Bone Block Augmentation of the Posterior Glenoid for Recurrent Posterior Shoulder Instability Is Associated With High Rates of Clinical Failure: A Systematic Review.

PURPOSE: To determine whether posterior glenoid bone block augmentation performed for the treatment of recurrent posterior shoulder instability succeeds in restoring stability and is associated with rates of complications or clinical failures comparable to other glenoid bone augmentation procedures. METHODS: A comprehensive search of PubMed, MEDLINE, and EMBASE databases was performed. Level of evidence studies I to IV pertaining to posterior bone block augmentation reporting on outcomes or complications were included. The search was carried out in accordance with the Preferred Reported Items for Systematic Reviews and Meta-analyses guidelines. RESULTS: Screening of titles, abstracts, and manuscripts with application of inclusion and exclusion criteria yielded 17 full-text articles reporting on 269 shoulders undergoing bone block augmentation. Surgical technique varied between studies with regard to graft type (iliac crest, 13 studies; scapular spine, 2; acromion, 1; distal tibia allograft, 1), graft positioning (medial to 1.5 cm lateral to glenoid surface, equatorial to subequatorial), and open versus arthroscopic technique (open, 10 studies; arthroscopic, 4; both, 3). Four of the 8 studies with pre- and postoperative patient-reported outcomes (PROs) showed significant improvements in these outcomes at final follow-up. The postoperative outcomes ranged from 60 to 90 for Rowe scores (n = 7 studies) and 79 to 90 for Walch-Duplay scores (n = 7 studies). Complications were commonly encountered, with high rates of recurrent instability (0% to 73%) and revision procedures (0% to 67%) across different studies. CONCLUSION: Posterior bone block augmentation for recurrent posterior shoulder instability does not reliably yield substantial improvements in PROs, and complications are frequently observed. The substantial heterogeneity across studies and the small number of patients precludes any substantive judgements as to the superiority of one surgical technique over another. LEVEL OF EVIDENCE: IV, systematic review of level III and IV studies.

Magnetic resonance imaging does not reliably detect Kaplan fiber injury in the setting of anterior cruciate ligament tear.

PURPOSE: There has been a continued effort to better understand the role Kaplan fiber injury plays in persistent instability following ACL tears. However, the prevalence of these injuries remains poorly understood. Therefore, the purpose of this study was to define the prevalence of Kaplan fiber injury in the setting of complete anterior cruciate ligament tear using a commonly used grading system for assessing ligament injuries. The inter-rater reliability of this commonly used grading system and the relationship between Kaplan fiber injury and injury to other structures commonly found in conjunction with ACL tears was also evaluated. METHODS: All isolated, complete anterior cruciate ligament tears confirmed on magnetic resonance imaging within 90 days of injury between 2014 and 2020 at a single institution were included for analysis. Each scan was read by two, fellowship-trained musculoskeletal radiologists. Kaplan fiber injury was evaluated using a previously described grading scheme. Kappa, [Formula: see text], of inter-rater agreement was determined for all magnetic resonance image scans. Kruskal Wallis test was performed to assess for associations between Kaplan fiber injury and magnet strength (1.5 T vs. 3.0 T), patient gender, the presence of medial and/or lateral meniscal tears, and/or posterolateral tibial bone bruise. RESULTS: Between 2014 and 2020, 131 patients (94 males, 37 females) with a complete anterior cruciate ligament tear were included in the final analysis. The mean age of the cohort was 27.8 ± 6.8 years. Kaplan fiber injuries were identified in 51 of 131 (38.9%, CI 31.0-47.5%) scans with complete anterior cruciate ligament injuries (Grade 1: 28, Grade 2: 18, and Grade 3: 5). Inter-rater agreement for Kaplan fiber injury was fair ([Formula: see text] with 43 (32.8%) scans requiring third reviewer adjudication. There were no significant associations between Kaplan fiber injury and gender, magnet strength, meniscal tears, or posterolateral tibial bone bruise. CONCLUSION: The prevalence of Kaplan fiber injuries was comparable to previously described rates; however, the classification system used to report Kaplan fiber injury was associated with low inter-rater reliability. The presence of Kaplan fiber injury was not associated with other injuries commonly observed in conjunction with ACL tear. The previously proposed Kaplan fiber injury classification system is not reproducible nor is it likely to aid surgeons in distinguishing higher grades of rotatory knee instability. LEVEL OF EVIDENCE: Level IV.

Primary and Revision Circumferential Labral Reconstruction for Femoroacetabular Impingement in Athletes: Return to Sport and Technique.

PURPOSE: To determine return-to-play rates and hip-specific outcomes in athlete hips with femoroacetabular impingement syndrome treated with circumferential labral reconstruction (CLR). METHODS: All consecutive patients who underwent CLR from January through December 2016 performed by the senior surgeon with complete 2-year outcome scores were identified. The hips of 57 non-athletes who underwent CLR were excluded from analysis, as were 165 patients who underwent labral repair and 4 patients who underwent labral debridement. Outcome measures were completed by patients within 1 week prior to surgery and between 22 and 26 months postoperatively. Thirty patients met the inclusion criteria for this study. All 30 participated in regular, competitive athletic events and had magnetic resonance arthrogram-confirmed labral tears, and nonsurgical measures had failed. Of the 30 patients, 5 (16.7%) participated in cutting sports; 5 (16.7%), asymmetrical or overhead sports; 4 (13.3%), contact sports; 13 (43.3%), endurance sports; and 3 (10.0%), flexibility sports. Moreover, 25 of 30 (83.3%) were high-level athletes. Both primary (n = 23) and revision (n = 7) procedures were included. RESULTS: As determined by the International Hip Outcome Tool 12 score, 28 of 30 patients (93.3%) met the patient acceptable symptomatic state whereas 30 of 30 (100%) achieved substantial clinical benefit and exceeded the minimal clinically important difference for their operative hip. In addition, 23 of 30 patients (76.6%) met the patient acceptable symptomatic state whereas 30 of 30 (100%) achieved substantial clinical benefit and exceeded the minimal clinically important difference for the operative hip as determined by the visual analog scale pain score. Of 30 patients, 26 (86.7%) were able to return to play. The mean time to return to play was 6.6 months (standard deviation, 2.4 months). CONCLUSIONS: Two-year outcomes in this population of athletes undergoing CLR for femoroacetabular impingement syndrome show a statistically and clinically significant improvement in patient-reported outcomes, a statistically and clinically significant decrease in pain, and an overall return-to-play rate of 86.7%. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

MRI Does Not Reliably Detect Kaplan Fiber Injury In Skeletally Immature Patients with an Acute ACL Tear.

Background: To our knowledge, there have been no previous efforts to evaluate the prevalence of Kaplan fiber (KF) injury in skeletally immature patients with an acute anterior cruciate ligament (ACL) tear on magnetic resonance imaging (MRI) nor has there been any comparison of the reliability of previously described KF diagnostic criteria in this cohort. Purpose: To define the prevalence of KF injury in the setting of acute ACL tears using MRI performed within 90 days of injury among skeletally immature patients, and to compare the reliability of MRI in detecting KF injuries using 2 previously described diagnostic criteria. Study Design: Cohort study; Level of evidence, 3. Methods: Skeletally immature patients with an acute ACL tear confirmed using MRI within 90 days of injury were assessed. Two fellowship-trained musculoskeletal radiologists independently interpreted each MRI scan twice. KF injury was first assessed using the Van Dyck scheme (grade 0, normal; grade 1, periligamentous; grade 2, partial tear; and grade 3, complete tear). MRI scans were then reviewed again using the KF injury criteria proposed by Batty. Discrepancies in KF injury schemes were adjudicated by a third musculoskeletal radiologist. Interrater agreement for both methods was determined using Cohen κ. Results: Included were 45 patients (33 male, 12 female) with a mean age of 13.2 ± 1.6 years. KF injuries were identified in 17 of 45 (37.7%) knees of using the traditional Van Dyck grading scheme (interrater agreement κ = 0.40). The Batty diagnostic criteria identified KF injury in 5 of 45 (11.1%) (interrater agreement κ = 0.45); 17 (37.8%) MRI scans required a third reviewer adjudication for the Van Dyck scheme, while 4 (8.9%) required a third reviewer using the Batty criteria. Conclusion: The Batty diagnostic criteria detected a lower KF injury prevalence than previously reported in the adult population, while the Van Dyck prevalence was similar to rates in adult populations. Both grading criteria had poor interrater reliability in diagnosing a KF injury.