondral collapse compared with the diffuse overload edema pattern found with root tears. The Level of Evidence for this study is III.

All-inside Posterior Cruciate Ligament Reconstruction: Surgical Technique and Outcome.

Several reconstructive techniques exist to treat posterior cruciate ligament (PCL) deficiency. The purpose of this study is to report knee function and clinical stability after PCL reconstruction (PCLR) using an all-inside technique. Thirty-two patients with isolated or combined PCL injuries treated with all-inside PCLR using soft tissue allograft were included. Documented physical examination findings including ligamentous stability examination were recorded. All-inside, single-bundle PCLR demonstrated satisfactory clinical and functional outcomes comparable with previous other PCLR techniques. The advantages of this technique include bone preservation, minimizing risk of tunnel convergence, and allowing for sequential graft tensioning.

Generational Differences in Grit, Self-Control, and Conscientiousness Among Orthopaedic Surgeons: From Millennials to Baby Boomers.

BACKGROUND: The training process and practice of orthopaedic surgery is demanding and arduous. Accordingly, grit, self-control, and conscientiousness are desirable qualities in orthopaedic surgeons. Some established orthopaedists have expressed concern that the future generation of surgeons may not possess the same level of grit as their predecessors. The purpose of this study was to evaluate levels of grit among attending orthopaedic surgeons, identify predictors of grit in orthopaedic surgeons, and compare grit scores between attending surgeons and orthopaedic residency applicants. We hypothesized that applicants would demonstrate lower grit and self-control scores but greater conscientiousness scores than attending surgeons. METHODS: A total of 2,342 attending orthopaedic surgeons and 895 orthopaedic residency applicants from the 2016-2017 National Resident Matching Program (NRMP) were given surveys that quantified their grit, self-control, and conscientiousness. Demographic and career information also was collected. RESULTS: Assessments were completed by 655 (28%) of 2,342 practicing orthopaedic surgeons and 455 (50.8%) of 895 orthopaedic residency applicants. The residency applicants demonstrated higher mean grit scores (4.12 of 5.0) than the attending orthopaedic surgeons (4.03) (p < 0.01). These average scores placed applicants and attending surgeons at the 70th and 65th percentile, respectively, when compared with the general population. There were no differences in self-control (p = 0.68) or conscientiousness (p = 0.93) between the 2 groups. Attending surgeons with more publications had increased grit (p < 0.01), self-control (p = 0.04), and conscientiousness (p = 0.01) scores. Attending surgeons who had been inducted into the Alpha Omega Alpha honor society as medical students demonstrated greater conscientiousness scores than those who were not members (p = 0.04). CONCLUSIONS: Orthopaedic residency applicants were at least as gritty, consistent in their interest, persevering in their efforts, and ambitious as currently practicing orthopaedic surgeons. Although these results may be encouraging and diverge from some preconceived perceptions of "millennials," it is unclear if they will be predictive of career success in the next generation of orthopaedists.

Is Grit the New Fit?-Assessing Non-Cognitive Variables in Orthopedic Surgery Trainees.

OBJECTIVE: The purpose of this study was to determine overall levels of grit, self-control, and conscientiousness among orthopedic surgery residents, to compare levels of grit across orthopedic resident training levels, and to identify common applicant variables which may correlate with these valuable noncognitive attributes. DESIGN: A cross-sectional study composed of a confidential electronic survey consisting of a 17-item Grit scale, 10-item Self-control scale, and 9-item Conscientiousness scale was completed by Orthopedic residents and fellows. SETTING: Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN; a tertiary medical center. PARTICIPANTS: Grit, ambition, consistency of interest, perseverance of effort, self-control, and conscientiousness were assessed in orthopedic surgery residents and fellows. The survey was distributed to program coordinators of ACGME accredited Orthopedic Surgery residency programs and fellowship. 431 (431 out of 621, 69.4%) respondents completed the assessment. RESULTS: Orthopedic residents demonstrated high baseline levels of grit (4.0 of 5.0), self-control (3.8 of 5.0), and conscientiousness (4.4 of 5.0). The grit score of 4.0 places them in the 65th percentile of the general adult population. There were no significant differences in scores between training levels of orthopedic residents and fellows. Significantly higher self-control scores were seen in female trainees (p = 0.042), inductees of Alpha Omega Alpha honor society (p = 0.008), and those with higher numbers of publications (p = 0.037). Orthopedic trainees with more publications scored higher in the ambition sub-score (0 publications: 4.0 ± 0.7; 1-3 publications: 4.2 ± 0.5, 3 or more publications: 4.3 ± 0.5; p < 0.001). CONCLUSIONS: Orthopedic surgery residents demonstrated high levels of grit compared to the general population. Key objective variables utilized in the residency application process including Alpha Omega Alpha status and volume of research publications were predictive of these qualities.

Anterior Cruciate Ligament Reconstruction With Hamstring Autograft: A Matched Cohort Comparison of the All-Inside and Complete Tibial Tunnel Techniques.

BACKGROUND: Surgical reconstruction of the anterior cruciate ligament (ACL) is one of the most common orthopaedic procedures, with an estimated 100,000 to 175,000 procedures performed annually. Recently, the all-inside reconstruction technique has come into favor and is theorized to be superior to the complete tibial tunnel technique. PURPOSE: To compare clinical and patient-reported outcomes (PROs) for hamstring autograft ACL reconstruction (ACLR) performed with an all-inside versus a complete tibial tunnel technique. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Patients who underwent hamstring autograft ACLR via either an all-inside approach (femoral and tibial sockets) or a complete tibial tunnel approach (femoral socket and full-length, transtibial tunnel) at a single institution between July 2011 and July 2015 were reviewed. Demographic information, preoperative comorbidities, surgical details, physical examination findings, and follow-up outcomes were extracted from the medical record. Physical examination data included pivot-shift, Lachman, and range of motion examinations, whereas PROs included the Tegner activity scale, Lysholm score, and International Knee Documentation Committee (IKDC) score at a minimum of 2 years after surgery. Return to sport and risk factors for failure were analyzed. RESULTS: A total of 82 patients (mean ± SD age, 25.8 ± 10.2 years) who underwent all-inside reconstruction (median PRO follow-up, 30.1 months; range, 24.7-72.9 months) and 54 patients (mean ± SD age, 21.1 ± 7.3 years) who underwent complete tibial tunnel reconstruction (median PRO follow-up, 25.8 months; range, 23.9-74.5 months) met the inclusion criteria. PRO scores at latest follow-up were comparable between the all-inside versus the complete tibial tunnel groups (Lysholm score, 93.8 vs 94.4, P = .621; IKDC score, 93.5 vs 93.3, P = .497; Tegner activity score, 6.4 vs 6.8, P = .048). Complications (including graft failure) were experienced by 20% of patients in the all-inside group compared with 24% in the complete tibial tunnel group (P = .530). Graft failure before the final follow-up was experienced by 10% of patients in the all-inside group compared with 19% in the complete tibial tunnel group (P = .200). Mean return to sport was 12.5 months in the all-inside group versus 9.9 months in the complete tibial tunnel group (P = .028). CONCLUSION: All-inside and complete tibial tunnel hamstring autograft ACLR resulted in excellent physical examination findings and PROs at minimum 2-year follow-up. Both techniques successfully restored knee stability and patient function.

Secondary Meniscal Tears in Patients With Anterior Cruciate Ligament Injury: Relationship Among Operative Management, Osteoarthritis, and Arthroplasty at 18-Year Mean Follow-up.

BACKGROUND: Anterior cruciate ligament (ACL) injury is one of the most frequent orthopaedic injuries and reasons for time loss in sports and carries significant implications, including posttraumatic osteoarthritis (OA). Instability associated with ACL injury has been linked to the development of secondary meniscal tears (defined as tears that develop after the initial ACL injury). To date, no study has examined secondary meniscal tears after ACL injury and their effect on OA and arthroplasty risk. PURPOSE: To describe the rates and natural history of secondary meniscal tears after ACL injury and to determine the effect of meniscal tear treatment on the development of OA and conversion to total knee arthroplasty (TKA). STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A geographic database of >500,000 patients was reviewed to identify patients with primary ACL injuries between January 1, 1990, and December 31, 2005. Information was collected with regard to ACL injury treatment, rates/characteristics of the secondary meniscal tears, and outcomes, including development of OA and conversion to TKA. Kaplan-Meier and adjusted multivariate survival analyses were performed to test for the effect of meniscal treatment on survivorship free of OA and TKA. RESULTS: Of 1398 primary ACL injuries, the overall rate of secondary meniscal tears was 16%. Significantly lower rates of secondary meniscal tears were noted among patients undergoing acute ACL reconstruction within 6 months (7%) as compared with patients with delayed ACL reconstruction (33%, P < .01) and nonoperative ACL management (19%, P < .01). Of the 235 secondary meniscal tears identified (196 patients), 11.5% underwent repair, 73% partial meniscectomy, and 16% were treated nonoperatively. Tears were most often medial in location (77%) and complex in morphology (56% of medial tears, 54% of lateral tears). At the time of final follow-up, no patient undergoing repair of a secondary meniscal tear (0%) underwent TKA, as opposed to 10.9% undergoing meniscectomy and 6.1% receiving nonoperative treatment ( P = .28). CONCLUSION: Secondary meniscal tears after ACL injury are most common among patients undergoing delayed surgical or nonoperative treatment of their primary ACL injuries. Secondary tears often present as complex tears of the medial meniscus and result in high rates of partial meniscectomy.

Nonreconstruction Options for Treating Medial Ulnar Collateral Ligament Injuries of the Elbow in Overhead Athletes.

PURPOSE OF REVIEW: This review aims to describe the nonreconstructive options for treating ulnar collateral ligament (UCL) injuries ranging from nonoperative measures, including physical therapy and biologic injections, to ligament repair with and without augmentation. RECENT FINDINGS: Nonoperative options for UCL injuries include guided physical therapy and biologic augmentation with platelet-rich plasma (PRP). In some patients, repair of the UCL has shown promising return to sport rates by using modern suture and suture anchor techniques. Proximal avulsion injuries have shown the best results after repair. Currently, there is growing interest in augmentation of UCL repair with an internal brace. The treatment of UCL injuries involves complex decision making. UCL reconstruction remains the gold standard for attritional injuries and complete tears, which occur commonly in professional athletes. However, nonreconstructive options have shown promising results for simple avulsion or partial thickness UCL injuries. Future research comparing reconstructive versus nonreconstructive options is necessary.