'Real world' clinical implementation of blood flow restriction therapy does not increase quadriceps strength after quadriceps tendon autograft ACL reconstruction.

PURPOSE: To retrospectively compare strength outcomes of individuals undergoing postoperative rehabilitation following quadriceps tendon (QT) autograft anterior cruciate ligament reconstruction (ACLR) with and without blood flow restriction therapy. METHODS: A retrospective review of consecutive patients undergoing ACLR with QT autograft with a minimum of two quantitative postoperative isometric strength assessments via an electromechanical dynamometer (Biodex) was included. Demographics, surgical variables and strength measurement outcomes were compared between patients undergoing blood flow restriction therapy as part of postoperative rehabilitation versus those who did not. RESULTS: Eighty-one (81) patients met the inclusion criteria. No differences were found in demographic and surgical characteristics between those who received blood flow restriction compared with those who did not. While both groups had improvements in quadriceps peak torque and limb symmetry index (LSI; defined as peak torque of the operative limb divided by the peak torque of the nonoperative limb) over the study period, the blood flow restriction group had significantly lower mean peak torque of the operative limb at first Biodex strength measurement (95.6 vs. 111.2 Nm; p = 0.03). Additionally, the blood flow restriction group had a significantly lower mean LSI than those with no blood flow restriction at the second Biodex measurement timepoint (81% vs. 90%; p = 0.02). No other significant differences were found between the strength outcomes measured. CONCLUSIONS: Results of this study show that the 'real world' clinical implementation of blood flow restriction therapy to the postoperative rehabilitation protocol following QT autograft ACLR did not result in an increase in absolute or longitudinal changes in quadriceps strength measurements. A better understanding and standardisation of the use of blood flow restriction therapy in the rehabilitation setting is necessary to delineate the true effects of this modality on strength recovery after QT autograft ACLR. LEVEL OF EVIDENCE: Level III.

Preoperative factors associated with 180°, 270°, and 360° labral tears.

BACKGROUND: Large, circumferential glenoid labral tears are an uncommon injury affecting young, athletic patients. There are limited data describing the clinical presentation of patients with larger tears, especially 270° and 360° labral tears. Additionally, examination and imaging findings have poor reliability in diagnosing these tears. The purpose of this study was to determine the clinical presentation among patients presenting with small (less than 180°), medium (180°-270°), and large (270°-360°) labral tears. METHODS: This is a retrospective comparative study of consecutive patients surgically managed by a single shoulder surgeon for all glenoid labral tears from 2018-2022. The primary outcome was demographic and preoperative clinical risk factors. Demographic data including age, sex, hand dominance, body mass index, as well as clinical presentation (subluxation vs. dislocation, instability history, and participation in contact sports) were recorded. RESULTS: A total of 188 patients met the inclusion criteria: 101 of 188 (53.70%) patients with small tears, 43 of 188 (22.90%) patients with medium tears, and 44 of 188 (23.40%) patients with large tears. Individuals with large and medium-sized labral tears were more likely to have participated in contact sports compared to those with smaller labral tears (P = .003). Medium and smaller tears were more likely to present as dominant-side injury (P = .02). Furthermore, medium and large tears were more likely to present with anterior instability symptoms compared with smaller tears, which more frequently presented with posterior instability and pain (P = .003). CONCLUSION: Males participating in contact sports were the most common demographic population presenting with large, 270°-360° labral tears. Instability was the primary complaint rather than pain, and compared with small tears, medium and large tears were more likely to present with primary anterior instability. Although arthroscopic repair of 270°-360° labral tears can yield excellent clinical outcomes similar to smaller tears, identifying factors associated with larger glenoid labral tears may help in surgical planning and patient counseling.

Arthroscopic Bankart Repair with Remplissage Yields Similar Outcomes to Open Latarjet for Primary and Revision Stabilization in The Setting of Subcritical Glenoid Bone Loss.

BACKGROUND: Management of patients with recurrent anterior glenohumeral instability in the setting of subcritical glenoid bone loss (GBL), defined in this study as 20% GBL or less, remains controversial. This study aimed to compare arthroscopic Bankart with remplissage (ABR+R) to open Latarjet for subcritical GBL in primary or revision procedures. We hypothesized that ABR+R would yield higher rates of recurrent instability and reoperation compared to Latarjet in both primary and revision settings. METHODS: A retrospective study was conducted on patients undergoing either arthroscopic ABR+R or an open Latarjet procedure. Patients with connective tissue disorders, critical GBL (>20%), < 2 year follow-up, or insufficient data were excluded. Recurrent instability and revision were the primary outcomes of interest. Additional outcomes of interest included subjective shoulder value (SSV), strength and range of motion (ROM) RESULTS: 108 patients (70 ABR+R, 38 Latarjet) were included with an average follow-up of 4.3 ±2.1 years. In the primary and revision settings, similar rates of recurrent instability (Primary: p=0.60; Revision: p=0.28) and reoperation (Primary: p=0.06; Revision: p=1.00) were observed between Latarjet and ABR+R. Primary ABR+R exhibited better SSV, active ROM, and internal rotation strength compared to primary open Latarjet. However, no differences were observed in the revision setting. CONCLUSION: Similar rates of recurrent instability and reoperation in addition to comparable outcomes with no differences in ROM were found for ABR+R and Latarjet in patients with subcritical GBL in both the primary and revision settings. ABR+R can be a safe and effective procedure in appropriately selected patients with less than 20% GBL for both primary and revision stabilization.

Reversing chronic pseudoparesis secondary to massive, irreparable rotator cuff tear: superior capsular reconstruction vs. reverse total shoulder arthroplasty.

INTRODUCTION: Recent studies have defined pseudoparesis as limited active forward elevation between 45° and 90° and maintained passive range of motion (ROM) in the setting of a massive rotator cuff tear (RCT). Although pseudoparesis can be reliably reversed with reverse total shoulder arthroplasty (RSA) or superior capsular reconstruction (SCR), the optimal treatment for this indication remains unknown. The purpose of this study was to compare the clinical outcomes of RSA to SCR in patients with pseudoparesis secondary to massive, irreparable RCT (miRCT). METHODS: This was a retrospective cohort study of consecutive patients aged 40-70 years with pseudoparesis secondary to miRCT who were treated with either RSA or SCR by a single fellowship-trained shoulder surgeon from 2016 to 2021 with a minimum 12-month follow-up. Multivariate linear regression modeling was used to compare active ROM, visual analog pain scale (VAS), Subjective Shoulder Value (SSV), and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score between RSA and SCR while controlling for confounding variables. RESULTS: Twenty-seven patients were included in the RSA cohort and 23 patients were included in the SCR cohort with similar mean follow-up times (26.2 ± 21.1 vs. 21.9 ± 14.7 months, respectively). The patients in the RSA group were significantly older than those in the SCR group (65.2 ± 4.4 vs. 54.2 ± 7.8 years, P < .001) and had more severe arthritis (1.8 ± 0.9 vs. 1.2 ± 0.5 Samilson-Prieto, P = .019). The pseudoparesis reversal rate among the RSA and SCR cohorts was 96.3% and 91.3%, respectively. On univariate analysis, the RSA cohort demonstrated significantly greater mean improvement in active FF (89° ± 26° vs. 73° ± 30° change, P = .048), greater postoperative SSV (91 ± 8% vs. 69 ± 25%, P < .001), lower postoperative VAS pain scores (0.6 ± 1.2 vs. 2.2 ± 2.9, P = .020), and less postoperative internal rotation (IR; 4.6° ± 1.6° vs. 6.9° ± 1.8°, P = .004) compared with SCR. On multivariate analysis controlling for age and osteoarthritis, RSA remained a significant predictor of greater SSV (ß = 21.5, P = .021) and lower VAS scores (ß = -1.4, P = .037), whereas SCR was predictive of greater IR ROM (ß = 3.0, P = .043). CONCLUSION: Although both RSA and SCR effectively reverse pseudoparesis, patients with RSA have higher SSV and lower pain scores but less IR after controlling for age and osteoarthritis. The results of this study may inform surgical decision making for patients who are suitable candidates for either procedure.

Differences in postoperative knee function based on concomitant treatment of lateral meniscal injury in the setting of primary ACL reconstruction.

BACKGROUND: Concomitant lateral meniscal (LM) injuries are common in acute anterior cruciate ligament (ACL) ruptures. However, the effect of addressing these injuries with various treatment methods during primary ACL reconstruction (ACLR) on patient-reported outcomes (PROs) is unknown. Therefore, the purpose of this study was to compare postoperative Knee injury and Osteoarthritis Outcome Score (KOOS) at 2-, 5-, and 10-years after isolated primary ACLR to primary ACLR with various treatment methods to address concomitant LM injury. METHODS: This study was based on data from the Swedish National Knee Ligament Registry. Patients ≥ 15 years with data on postoperative KOOS who underwent primary ACLR between the years 2005 and 2018 were included in this study. The study population was divided into five groups: 1) Isolated ACLR, 2) ACLR + LM repair, 3) ACLR + LM resection, 4) ACLR + LM injury left in situ, and 5) ACLR + LM repair + LM resection. Patients with concomitant medial meniscal or other surgically treated ligament injuries were excluded. RESULTS: Of 31,819 included patients, 24% had LM injury. After post hoc comparisons, significantly lower scores were found for the KOOS Symptoms subscale in ACLR + LM repair group compared to isolated ACLR (76.0 vs 78.3, p = 0.0097) and ACLR + LM injury left in situ groups (76.0 vs 78.3, p = 0.041) at 2-year follow-up. However, at 10-year follow-up, no differences were found between ACLR + LM repair and isolated ACLR, but ACLR + LM resection resulted in significantly lower KOOS Symptoms scores compared to isolated ACLR (80.4 vs 82.3, p = 0.041). CONCLUSION: The results of this study suggest that LM injury during ACLR is associated with lower KOOS scores, particularly in the Symptoms subscale, at short- and long-term follow-up. However, this finding falls below minimal clinical important difference and therefore may not be clinically relevant. LEVEL OF EVIDENCE: III.

Anterior cruciate ligament reconstruction with all-soft tissue quadriceps tendon versus quadriceps tendon with bone block.

PURPOSE: The purpose of this study was to evaluate whether there was a difference in clinical outcomes between patients who underwent primary ACL reconstruction (ACLR) with all-soft tissue quadriceps tendon (sQT) autograft versus QT with bone block (bQT). METHODS: A retrospective cohort study of 708 patients who underwent QT ACLR was conducted. Primary ACLR patients with at least 1 year of follow-up were identified and those who received sQT were compared to those who received bQT. Data collection entailed patient demographics, surgical variables, patient reported outcomes (PROs), knee stability testing, and complications. The primary outcome of interest was International Knee Documentation Committee (IKDC) score, reported as mean score, pre- and postoperative difference, and number who met minimum clinically important difference (MCID). Secondary outcomes included Lachman and pivot shift grade, other patient reported outcomes (PROs), complication rates, and return to sport (RTS). RESULTS: A total of 195 patients (147 sQT, 48 bQT) who underwent primary QT ACLR met criteria for analysis, with mean follow-up of 17.0 ± 7.9 months. No difference was detected between cohorts with respect to postoperative IKDC score (sQT: n = 120, 81.0 ± 18.9, bQT: n = 10, 80.9 ± 20.4, n.s.), proportion of patients who met MCID (sQT: 68/78 [87%], bQT: 6/7 [86%], n.s.), or results of stability testing. In the sQT cohort, 86% (106/123) of athletes achieved full RTS, compared to 85% (34/40) in the bQT cohort (n.s.). Time to RTS was less than a year in both cohorts (sQT: 10.5 ± 3.8 months [n = 106], bQT: 11.1 ± 3.9 months [n = 31], n.s.). Graft rupture occurred in 7 (5%) sQT patients and 3 (6%) bQT patients (n.s.), and all clinical failures were due to graft rupture (n.s.). No differences were detected for rates of postoperative complications. CONCLUSION: No differences in clinical outcomes were detected between patients who underwent primary ACLR with sQT autograft versus bQT autograft. Currently, the decision to employ sQT or bQT is largely determined by surgeon preference. This study demonstrates excellent outcomes with both preparations and supports the use of either graft type at the discretion of the treating surgeon. LEVEL OF EVIDENCE: III.

Remplissage reduces recurrent instability in high-risk patients with on-track Hill-Sachs lesions.

BACKGROUND: The purpose of this study was to compare recurrent instability rates between patients with on-track Hill-Sachs lesions who underwent arthroscopic labral repair (ALR) alone and those who underwent ALR with remplissage (ALR-R). Our hypothesis was that ALR-R would decrease the rate of recurrent instability, especially among patients at high risk of recurrent instability after ALR, such as contact athletes with near-track Hill-Sachs lesions. METHODS: We performed a multicenter, retrospective analysis of patients aged 14-50 years with on-track Hill-Sachs lesions who underwent ALR-R or ALR without remplissage between January 2014 and December 2019 with minimum 2-year follow-up. The exclusion criteria included prior ipsilateral shoulder surgery, >15% glenoid bone loss (GBL), off-track Hill-Sachs lesion, concomitant shoulder procedure, and connective tissue disorder. Age, sex, follow-up, and contact sports participation were recorded. GBL, Hills-Sachs interval (HSI), glenoid track, and distance to dislocation (DTD) were determined from preoperative magnetic resonance imaging scans. Affected-shoulder range of motion, Western Ontario Shoulder Instability Index scores, Subjective Shoulder Value scores, and recurrent dislocation and/or revision surgery status were also collected. A subgroup analysis was performed on "high-risk" patients (defined as participants in contact sports with DTD <10 mm) from each cohort. RESULTS: The ALR-R cohort included 56 patients, and the ALR cohort included 127. ALR-R patients had greater GBL (P = .004) and a greater HSI (P < .001). In the ALR-R cohort, only 1 patient (1.8%) had a recurrent dislocation and there were no revision operations. In comparison, in the ALR cohort, 14 patients (11.0%) had recurrent dislocations (P = .040) and 8 (6.3%) underwent revision operations (P = .11). Univariate analysis showed that remplissage protected against recurrent dislocation (P = .040) whereas younger age (P = .004), contact sports participation (P = .001), and increased GBL (P = .048) were associated with recurrent dislocation. Multivariate analysis showed that HSI (P = .001) and contact sports participation (P = .002) predicted recurrent dislocation. Among high-risk patients, only 1 patient (4.2%) in the ALR-R group had a recurrent instability event vs. 6 (66.7%) in the ALR group (P < .001). The high-risk ALR-R subgroup also had significantly better final Western Ontario Shoulder Instability Index (P = .008) and Subjective Shoulder Value (P = .001) scores than the high-risk ALR subgroup. CONCLUSIONS: Anterior shoulder instability patients with on-track Hill-Sachs lesions have lower recurrent dislocation rates after ALR plus remplissage when compared with ALR alone. This is especially true for high-risk patients, such as contact athletes with a DTD <10 mm.

Overhead athletes have comparable intraoperative injury patterns and clinical outcomes to non-overhead athletes following surgical stabilization for first-time anterior shoulder instability at average 6-year follow-up.

BACKGROUND AND HYPOTHESIS: Anterior shoulder instability is a common problem affecting young, athletic populations that results in potential career-altering functional limitations. However, little is known regarding the differences in clinical outcomes after operative management of overhead vs. non-overhead athletes presenting with first-time anterior shoulder instability. We hypothesized that overhead athletes would have milder clinical presentations, similar surgical characteristics, and diminished postoperative outcomes when compared with non-overhead athletes after surgical stabilization following first-time anterior shoulder instability episodes. METHODS: Patients with first-time anterior shoulder instability events (subluxations and dislocations) undergoing operative management between 2013 and 2020 were included. The exclusion criteria included multiple dislocations and multidirectional shoulder instability. Baseline demographic characteristics, imaging data, examination findings, and intraoperative findings were retrospectively collected. Patients were contacted to collect postoperative patient-reported outcomes including American Shoulder and Elbow Surgeons score, Western Ontario Shoulder Instability Index score, Brophy activity index score, and Subjective Shoulder Value, in addition to return-to-work and -sport, recurrent dislocation, and revision rates. RESULTS: A total of 256 patients met the inclusion criteria, of whom 178 (70%) were non-overhead athletes. The mean age of the entire population was 23.1 years. There was no significant difference in concomitant shoulder pathology, preoperative range of motion, or preoperative strength between cohorts. A greater proportion of overhead athletes presented with instability events not requiring manual reduction (defined as subluxations; 64.1% vs. 50.6%; P < .001) and underwent arthroscopic surgery (97% vs. 76%, P < .001) compared with non-overhead athletes. A smaller proportion of overhead athletes underwent open soft-tissue stabilization compared with non-overhead athletes (1% vs. 19%, P < .001). Outcome data were available for 60 patients with an average follow-up period of 6.7 years. No significant differences were found between groups with respect to recurrent postoperative instability event rate (13.0% for overhead athletes vs. 16.8% for non-overhead athletes), revision rate (13.0% for overhead athletes vs. 11.1% for non-overhead athletes), American Shoulder and Elbow Surgeons score, Western Ontario Shoulder Instability Index score, Brophy score, Subjective Shoulder Value, or rates of return to work or sport. CONCLUSION: Overhead athletes who underwent surgery after an initial instability event were more likely to present with subluxations compared with non-overhead athletes. With limited follow-up subject to biases, this study found no differences in recurrence or revision rates, postoperative patient-reported outcomes, or return-to-work or -sport rates between overhead and non-overhead athletes undergoing shoulder stabilization surgery following first-time instability events. Although larger prospective studies are necessary to draw firmer conclusions, the findings of this study suggest that overhead athletes can be considered in the same treatment pathway for first-time dislocation as non-overhead athletes.

Surgical Techniques in Primary ACL Reconstruction: Getting It Right the First Time.

The ideal anterior cruciate ligament reconstruction (ACLR) is an individualized anatomic approach aimed at restoring the native structure and function of the knee. Surgeons are tasked with difficult decisions during operative planning, including the optimal graft choice for the patient and appropriate anatomic tunnel placement. Special considerations should additionally be given for skeletally immature patients and those at high-risk for failure, including younger, active patients participating in pivoting sports. The purpose of this review is to provide an overview of the individualized approach to ACLR, including the necessary preoperative and operative considerations to optimize patient outcomes.

Rehabilitation and Return to Sport following Operative and Nonoperative Treatment of Anterior Shoulder Instability.

There has been growing interest in the rehabilitation process and timing of returning an athlete to sport following the management options for anterior shoulder instability. The purpose of this article is to review the current rehabilitation and return to sport (RTS) protocols for various nonoperative and operative management strategies following anterior shoulder instability events. When appropriate in the rehabilitation protocol, RTS testing should be criteria based, rather than time based, with a special focus given to psychological readiness in order to promote successful return to athletics and prevention of recurrent instability episodes in the future.

Precision Anterior Cruciate Ligament Reconstruction.

Precision anterior cruciate ligament reconstruction (ACLR) refers to the individualized approach to prerehabilitation, surgery (including anatomy, bony morphology, and repair/reconstruction of concomitant injuries), postrehabilitation, and functional recovery. This individualized approach is poised to revolutionize orthopedic sports medicine, aiming to improve patient outcomes. The purpose of this article is to provide a summary of precision ACLR, from the time of diagnosis to the time of return to play, with additional insight into the future of ACLR.

The Role of Osteotomy in Anterior Cruciate Ligament Reconstruction.

Coronal and sagittal plane knee malalignments have been shown to increase the forces on anterior cruciate ligament (ACL) grafts after ACL reconstruction (ACLR). Studies have shown the benefit of high tibial osteotomy to address coronal and sagittal imbalance in revision ACLR. The purpose of this article is to further describe the use of osteotomy by reviewing preoperative planning, indications, techniques, and outcomes of high tibial opening and closing wedge as well as anterior tibial closing wedge osteotomies in the setting of ACLR.

Revision Anterior Cruciate Ligament Reconstruction and Associated Procedures.

Failure of anterior cruciate ligament reconstruction (ACLR) is a common yet devastating complication due to inferior clinical outcomes associated with revision ACLR. Identifying the cause and associated risk factors for failure is the most important consideration during preoperative planning. Special attention to tunnel quality, concomitant injuries, and modifiable risk factors will help determine the optimal approach and staging for revision ACLR. Additional procedures including lateral extra-articular tenodesis and osteotomy may be considered for at-risk populations. The purpose of this review is to explore causes of ACLR failure, clinical indications and appropriate patient evaluation, and technical considerations when performing revision ACLR.

Registry-based cohort study comparing percentages of patients reaching PASS for knee function outcomes after revision ACLR compared to primary ACLR.

OBJECTIVES: Reaching the Patient-Acceptable Symptom State (PASS) threshold for the Knee injury and Osteoarthritis Outcome Score (KOOS) has previously been reported to successfully identify individuals experiencing clinical success after anterior cruciate ligament reconstruction (ACLR). Thus, the objectives of this study were to examine and compare the percentages of patients meeting PASS thresholds for the different KOOS subscales 1 year postoperatively after primary ACLR compared with revision ACLR (rACLR) and multiply revised ACLR (mrACLR), and second, to examine the predictors for reaching PASS for KOOS Quality of Life (QoL) and Function in Sport and Recreation (Sport/Rec) after mrACLR. DESIGN: Prospective observational registry study. SETTING: The data used in this study was obtained from the Swedish National Ligament Registry and collected between 2005 and 2020. PARTICIPANTS: The study sample was divided into three different groups: (1) primary ACLR, (2) rACLR and (3) mrACLR. Data on patient demographic, injury and surgical characteristics were obtained as well as mean 1-year postoperative scores for KOOS subscales and the per cent of patients meeting PASS for each subscale. Additionally, the predictors of reaching PASS for KOOS Sport/Rec, and QoL subscales were evaluated in patients undergoing mrACLR. RESULTS: Of the 22 928 patients included in the study, 1144 underwent rACLR and 36 underwent mrACLR. Across all KOOS subscales, the percentage of patients meeting PASS thresholds was statistically lower for rACLR compared with primary ACLR (KOOS Symptoms 22.5% vs 32.9%, KOOS Pain 84.9% vs 92.9%, KOOS Activities of Daily Living 23.5% vs 31.4%, KOOS Sport/Rec 26.3% vs 45.6%, KOOS QoL 26.9% vs 51.4%). Percentages of patients reaching PASS thresholds for all KOOS subscales were comparable between patients undergoing rACLR versus mrACLR. No predictive factors were found to be associated with reaching PASS for KOOS QoL and KOOS Sport/Rec 1 year postoperatively after mrACLR. CONCLUSION: Patients undergoing ACLR in the revision setting had lower rates of reaching acceptable symptom states for functional knee outcomes than those undergoing primary ACLR. LEVEL OF EVIDENCE: Prospective observational registry study, level of evidence II.

Criteria-based return to sport testing after open Latarjet reveals residual deficits and can be utilized for sports clearance with excellent outcomes at mean 3.6 year follow-up: A small case series of competitive athletes.

OBJECTIVE: The purpose of this study was to assess the use of a criteria-based return to sport (CBRTS) test to evaluate readiness for return to play (RTP) in competitive athletes that underwent open Latarjet. DESIGN: Retrospective case series. METHODS: Ten competitive athletes (mean age 19.9 years) treated with open Latarjet for recurrent glenohumeral instability underwent CBRTS testing at a mean of 5.3 months postoperatively. Testing consisted of four components: 1. isometric strength, 2. isokinetic strength, 3. endurance, and 4. function. Patients failing 0 or 1 component of the test were cleared to RTP. Patients failing multiple components underwent additional deficit-based rehabilitation. RESULTS: Of the 10 patients that tested, 4 passed their overall CBRTS test and were cleared to RTP. The remaining 6 patients failed the overall CBRTS test. Seven patients (70%) failed at least one section of the strength testing, two patients (20%) failed endurance testing, and two patients (20%) failed functional testing. At final follow-up (mean 3.6 years), 1 patient had recurrent instability (10%) and 9 patients returned to play (90%). CONCLUSIONS: CBRTS testing may be clinically useful for return to play clearance decisions after open Latarjet procedure, as it can reveal deficits that may not be identified with time-based clearance alone.

Return to Work After Anterior Cruciate Ligament Reconstruction: A Systematic Review.

Background: The timing of return to work (RTW) after anterior cruciate ligament (ACL) reconstruction (ACLR) is a less studied milestone compared with return to sports. Purpose: To systematically review the rate and postoperative timing of RTW after ACLR. Study Design: Systematic review; Level of evidence, 4. Methods: This study was conducted in accordance with the 2020 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. A literature search was performed in PubMed, Embase, Cochrane, and Ovid databases for clinical studies reporting RTW after ACLR, and 806 studies were identified in August 2022. A quality assessment was performed using the Methodological Index of Nonrandomized Studies (MINORS) grading system. The following data were extracted from studies: study characteristics, cohort demographics, ACLR technique, concomitant meniscal and/or cartilage procedures, preoperative patient-reported outcomes, rates of RTW, and days required for RTW after ACLR. Results: A total of 13 studies met inclusion criteria, totaling 1791 patients (86.4% male). Wide variability was observed in the methodological quality of the assessed studies (MINORS score range, 8-17). Hamstring tendon (HT) autograft was used in 76.8% (n = 1377; mean age, 30.5 years old), allograft in 17.1% (n = 308; mean age, 33.1 years old), the ligament advanced reinforcement system in 2.5% (n = 46; mean age, 33.2 years old), bone-patellar tendon-bone autograft in 2% (n = 36; mean age, 28.5 years old), and quadriceps tendon autograft in 1.3% (n = 24; mean age, 24.1 years old). Among the included patients, 99.1% (n = 1781) reported successful RTW after surgery. The mean time to RTW was 84.2 days (range, 31.4-107.1 days) for HT and 69.5 days (range, 49-56.6 days) for allograft. Conclusion: While data regarding work intensity before and after ACL injury were absent, our study results suggested that patients most often RTW within 90 days of surgery. Patients with allograft ACLR may RTW earlier than patients undergoing ACLR with HT autograft.

Timing of Surgery & Rehabilitation After Multiligamentous Knee Reconstruction.

PURPOSE OF REVIEW: To provide an overview of the current evidence of the timing of surgery and rehabilitation after multiligamentous knee injuries (MLKIs) and offer insights into the ongoing multi-center randomized controlled study, the 'STaR trial'. RECENT FINDINGS: Due to the complexity of the MKLIs, they are usually treated surgically with the goal of either repairing or reconstructing the injured ligaments. Although the current literature on MLKIs is relatively extensive, the consensus on the timing of surgery or rehabilitation following surgery for MLKIs is still lacking. While current literature mostly suggests early treatment, there is also evidence preferring delayed treatment. Furthermore, evidence on the timing of postoperative rehabilitation is limited. Thus, the current multi-center randomized controlled study, the 'STaR trial', is expected to respond to these questions by adding new high-level evidence. The MLKIs are often associated with knee dislocation and constitute a highly complex entity, including concomitant injuries, such as neurovascular, meniscal, and cartilaginous injuries. The treatment of MLKIs usually aims to either repair or reconstruct the injured ligaments, however, there is no general consensus on the timing of surgery or rehabilitation following an MLKI surgery. This current review stresses the need for more high-level research to address the paucity of evidence-based treatment guidelines for the treatment of complex MLKIs.

Bipolar bone loss and distance to dislocation.

Studies have shown that glenoid- and humeral-sided bone loss may be present in up to 73-93% of individuals with recurrent anterior shoulder instability. As such, bone loss must be addressed appropriately, as the amount of bone loss drives surgical decision making and influences outcomes. Methods to describe and measure bone loss have changed over time. Originally, glenoid and humeral bone loss were viewed separately. However, the concepts of bipolar bone loss, the glenoid track (GT), and "on/off-track" lesions arose, highlighting the interplay between the two entities in contributing to recurrent instability. Classically, "off-track" lesions have been described as those Hill-Sachs interval (HSI) greater than the GT, and have been shown to result in higher rates of re-instability when addressed nonoperatively or with Bankart repair alone. More recently, further attention has been given to "on-track" lesions (HSI < GT). The new concept of "distance to dislocation" (DTD) has gained popularity. DTD is calculated as the difference between the GT and HSI, and literature evaluating DTD suggests that not all "on-track" lesions should be treated in the same manner. The purpose of this concept review article is twofold: (I) describe glenoid, humeral, and bipolar bone loss in the setting of anterior shoulder instability; and (II) elaborate on the new concept of "DTD" and its use in guidance of management.

Strength symmetry after autograft anterior cruciate ligament reconstruction.

OBJECTIVE: To compare postoperative isometric quadriceps strength indices (QI%) and hamstring strength limb symmetry indices (HI%) between partial thickness quadriceps tendon (pQT), full thickness quadriceps tendon (fQT), and bone-patellar-tendon bone (BPTB) autograft anterior cruciate ligament reconstruction (ACLR). METHODS: Patients with primary ACLR with pQT, fQT, or BPTB autograft with the documentation of quantitative postoperative strength assessments between 2016 and 2021 were included. Isometric Biodex data, including QI% and HI% (calculated as the percentage of involved to uninvolved limb strength) were collected between 5 and 8 months and between 9 and 15 months postoperatively. RESULTS: In total, 124 and 51 patients had 5-8- and 9-15-month follow-up strength data, respectively. No significant difference was detected between groups for sex. However, patients undergoing fQT were found to be older than those undergoing BPTB (24.6±7 vs 20.2±5; â€‹p = 0.01). There were no significant differences in the number of concomitant meniscus repairs between the groups (pQT vs. fQT vs. BPTB). No significant differences were detected in median (min-max) QI% between pQT, fQT, and BPTB 5-8 months [87 â€‹% (44%-130 â€‹%), 84 â€‹% (44%-110 â€‹%), 82 â€‹% (37%-110 â€‹%) or 9-15 months [89 â€‹% (50%-110 â€‹%), 89 â€‹% (67%-110 â€‹%), and 90 â€‹% (74%-140 â€‹%)] postoperatively. Similarly, no differences were detected in median HI% between the groups 5-8 months or 9-15 months postoperatively. CONCLUSION: The study was unable to detect differences in the recovery of quadriceps strength between patients undergoing ACLR with pQT, fQT, and BPTB autografts at 5-8 months and 9-15-months postoperatively. LEVEL OF EVIDENCE: III.