Suture Anchor Fixation Has Less Gap Formation and No Difference in Complications or Revisions for Patellar Tendon Repair: A Systematic Review.

PURPOSE: To evaluate the literature on suture anchor (SA) usage for patellar tendon repair, summarize the overall biomechanical and clinical outcomes, and assess whether the cumulative research supports the adoption of this technique compared with transosseous (TO) repair. METHODS: A systematic literature review using the Preferred Reporting Items for Systematic and Meta-Analyses guidelines was performed. Multiple electronic databases were searched to identify studies focusing on surgical outcomes of patellar tendon repair with suture anchor usage. Cadaver and animal biomechanical studies, technical studies, and clinical studies were included. RESULTS: A total of 29 studies met the inclusion criteria: 6 cadaver, 3 animal, 9 technical, and 11 clinical reports. Four of the 6 cadaver studies and 1 of the 2 animal studies found significantly less gap formation from SA than from TO repair. Average gap formation in human studies ranged from 0.9 to 4.1 mm in the SA group compared with 2.9 to 10.3 mm in TO groups. Load to failure was significantly stronger in 1 of 5 cadaver studies and 2 of 3 animal studies, with human studies SA load to failure ranging from 258 to 868 N and TO load to failure ranging from 287 to 763 N. There were 11 clinical studies that included 133 knees repaired using SA. Nine studies showed no difference between complication rate or risk for reoperation, where one study reported a significantly lower re-rupture rate after SA repair compared with TO repair. CONCLUSIONS: SA repair is a viable option for patellar tendon repair and could have several advantages over TO repair. Multiple studies indicate that SA repair has less gap formation during biomechanical testing compared with TO repair in human cadaver and animal models. No differences in complications or revisions were found in the majority of clinical studies. CLINICAL RELEVANCE: Both animal and human models suggest SA fixation has potential biomechanical benefits when compared with TO tunnels for patellar tendon repair, whereas clinical studies show no difference in complications and revisions postoperatively.

Platelet-Rich Plasma, Bone Marrow Aspirate Concentrate, and Hyaluronic Acid Injections Outperform Corticosteroids in Pain and Function Scores at a Minimum of 6 Months as Intra-Articular Injections for Knee Osteoarthritis: A Systematic Review and Network Meta-analysis.

PURPOSE: To compare the efficacy of common intra-articular injections used in the treatment of knee osteoarthritis, including corticosteroid (CS), hyaluronic acid (HA), platelet-rich plasma (PRP), and bone marrow aspirate concentrate (BMAC), with a minimum follow-up of 6-months. METHODS: A literature search was conducted using the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines in August 2022 in the following databases: PubMed/MEDLINE, Scopus, Cochrane Database of Controlled Trials, and the Cochrane Database of Systematic Reviews. Level I to II randomized clinical trials with a minimum follow-up of 6 months that investigated the treatments of interest were included. Patient-reported outcome scores for pain and function at baseline and at latest follow-up were extracted, and the change in scores was converted to uniform 0 to 100 scales. Arm-based Bayesian network meta-analysis using a random-effects model was created to compare the treatment arms in pain and function. RESULTS: Forty-eight studies comprising a total of 9,338 knees were included. The most studied intra-articular injection was HA (40.9%), followed by placebo (26.2%), PRP (21.5%), CS (8.8%), and then BMAC (2.5%). HA and PRP both led to a significant improvement in pain compared with placebo. HA, PRP, and BMAC all led to a significant improvement in function scores when compared with placebo. Surface under the cumulative ranking curves (SUCRAs) of the interventions revealed that PRP, BMAC, and HA were the treatments with the highest likelihood of improvement in both pain and function, with overall SUCRA scores of 91.54, 76.46, and 53.12, respectively. The overall SUCRA scores for CS and placebo were 15.18 and 13.70, respectively. CONCLUSIONS: At a minimum 6-month follow-up, PRP demonstrated significantly improved pain and function for patients with knee osteoarthritis compared with placebo. Additionally, PRP exhibited the highest SUCRA values for these outcomes when compared with BMAC, HA, and CS. LEVEL OF EVIDENCE: Level II, meta-analysis of Level I to II studies.

Correlation between articular cartilage status on outcomes and survivorship following meniscal allograft transplantation: A systematic review.

PURPOSE: To conduct a systematic review evaluating potential correlations between preoperative articular cartilage integrity on outcomes and survivorship in patients undergoing meniscal allograft transplantation (MAT). METHODS: A literature search was performed by querying SCOPUS, PubMed, Medline, and the Cochrane Central Register for Controlled Trials from database inception through May 2023 according to the 2020 PRISMA statement. Inclusion criteria were limited to studies reporting on outcomes and survivorship following MAT based on preoperative cartilage status. RESULTS: Sixteen studies, consisting of 1723 patients (n = 1758 total menisci), were identified in six level III and 10 level IV evidence studies. There was high heterogeneity in cartilage grading scales, reporting of concomitant cartilage procedures, and indications for MAT based on osteoarthritis. Patients with lower limb malalignment were either excluded or corrected with an osteotomy. MAT failure rate was reported in nine studies, with four studies reporting a greater rate of failure in knees with higher degrees of cartilage damage. Eight studies reported on clinical outcomes based on cartilage grade, with two studies reporting significant differences in clinical outcomes based on cartilage grade. Of the five studies reporting management of full-thickness chondral defects with cartilage surgery, three studies reported no significant difference in survivorship based on preoperative cartilage grade, while one study reported lower survivorship and one study reported unclear results. No studies found significant differences in survivorship and outcomes between medial and lateral MAT. CONCLUSIONS: Conflicting results and high variability in reporting of concomitant cartilage repair and indications for MAT exist in studies evaluating the efficacy of MAT based on articular cartilage status. The degree of preoperative chondral damage did not have a strong relationship with clinical outcomes following MAT. Higher degrees of cartilage damage were associated with higher MAT failure rates, with possible improvement in survivorship when treated with an appropriate cartilage procedure. LEVEL OF EVIDENCE: Level IV.

Medial Collateral Ligament Reconstruction and Repair Show Similar Improvement in Outcome Scores, But Repair Shows Higher Rates of Knee Stiffness and Failure: A Systematic Review.

PURPOSE: To compare patient-reported outcomes and complications in patients with medial collateral ligament (MCL) injuries undergoing repair versus reconstruction with a minimum 2-year follow-up. METHODS: A literature search was conducted using the PubMed, Scopus, and Embase-computerized databases from database inception to November 2022, according to the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies evaluating clinical outcomes and complications at a minimum of 2 years following MCL repair versus reconstruction were included. Study quality was assessed using the MINORS criteria. RESULTS: A total of 18 studies published from 1997 to 2022, consisting of 503 patients were identified. Twelve studies (n = 308 patients; mean age: 32.6 years) reported outcomes following MCL reconstruction, and 8 studies (n = 195 patients; mean age: 28.5 years) reported results following MCL repair. Postoperative International Knee Documentation Committee, Lysholm, and Tegner scores ranged from 67.6 to 91, 75.8 to 94.8, and 4.4 to 8, respectively, in the MCL reconstruction group, compared to 73 to 91, 75.1 to 98.5, and 5.2 to 10, respectively, in the MCL repair group. Knee stiffness was the most commonly reported complication following MCL repair (range: 0% - 50%) and reconstruction (range: 0% - 26.7%). Failures occurred in 0% to 14.6% of patients following reconstruction versus 0% to 35.1% of patients undergoing MCL repair. Manipulation under anesthesia (MUA) for postoperative arthrofibrosis (range: 0% - 12.2%) and surgical debridement for arthrofibrosis (range: 0% - 20%) were the most commonly reported reoperations in the MCL reconstruction and repair groups, respectively. CONCLUSIONS: MCL reconstruction versus repair both demonstrate improved International Knee Documentation Committee, Lysholm, and Tegner scores. MCL repair demonstrates higher rates of postoperative knee stiffness and failure at a minimum 2-year follow-up. LEVEL OF EVIDENCE: Level IV, systematic review of Level III and IV studies.

Suture Augmentation in Orthopaedic Surgery Offers Improved Time-Zero Biomechanics and Promising Short-Term Clinical Outcomes.

Ligament and tendon ruptures have historically been addressed with varying techniques involving either repair or reconstruction. More recently, the potential biomechanical benefits of suture augmentation (SA), also known as internal brace, have attracted substantial attention and helped renew interest in ligament repair surgery. We evaluated the biomechanical and clinical outcomes of SA-based techniques in the following sports medicine procedures: medial ulnar collateral ligament repair of the elbow, thumb collateral ligament repair, anterior cruciate ligament repair, Achilles' tendon repair, and deltoid ligament repair. Published data on the use of SA to augment repairs of the ulnar collateral ligament, thumb collateral ligament, anterior cruciate ligament, Achilles' tendon, and deltoid ligament repair demonstrate improved time-zero biomechanical and promising short- to mid-term clinical outcomes. However, surgeons must be wary of potential complications, including joint overconstraint, nerve paresthesia, and infection. LEVEL OF EVIDENCE: Level V, expert opinion.

Complication Rates After Medial Patellofemoral Ligament Reconstruction Range From 0% to 32% With 0% to 11% Recurrent Instability: A Systematic Review.

PURPOSE: To review the incidence of complications following primary medial patellofemoral ligament (MPFL) reconstruction for recurrent patellar instability. METHODS: A literature search was conducted by querying PubMed and Scopus databases from database inception through August 2022 according to the 2020 Preferred Reporting Items for Systematic Review and Meta-analysis guidelines using the terms "Medial Patellofemoral Ligament," "MPFL," "reconstruction," "patellar," and "instability." Inclusion criteria included studies reporting complications following primary MPFL reconstruction for recurrent patellar instability. Exclusion criteria consisted of studies reporting on patients undergoing concurrent osteotomy procedures, revision reconstruction, and biomechanical or anatomic studies. The incidence of specific complications was aggregated from the included studies. RESULTS: Twenty-eight studies, consisting of 1,478 patients (n = 1521 knees), with a mean age of 23.3 years (mean range, 19-34.3 years) were identified. The overall incidence of complications ranged from 0% to 32.3% of knees. Failure ranged from 0% to 10.7% of knees, whereas patellar fractures occurred in 0% to 8.3% of knees, primarily in patients treated with full-length transverse tunnel or 2-tunnel techniques. All patellar fractures occurred in patients with patellar tunnels ranging from 4.5 to 6.0 mm in diameter. The incidence of postoperative knee stiffness/range of motion deficit ranged from 0% to 20%. Persistent anterior knee pain, ranged from 0% to 32.3%. CONCLUSIONS: Complications following primary MPFL reconstruction ranged from 0% to 32.3% of knees, primarily consisting of residual anterior knee pain. Failure ranged from 0% to 10.7% of knees, whereas patellar fractures were reported in 0% to 8.3% of knees. Fractures primarily occurred with a full-length transverse tunnel or 2-tunnel techniques, whereas all fractures occurred with patellar tunnels ranging from 4.5 mm to 6.0 mm in diameter. LEVEL OF EVIDENCE: IV; Systematic Review of Level I-IV studies.

Meniscal Radial Tears: A Classification System Based on Tear Morphology.

Appropriate management of radial meniscal tears is complex, with continued efforts focused on optimizing diagnostic methods for identification to help dictate treatment, especially as surgical indications for repair have expanded, coupled with improvements in surgical techniques and instrumentation. Currently, no standardized classification system for radial meniscal tears exists, limiting the ability to accurately characterize injury patterns and guide surgical decision-making.

Bone Marrow Aspirate Concentrate Harvest Techniques for the Sports Medicine Surgeon.

The use of bone marrow aspirate concentrate (BMAC) as a surgical augment to enhance biologic healing has been gaining popularity in a variety of sports medicine procedures. Due to its reliable availability from multiple sites, including the proximal tibia, proximal humerus, and anterior superior iliac spine, BMAC can be harvested at a location selected to be adjacent to the primary procedure. This Technical Note aims to highlight 3 different harvest sites for BMAC, allowing orthopaedic sports medicine surgeons to localize their harvest site based on the proximity of the planned procedure and ultimately increase efficiency.

Analysis of patient-directed search content and online resource quality for ulnar collateral ligament injury and surgery.

Background: Patients use the Internet to learn information about injuries, yet online content remains largely unstudied. This study analyzed patient questions posed online regarding ulnar collateral ligament (UCL) tears or UCL surgical management. Methods: Three separate search strings about UCL tear and UCL surgery were queried on the Google search engine. The 300 most commonly asked questions were compiled for each topic and associated webpage information was collected from the "People also ask" section. Questions were categorized using the Rothwell classification and webpages by Journal of the American Medical Association (JAMA) benchmark criteria. Results: The most frequent UCL tear questions were "how long does it take to heal a torn UCL?" and "what is nonsurgical treatment for the UCL?" The most frequent UCL surgery question was "can you retear your UCL after surgery?" The Rothwell classification of questions for UCL tear/UCL surgery was 55%/32% policy, 38%/57% fact, and 7%/11% value with highest subcategories being indications/management (46%/25%) and technical details (24%/25%). The most common webpages were academic (39%/29%) and medical practice (24%/26%). Mean JAMA score for all 600 webpages was low (1.2), with journals (mean = 3.4) having the highest score. Medical practice (mean = 0.5) and legal websites (mean = 0.0) had the lowest JAMA scores. Only 30% of webpages provided UCL-specific information. Conclusion: Online UCL patient questions commonly pertain to technical details and injury management. Webpages suggested by search engines contain information specific to UCL tears and surgery only one-third of the time. The quality of most webpages provided to patients is poor, with minimal source transparency.

Elbow Ulnar Collateral Ligament Repair With Suture Augmentation Results in Good Clinical Results, a Return-to-Play Rate Between 67% and 93%, and a Postoperative Complication Rate Up to 11.9%: A Systematic Review.

Purpose: To review the Kerlan-Jobe Orthopaedic Clinic (KJOC) scores, return-to-play rates, and complications after ulnar collateral ligament (UCL) repair with suture augmentation. Methods: A literature search of the PubMed and Scopus databases was conducted on February 17, 2023, using the terms "ulnar collateral ligament," "repair," "internal brace," and "suture augmentation." The search strategy was based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) protocol and included 4 articles published from 2019 to 2022. The inclusion criteria included studies reporting outcomes, return-to-play rates, and/or complications after UCL repair with suture augmentation. The exclusion criteria consisted of non-English language studies, case reports, cadaveric studies, animal studies, letters to the editor, studies with overlapping cohorts, and review articles. The risk of bias was evaluated using the Methodological Index for Non-Randomized Studies (MINORS) criteria. Results: The final analysis included 4 studies with 510 patients (457 male and 53 female patients), ranging in age between 17.8 and 27.5 years, treated with repair and suture augmentation for UCL tears. In this review, we found a mean postoperative KJOC score ranging from 87.9 to 92.6. The overall rate of return to play at the preinjury level or at a higher level than the preinjury level ranged from 67% to 93%; the mean time to return to play ranged from 6.7 to 17.6 months. The postoperative complication rate in this review ranged from 0% to 11.9%. Among the complications, the most common were ulnar nerve paresthesia (range, 0%-8.2%) and postoperative medial elbow pain (range, 0%-3.1%). Overall, the reoperation rate ranged from 0% to 3.4%. No reruptures were reported. Conclusions: UCL repair with the use of suture augmentation results in postoperative KJOC scores ranging from 87.9 to 92.6, a return-to-play rate between 67% and 93%, and a postoperative complication rate up to 11.9%. Level of Evidence: Level IV, systematic review of Level IV studies.

Meniscus Radial Tears: Current Concepts on Management and Repair Techniques.

PURPOSE OF REVIEW: This review provides a historical perspective on the approach to radial tears and collates the currently available evidence on repair techniques, rehabilitation, and outcomes following the treatment of meniscus radial tears. RECENT FINDINGS: Recent literature shows that the repair of meniscus radial tears reports improved patient-reported outcome scores with high return to function and activity. However, no single technique nor construct was proven better than the other. Various methods of repairing radial tears can be employed, with biomechanical research supporting all-inside double vertical sutures, the addition of vertical "rip-stop" mattress sutures, and transtibial pullout augmentation. To ensure proper healing before undergoing physical therapy, it is crucial to abstain from weight-bearing and deep knee flexion for the first 6 weeks after surgery. Despite considerable heterogeneity in surgical techniques and rehabilitation protocols found in the current literature, studies reporting on radial repairs report positive results, with high healing rates and improved patient-reported outcomes.

Return to Sport After Nonoperative Management of Elbow Ulnar Collateral Ligament Injuries: A Systematic Review and Meta-analysis.

BACKGROUND: Elbow ulnar collateral ligament (UCL) injuries can result in significant functional impairment in throwing and overhead athletes. UCL reconstruction and repair are proven treatments to restore stability, but the efficacy of nonoperative management is unclear. PURPOSE: To determine the rate of return to sports (RTS) and return to previous level of play (RTLP) in athletes sustaining medial elbow ulnar collateral ligament (UCL) injuries treated nonoperatively. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: A literature search was performed using Scopus, PubMed, Medline, the Cochrane Database for Systematic Review, and the Cochrane Central Register for Controlled Trials according to the 2020 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. Inclusion criteria were limited to level 1 to 4 human studies reporting on RTS outcomes after nonoperative management of UCL injuries. RESULTS: A total of 15 studies, consisting of 365 patients with a mean age of 20.45 ± 3.26 years, were identified. Treatment primarily consisted of platelet-rich plasma (PRP) injections with physical therapy (n = 189 patients; n = 7 studies) versus physical therapy alone (n = 176 patients; n = 8 studies). The overall RTS rate was 79.7% and the overall RTLP rate was 77.9%. Increasing UCL injury severity grade was associated with lower RTS rates. The RTS rate for proximal tears (89.7%; n = 61/68) was significantly greater than that for distal tears (41.2%; n = 14/34) (P < .0001). No significant difference in RTS rate was seen in patients treated with PRP versus those who did not receive PRP (P = .757). CONCLUSION: For athletes undergoing nonoperative management of UCL injuries, the overall RTS and RTLP rates were 79.7% and 77.9%, respectively, with excellent outcomes in grade 1 and grade 2 UCL injuries, specifically. The RTS rate for proximal tears was significantly higher than that for distal tears. Athletes were most commonly treated with PRP injection and physical therapy.

Nonoperative Management of Tibial Stress Fractures Result in Higher Return to Sport Rates Despite Increased Failure Versus Operative Management: A Systematic Review.

Purpose: To compare return to sport (RTS) rates and complications after nonoperative versus operative management of tibial stress fractures. Methods: A literature search was conducted per the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using EMBASE, PubMed, and Scopus computerized data from database inception to February 2023. Studies evaluating RTS sport rates and complications after nonoperative or operative management of tibial stress fractures were included. Failure was defined as defined by persistent stress fracture line seen on radiographic imaging. Study quality was assessed using the Modified Coleman Methodology Score. Results: Twenty-two studies consisting of 341 patients were identified. The overall RTS rate ranged from 91.2% to 100% in the nonoperative group and 75.5% to 100% in the operative group. Failures rates ranged from 0% to 25% in the nonoperative groups and 0% to 6% in the operative group. Reoperations were reported in 0% to 6.1% of patients in the operative group, whereas 0% to 12.5% of patients initially managed nonoperatively eventually required operative treatment. Conclusions: Patients can expect high RTS rates after appropriate nonoperative and operative management of tibial stress fractures. Treatment failure rates were greater in patients undergoing nonoperative management, with up to 12.5% initially treated nonoperatively later undergoing operative treatment. Level of Evidence: Level IV; Systematic Review of level I-IV studies.

Radiofrequency Chondroplasty of the Knee Yields Excellent Clinical Outcomes and Minimal Complications: A Systematic Review.

Purpose: To evaluate reported clinical outcomes and complications following radiofrequency (RF) ablation for the treatment of knee chondral lesions. Methods: A literature search was performed according to the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines by querying EMBASE, PubMed, and Scopus computerized databases from database inception through October 2022. Level I to IV clinical studies that reported outcomes or complications following RF-based chondroplasty were included. Postoperative outcome scores and complications were aggregated. Study quality was assessed via the Newcastle-Ottawa Scale. Results: Ten articles from 2002 to 2018 consisting of 1,107 patients (n = 1,504 lesions) were identified. Four studies were of Level I evidence, 3 studies were Level II, 1 study was Level III, and 2 studies were Level IV. The mean patient age was 41.8 ± 6.3 years (range, 12-87). Seven studies (n = 1,037 patients) used bipolar RF devices, and 3 studies (n = 70 patients) used monopolar RF devices. The overall mean postoperative Lysholm, Tegner, and IKDC scores ranged from 83 to 91, 3.8 to 7, and 49 to 90, respectively, in lesions ranging from grade I-IV according to the Outerbridge Classification. Monopolar RF devices reported qualitatively similar mean changes in Lysholm scores (83), Tegner scores (3.8), and IKDC scores (range, 49-69) compared with bipolar RF devices (range, 86.4-91, 4.5-7, 90, respectively). The incidence of complications ranged from 0% to 4%. The most commonly reported complication was osteonecrosis (range, 0% to 4%). The incidence rate of patients undergoing additional surgery ranged from 0% to 4.5%. Conclusions: The available literature on RF-based chondroplasty shows its efficacy and safety for the treatment of knee chondral lesions, with good clinical outcome scores and low complication and reoperation rates. Level of Evidence: Level IV, systematic review of Level I-IV studies.

Single-stage autologous cartilage repair results in positive patient-reported outcomes for chondral lesions of the knee: a systematic review.

AIM: This article aims to perform a systematic review of the clinical literature regarding the efficacy of single-stage autologous cartilage repair. METHODS: A systematic review of the literature was performed using PubMed, Scopus, Web of Science, and the Cochrane Library. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. RESULTS: Twelve studies were identified; however, due to overlapping patient cohorts, nine studies were included for data extraction and analysis. Six studies applied minced cartilage, while three studies utilized enzymatically processed cartilage. Two authorship groups described single-stage techniques that exclusively utilized cartilage from the debrided lesion rim, while the remaining groups either utilized healthy cartilage or combined healthy cartilage with cartilage debrided from lesion rim. Among the included techniques, scaffold augments were used in four studies, and three studies implemented bone autograft augmentation. When summarizing patient reported outcome measures for the included studies, single-stage autologous cartilage repair demonstrated an average improvement ranging from 18.7 â€‹± â€‹5.3 to 30.0 â€‹± â€‹8.0 amongst the Knee Injury and Osteoarthritis Outcome Scores subsections, 24.3 â€‹± â€‹10.5 for the International Knee Documentation Committee subjective score, and 41.0 â€‹± â€‹10.0 for Visual Analogue Scale-Pain. CONCLUSION: Single-stage autologous cartilage repair is a promising technique with positive clinical data to date. The current study highlights the overall improvement in patient reported outcomes after repair for chondral defects to the knee with average follow-up ranging from 12 to 201 months and also the heterogeneity and variability of the single-stage surgical technique. Further discussion on the standardization of practices for a cost-effective single-stage augmented autologous cartilage technique is needed. In the future, a well-designed randomized controlled trial is needed to explore the efficacy of this therapeutic modality relative to established intervention. LEVEL OF EVIDENCE: Systematic review; Level IV.

Patient-specific instrumentation for medial opening wedge high tibial osteotomies in the management of medial compartment osteoarthritis yields high accuracy and low complication rates: A systematic review.

IMPORTANCE: There has been growing interest in the use of patient-specific instrumentation (PSI) to maximise accuracy and minimise the risk of major complications for medial opening-wedge high tibial osteotomies (MOW-HTOs). Numerous studies have reported the efficacy and safety of implementing this technology into clinical practice, yet no systematic review summarising the clinical literature on PSI for MOW-HTOs has been performed to date. AIM: The aim of this investigation was to perform a systematic review summarising the evidence surrounding the use of PSI for MOW-HTOs in the management of medial compartment osteoarthritis. EVIDENCE REVIEW: PubMed, Scopus, and the Cochrane Library were queried in October 2021 for studies that used PSI for MOW-HTOs when managing medial compartment knee osteoarthritis. Primary outcomes included accuracy in coronal plane correction (mechanical medial proximal tibial angle), sagittal plane correction (posterior tibial slope), and mechanical axis correction (hip-knee-ankle angle [HKA], mechanical femorotibial angle, and weight-bearing line). Accuracy was defined as error between post-operative measurements relative to the planned pre-operative correction. A secondary outcome was the incidence of major complications. FINDINGS: This review included eight different techniques among the 14 included studies. There was a weighted mean error of 0.5° (range: 0.1°-1.3°) for the mechanical medial proximal tibial angle, 0.6° (range: 0.3°-2.7°) for the posterior tibial slope, and 0.8° (range: 0.1°-1.0°) for the hip-knee-ankle angle. Four studies compared the correctional error of the mechanical axis between conventional techniques and PSI techniques. The comparative difference between the two techniques favoured the use of PSI for MOW-HTOs (standardised mean difference â€‹= â€‹0.52; 95% confidence interval, 0.16 to 0.87; p â€‹= â€‹0.004). Among the 14 studies evaluated, four studies explicitly reported no major complications, while five studies reported a non-zero incidence of major complications. Among these nine studies, the weighted mean major complication rate was 7.1% (range: 0.0-13.0%). CONCLUSIONS AND RELEVANCE: The findings of this present systematic review suggest that the use of PSI for MOW-HTOs leads to high accuracy relative to the planned corrections in the coronal plane, sagittal plane, and mechanical axis. Furthermore, these findings would suggest there is a low risk of major complications when implementing PSI for MOW-HTOs. LEVEL OF EVIDENCE: Systematic review; IV.

Single-Incision Distal Biceps Tendon Repair With Bicortical Tensionable Locking Button Fixation.

Acute, traumatic distal biceps tendon injuries are common among the middle-aged athletic male population. Surgical repair of distal biceps tendon remains the most effective means to restore maximal strength of forearm supination and elbow flexion with relief of antecubital pain. To date, no consensus exists on the optimal fixation method during distal biceps tendon repair and multiple techniques are accepted, including 1- and 2-incision approaches and tendon fixation with suture anchors, transosseous sutures, interference screws, and cortical buttons. In this Technical Note, we demonstrate a distal biceps tendon repair technique using a single-incision approach with bicortical, tensionable suspensory button fixation.

Anterior Opening-Wedge High Tibial Osteotomy in the Setting of Genu Recurvatum.

Patients with pathologic genu recurvatum may present with complaints regarding anterior knee pain, instability, loss of range of motion, or locking episodes of the knee. Symptomatic genu recurvatum refractory to conservative measures may require surgical treatment. In this Technical Note, the authors describe a surgical technique involving an anterior opening-wedge high tibial osteotomy for a patient with symptomatic genu recurvatum from a knee hyperextension injury resulting in posterior soft-tissue laxity. The surgical technique aims to correct the limb sagittal alignment and provide stability to the knee joint, with the ultimate goal of improving patient outcomes.

The effect of an attending versus neutral observer on peg transfer and intracorporeal knot-tying laparoscopic tasks.

BACKGROUND: Surgery is an outcome-based specialty where maintaining peak performance is crucial to patient care. There are a variety of identified surgeon stressors that can have an impact on performance, but one factor unique to surgical residents is the observation by an attending surgeon. This study explored how the perceived authority of the observer had an impact on the participants' physiologic markers of stress and task completion times. METHODS: Eighteen general surgery residents performed the Fundamentals of Laparoscopic Surgery skills intracorporeal knot-tying and peg transfer tasks in a crossover study design while under the observation of an attending and a neutral observer. Heart rate variability, mean R-R interval, the time between R spikes on an EKG, minimum heart rate, maximum heart rate, average heart rate, and time to task completion were recorded. Analyses were completed via 2 × 2 analysis of variance with repeated measures. RESULTS: When observed by an attending, participants demonstrated higher minimum, average, and maximum heart rates (P = .046, = .007, and < .001, respectively) than when observed by a neutral observer. Attending observation also significantly shortened time to task completion, relative to neutral observation (P = .022). CONCLUSION: Attending observation is linked to increased objective measures of stress at the time of performance with decreased task completion times. Educational efforts to optimize the response to stress during learning may lead to better outcomes.