The accuracy of routine knee MR imaging in detection of acute neurovascular injury following multiligamentous knee injury.

OBJECTIVE: To assess the accuracy of routine knee MRI in detecting acute popliteal artery and/or common peroneal nerve (CPN) dysfunction following multiligamentous knee injury (MLKI), with correlation of MRI findings to clinical outcome. MATERIALS AND METHODS: Routine MRI knee examinations in 115 MLKI patients (54/115 with acute neurovascular injury, 61/115 without neurovascular injury) were retrospectively reviewed. Cases were classified by injury mechanism and ligamentous injuries sustained. MRI examinations were reviewed by two readers for vascular (arterial flow void, arterial calibre, intimal flap, perivascular hematoma) and CPN (intraneural T2-hyperintensity, calibre, discontinuity, perineural hematoma) injuries. Accuracy of routine knee MRI in the diagnosis of acute neurovascular injury and correlation of MRI findings to clinical outcome were evaluated. RESULTS: Patients included 86/115 males, mean age 33 years. The accuracy of MRI in diagnosis of acute CPN injury was 80.6%, 83.6% (readers 1 and 2): sensitivity (78%, 79.7%), specificity (80%, 86.7%), PPV (78%, 82.5%), and NPV (82.7%, 84.4%). Increased intraneural T2 signal showed a significant correlation to acute CPN dysfunction (p < 0.05). MRI was 75%, 69.8% (readers 1 and 2) accurate in detecting acute vascular injury: sensitivity (73.3%, 86.7%), specificity (75.2%, 67.3%), PPV (30.5%, 36.1%), and NPV (95%, 97.1%). No MRI features of vascular injury showed a statistical correlation with clinical outcome. Neurovascular complications were more common in ultra-low-energy injuries and KD-V3L pattern of ligament disruption. CONCLUSION: Routine MRI is of limited accuracy in assessing vascular complication, but higher accuracy in assessing CPN injury following MLKI. Increased intraneural T2 signal on conventional knee MR imaging shows statistically significant association with clinically documented acute CPN dysfunction following MLKI.

Anterior Cruciate Ligament Patellar Tendon Autograft Fixation at 0° Versus 30° Results in Improved Activity Scores and a Greater Proportion of Patients Achieving the Minimal Clinical Important Difference For Knee Injury and Osteoarthritis Outcome Score Pain: A Randomized Controlled Trial.

PURPOSE: The aim of the current study was to determine the effect of the knee flexion angle (KFA) during tibial anterior cruciate ligament (ACL) graft fixation on patient-reported outcomes, graft stability, extension loss, and reoperation after anatomic single-bundle ACL reconstruction. METHODS: All 169 included patients (mean age 28.5 years, 65% male) were treated with anatomic single-bundle ACL reconstruction using patellar tendon autograft and were randomized to tibial fixation of the ACL graft at either 0° (n = 85) or 30° (n = 84). The primary outcome was the Knee Injury and Osteoarthritis Outcome Score (KOOS) 2 years after surgery. Secondary outcomes were the Marx Activity Scale (MAS), the rate of reoperation, and physical examination findings at 1 year, including KT-1000 and side-to-side differences in knee extension. RESULTS: The follow-up rate was 82% (n = 139) for the primary outcome. Graft failure rate at 2 years was 1% (n = 2, 1 per group). ACL tibial graft fixation at 0° or 30° did not have a significant effect on KOOS scores at 2 years after ACLR. Patients whose graft was fixed at a knee flexion angle of 0° had greater scores on the MAS (mean 9.6 95% confidence interval [CI] 8.5 to 10.6, versus 8.0, 95% CI 6.9 to 9.1; P = .04), and a greater proportion achieved the minimal clinical important difference (MCID) for the KOOS pain subdomain (94% versus 81%; P = .04). There was no significant difference in knee extension loss, KT-1000 measurements, or reoperation between the 2 groups. CONCLUSION: In the setting of anatomic single-bundle ACLR using patellar tendon autograft and anteromedial portal femoral drilling, there was no difference in KOOS scores between patients fixed at 0° and 30°. Patient fixed in full extension did demonstrate higher activity scores at 2 years after surgery and a greater likelihood of achieving the MCID for KOOS pain. LEVEL OF EVIDENCE: II, prospective randomized trial.

Is There a Disadvantage to Early Physical Therapy After Multiligament Surgery for Knee Dislocation? A Pilot Randomized Clinical Trial.

BACKGROUND: Multiligament knee injuries, though rare, can be profoundly disabling. Surgeons disagree about when to initiate rehabilitation after surgical reconstruction due to the conflicting priorities of postoperative stability and motion. QUESTIONS/PURPOSES: (1) Does early or late initiation of physical therapy after multiligament knee surgery result in fewer postoperative manipulations? (2) Does early versus late physical therapy compromise stability postoperatively? (3) Does early initiation of physical therapy result in improved patient-reported outcomes, as measured by the Multi-ligament Quality of Life (ML-QOL) score? METHODS: Between 2011 and 2016, 36 adults undergoing multiligament repair or reconstruction were prospectively enrolled in a randomized controlled trial and randomized 1:1 to either early rehabilitation or late rehabilitation after surgery. Eligibility included those with an injury to the posterior cruciate ligament (PCL) and at least one other ligament, as well as the ability to participate in early rehabilitation. Patients who were obtunded or unable to adhere to the protocols for other reasons were excluded. Early rehabilitation consisted of initiating a standardized physical therapy protocol on postoperative day 1 involving removal of the extension splint for quadriceps activation and ROM exercises. Late rehabilitation consisted of full-time immobilization in an extension splint for 3 weeks. Following this 3-week period, both groups engaged in the same standardized physical therapy protocol. All surgical reconstructions were performed at a single center by one of two fellowship-trained sports orthopaedic surgeons, and all involved allograft Achilles tendon PCL reconstruction. When possible, hamstring autograft was used for ACL and medial collateral ligament reconstructions, whereas lateral collateral ligament and posterolateral reconstruction was performed primarily with allograft. The primary outcome was the number of patients undergoing manipulation during the first 6 months. Additional outcomes added after trial registration were patient-reported quality of life scores (ML-QOL) at 1 year and an objective assessment of laxity through a physical examination and stress radiographs at 1 year. One patient from each group was not assessed for laxity or ROM at 1 year, and one patient from each group did not complete the ML-QOL questionnaires. No patient crossover was observed. RESULTS: With the numbers available, there was no difference in the use of knee manipulation during the first 6 months between the rehabilitation groups: 1 of 18 patients in the early group and 4 of 18 patients in the late group (p = 0.34). Similarly, there were no differences in knee ROM, stability, or patient-reported quality of life (ML-QOL) between the groups at 1 year. CONCLUSION: With the numbers available in this study, we were unable to demonstrate a difference between early and late knee rehabilitation with regard to knee stiffness, laxity, or patient-reported quality of life outcomes. The results of this small, randomized pilot study suggest a potential role for early rehabilitation after multiligament reconstruction for knee dislocation, which should be further explored in larger multi-institutional studies. LEVEL OF EVIDENCE: Level II, therapeutic study.

Imaging of the Postoperative Condition of Posterolateral Corner Injuries.

Posterolateral corner (PLC) injuries of the knee are often sustained in combination with anterior or posterior cruciate ligament injuries. A variety of surgical techniques including acute repair, nonanatomical reconstructions, and anatomical reconstructions have been used to treat grade III PLC injuries. Scant literature is available on postoperative imaging of the PLC. This article reviews the more commonly used surgical techniques and the postoperative imaging assessment of the PLC of the knee.

Meniscal root tears occur frequently in multi-ligament knee injury and can be predicted by associated MRI injury patterns.

PURPOSE: The frequency of meniscal root tears in association with multi-ligament knee injury has not been established but adds to the complexity of surgical reconstruction and may have long-term consequences. Therefore, identifying root tears, on preoperative imaging, is important. The aim of this study was to identify the frequency of meniscal root tears, on preoperative magnetic resonance imaging, following multi-ligament injury and distinguish associated injury patterns that may aid detection. METHODS: Cases were identified from a prospectively collected institutional database. The magnetic resonance imaging of 188 multi-ligament injuries [median age 31 years (range 16-64)] was retrospectively reviewed by three musculoskeletal radiologists with the presence of meniscal injuries recorded alongside the ligament injury pattern and intra-articular fractures. Assessment of injury pattern was solely made on this imaging. RESULTS: 38 meniscal root injuries were identified in 37 knees (overall frequency = 20.2%; medial = 10.6%; lateral = 9.6%). The frequency of meniscal root tears was not increased in higher grade injuries (21.5% vs. 17.0%, n.s.). Valgus injury patterns were associated with lateral root tears (p < 0.05) and varus patterns were associated with medial root tears (p < 0.05). Further, fractures in the same compartment were associated with both medial and lateral root tears (p < 0.05). CONCLUSIONS: Meniscal root tears occur more frequently in multi-ligament knee injury than previously reported with isolated anterior cruciate rupture. Root tears can be predicted by ligament injury patterns and fractures sustained (suggestive of a compressive force). In multi-ligament cases, the preoperative magnetic resonance imaging can be used to detect these tears and associated patterns of injury. LEVEL OF EVIDENCE: IV.

Adductor Canal Block Provides Noninferior Analgesia and Superior Quadriceps Strength Compared with Femoral Nerve Block in Anterior Cruciate Ligament Reconstruction.

BACKGROUND: By targeting the distal branches of the femoral nerve in the mid-thigh, the adductor canal block (ACB) can preserve quadriceps muscle strength while providing analgesia similar to a conventional femoral nerve block (FNB) for inpatients undergoing major knee surgery. In this randomized, double-blind, noninferiority trial, the authors hypothesized that ACB provides postoperative analgesia that is at least as good as FNB while preserving quadriceps strength after outpatient anterior cruciate ligament reconstruction. METHODS: A total of 100 patients were randomized to receive ACB or FNB with 20 ml ropivacaine 0.5% (with epinephrine). The authors sequentially tested the joint hypothesis that ACB is noninferior to FNB for cumulative oral morphine equivalent consumption and area under the curve for pain scores during the first 24 h postoperatively and also superior to FNB for postblock quadriceps maximal voluntary isometric contraction. RESULTS: The authors analyzed 52 and 48 patients who received ACB and FNB, respectively. Compared with preset noninferiority margins, the ACB-FNB difference (95% CI) in morphine consumption and area under the curve for pain scores were -4.8 mg (-12.3 to 2.7) (P = 0.03) and -71 mm h (-148 to 6) (P < 0.00001), respectively, indicating noninferiority of ACB for both outcomes. The maximal voluntary isometric contraction for ACB and FNB at 45 min were 26.6 pound-force (24.7-28.6) and 10.6 pound-force (8.3-13.0) (P < 0.00001), respectively, indicating superiority of ACB. CONCLUSION: Compared with FNB, the study findings suggest that ACB preserves quadriceps strength and provides noninferior postoperative analgesia for outpatients undergoing anterior cruciate ligament reconstruction.

Editorial Commentary: Book? Book Report? or Just a New Chapter in an Ongoing Story?: Knee Partial Meniscectomy Has Limited Benefit for "Nonobstructive" Meniscal Tears, but We Need to Know if Patients Have Osteoarthritis.

Knee partial meniscectomy has limited benefit for "nonobstructive" meniscal tears, but we need to know if included patients have osteoarthritis. Research on outcomes of arthroscopic partial meniscectomy versus nonsurgical treatment must consider not only signs and symptoms but also imaging findings, to determine the indications for surgical versus nonsurgical in a selected patient.

Acute Management and Surgical Timing of the Multiligament-injured Knee.

Multiligament knee injuries are relatively rare, but the outcomes can be disastrous if they are not identified and treated appropriately. Recent trends in the literature are showing more focus on early identification and subspecialist management as important ways to achieve the best possible outcomes for these injuries. Early identification and the appropriate treatment of associated injury patterns are the keys to improving outcomes. These injuries are usually associated with high-energy trauma, but low-energy injuries also cause these severe injuries in patients with other comorbidities, such as those with high body mass indices. Familiarity with an evidence-based approach is helpful for managing these complex injuries.

The sizing of hamstring grafts for anterior cruciate reconstruction: intra- and inter-observer reliability.

PURPOSE: The objective of this study was to establish the intra- and inter-observer reliability of hamstring graft measurement using cylindrical sizing tubes. METHODS: Hamstring tendons (gracilis and semitendinosus) were harvested from ten cadavers by a single surgeon and whip stitched together to create ten 4-strand hamstring grafts. Ten sports medicine surgeons and fellows sized each graft independently using either hollow cylindrical sizers or block sizers in 0.5-mm increments­the sizing technique used was applied consistently to each graft. Surgeons moved sequentially from graft to graft and measured each hamstring graft twice. Surgeons were asked to state the measured proximal (femoral) and distal (tibial) diameter of each graft, as well as the diameter of the tibial and femoral tunnels that they would drill if performing an anterior cruciate ligament (ACL) reconstruction using that graft. Reliability was established using intra-class correlation coefficients. RESULTS: Overall, both the inter-observer and intra-observer agreement were >0.9, demonstrating excellent reliability. The inter-observer reliability for drill sizes was also excellent (>0.9). Excellent correlation was seen between cylindrical sizing, and drill sizes (>0.9). CONCLUSIONS: Sizing of hamstring grafts by multiple surgeons demonstrated excellent intra-observer and intra-observer reliability, potentially validating clinical studies exploring ACL reconstruction outcomes by hamstring graft diameter when standard techniques are used. LEVEL OF EVIDENCE: III.

Risk factors for the development of heterotopic ossification after knee dislocation.

BACKGROUND: Results of treatment for acute knee dislocations and multiligament knee injuries may be influenced by a multitude of patient- and injury-related factors, including neurologic function, vascular status, ipsilateral fractures, and joint stability. The development of heterotopic ossification (HO) may nullify any benefits of reconstruction, because it can cause stiffness and discomfort. Identifying factors associated with HO after knee dislocation may help identify patients who might benefit from prophylaxis. QUESTIONS/PURPOSES: The purposes of this study were (1) to identify specific risk factors for the development of HO in patients with knee dislocation; and (2) to elucidate the relationship between the presence of absence of HO and postoperative range of motion. METHODS: Between 2005 and 2010, we performed 101 multiligament reconstructions for patients with knee dislocations, of which 91 (90%) in 91 patients were available for followup at a minimum of 6 months (mean, 18 months; range, 6-44 months), and were reviewed here. AP and lateral radiographs were reviewed for all patients and HO was classified according to the Mills and Tejwani classification system. This knee dislocation cohort was separated into two groups based on the presence or absence of HO for comparison. Using a significance level of p < 0.05 for factors in the univariate analyses, we identified potential variables for a multivariate logistic regression model to identify risk factors predicting development of HO in patients with multiligament knee injuries; multivariate analysis then was performed to mitigate the influence of potentially confounding variables. Thirty patients (34%) developed HO after multiligament knee injury in our series. RESULTS: Posterior cruciate ligament reconstruction was the only independent predictor of HO that we identified (odds ratio, 6.3; 95% confidence interval, 1.2-34.6). Patients who developed HO were more likely to develop stiff knees and undergo surgery (50%; 15 of 30 patients) versus those without HO (12%; seven of 58 patients) to attempt to restore functional range of motion (p < 0.001). CONCLUSIONS: HO is a common complication after knee dislocation and can diminish range of motion and cause patients to undergo further surgery. Posterior cruciate ligament reconstruction is an independent risk factor for the development of HO. Strategies to identify risk factors for, and safe prevention of, HO after multiple ligament injury and surgery should be investigated going forward. LEVEL OF EVIDENCE: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

External rotation immobilization for primary shoulder dislocation: a randomized controlled trial.

BACKGROUND: The traditional treatment for primary anterior shoulder dislocations has been immobilization in a sling with the arm in a position of adduction and internal rotation. However, recent basic science and clinical data have suggested recurrent instability may be reduced with immobilization in external rotation after primary shoulder dislocation. QUESTIONS/PURPOSES: We performed a randomized controlled trial to compare the (1) frequency of recurrent instability and (2) disease-specific quality-of-life scores after treatment of first-time shoulder dislocation using either immobilization in external rotation or immobilization in internal rotation in a group of young patients. METHODS: Sixty patients younger than 35 years of age with primary, traumatic, anterior shoulder dislocations were randomized (concealed, computer-generated) to immobilization with either an internal rotation sling (n = 29) or an external rotation brace (n = 31) at a mean of 4 days after closed reduction (range, 1-7 days). Patients with large bony lesions or polytrauma were excluded. The two groups were similar at baseline. Both groups were immobilized for 4 weeks with identical therapy protocols thereafter. Blinded assessments were completed by independent observers for a minimum of 12 months (mean, 25 months; range, 12-43 months). Recurrent instability was defined as a second documented anterior dislocation or multiple episodes of shoulder subluxation severe enough for the patient to request surgical stabilization. Validated disease-specific quality-of-life data (Western Ontario Shoulder Instability index [WOSI], American Shoulder and Elbow Surgeons evaluation [ASES]) were also collected. Ten patients (17%, five from each group) were lost to followup. Reported compliance with immobilization in both groups was excellent (80%). RESULTS: With the numbers available, there was no difference in the rate of recurrent instability between groups: 10 of 27 patients (37%) with the external rotation brace versus 10 of 25 patients (40%) with the sling redislocated or developed symptomatic recurrent instability (p = 0.41). WOSI scores were not different between groups (p = 0.74) and, although the difference in ASES scores approached statistical significance (p = 0.05), the magnitude of this difference was small and of uncertain clinical importance. CONCLUSIONS: Despite previous published findings, our results show immobilization in external rotation did not confer a significant benefit versus sling immobilization in the prevention of recurrent instability after primary anterior shoulder dislocation. Further studies with larger numbers may elucidate whether functional outcomes, compliance, or comfort with immobilization can be improved with this device. LEVEL OF EVIDENCE: Level I, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Accuracy and reliability of determining the isometric point of the knee for multiligament knee reconstruction.

PURPOSE: To compare the accuracy and reliability of the anatomic and radiographic techniques for identifying the isometric point of the knee. METHODS: Only four specimens were used; however, eight experienced multiligament knee injury surgeons were recruited to address this limitation. Surgeons estimated the isometric point (EIP) on the medial and lateral sides using an anatomic and radiographic method. The x and y coordinates of the EIP were compared to the true isometric point (TIP). T-tests and interclass correlation coefficients (ICC) were performed to determine the accuracy and reliability between the methods. RESULTS: There was no difference in placement of the EIP on the medial side of the knee in the anterior/posterior (x; p = n.s.) and superior/inferior direction (y; p = n.s). The EIP was anterior (p = 0.001) to the TIP with the radiographic method on the lateral side and approached significance (p = 0.05) in the superior/inferior direction. The ICC (95% CI) for identifying the EIP on the medial side in the anterior/posterior direction using the anatomic method was 0.64 (0.28-0.96) and 0.11 (-0.06 to 0.77) in the superior/inferior direction. Using the radiographic method, the ICC in the anterior/posterior and superior/inferior direction was 0.49 (0.14-0.94) and 0.15 (-0.47 to 0.81), respectively. On the lateral side, the ICC for the anatomic method was 0.84 (0.56-0.99) in the anterior/posterior direction and 0.36 (0.05-0.90) in the superior/inferior direction. Using the radiographic method, the ICC in the anterior/posterior and superior/inferior direction was 0.61 (0.26-0.96) and 0.89 (0.67-0.99), respectively. CONCLUSIONS: There was no difference in accuracy on the medial side of the knee. On the lateral side, the anatomic method was more accurate in the anterior/posterior direction. Reliability was greater in the anterior/posterior direction on both sides of the knee. Surgeons were most likely to place the isometric point anterior and superior to the TIP on both the medial and lateral sides of the knee with either method which has the potential to cause graft lengthening. This should be taken into consideration during reconstruction/repair of the MCL/PMC and LCL/PLC.

Early Versus Delayed Weight Bearing and Mobilization After Ankle Fracture Fixation Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

The purpose of this review was to determine whether there is a benefit to early weight bearing or mobilization in surgically treated ankle fractures. All randomized controlled trials that analyzed early vs delayed weight bearing and/or mobilization after an ankle surgery were included. The primary outcome measure was the pooled Olerud Molander Ankle Score 1 year postoperatively. No significant differences in ankle function were found at 1 year postoperatively between early and delayed weight bearing and mobilization. The 12-week results demonstrated superior early ankle function scores for patients who had early weight bearing. Patients who had early mobilization were at increased risk for postoperative complications. In surgically treated ankle fractures, early weight bearing resulted in improved short-term ankle function scores. [Orthopedics. 2024;47(2):71-78.].

Comparing the Interobserver Reliability of 4 Methods Used to Measure Knee Laxity on Coronal Plane Stress Radiograph.

Background: Varus and valgus knee stress radiographs provide valuable information in the pre- and postoperative evaluation of joint laxity in patients with multiligament knee injuries (MLKIs). Purpose: To review the literature for described techniques of quantifying laxity on coronal stress radiographs of the knee and identify the most reliable method. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: A thorough literature search using the MEDLINE and Embase databases identified 4 studies with distinct methods for objectively measuring laxity on varus and valgus stress radiographs: Heesterbeek et al (2008), Jacobsen (1976), LaPrade et al (2004), and Sawant et al (2004). To compare these methods, 200 coronal plane stress radiographs from 50 patients with MLKIs were retrospectively reviewed from an MLKI database at a single institution. The amount of varus and valgus laxity on each radiograph was measured independently by 4 reviewers using each method. Intraclass correlation coefficients (ICCs) with 95% CIs were calculated to assess the interobserver reliability of each method overall and the varus and valgus measurements individually. Results: For all 4 methods, the overall interobserver reliability was considered at least moderate. The method by Heesterbeek et al proved to have the highest interrater reliability in all domains-overall (ICC, 0.87 [95% CI, 0.85-0.90]), valgus (ICC, 0.83 [95% CI, 0.78-0.88]), and varus (ICC, 0.87 [95% CI, 0.83-0.90])-demonstrating good to excellent reliability both overall and in varus measurements and showing good reliability in valgus measurements. The method by Sawant et al demonstrated good reliability in valgus measurements. All other measures demonstrated moderate reliability. Conclusion: Available methods for measuring knee joint laxity on varus and valgus knee stress radiographs in patients with MLKIs demonstrated moderate to good interobserver reliability. The method described by Heesterbeek et al proved to have the highest reliability overall as well as in measurements on varus and valgus views individually.

Outcomes of osteochondral allograft transplantation in the knee.

PURPOSE: The objectives of this study were (1) to conduct a systematic review of clinical outcomes after osteochondral allograft transplantation in the knee and (2) to identify patient-, defect-, and graft-specific prognostic factors. METHODS: We searched PubMed, Medline, EMBASE, and the Cochrane Central Register of Controlled Trials. Studies that evaluated clinical outcomes in adult patients after osteochondral allograft transplantation for chondral defects in the knee were included. Pooled analyses for pertinent continuous and dichotomous variables were performed where appropriate. RESULTS: There were 19 eligible studies resulting in a total of 644 knees with a mean follow-up of 58 months (range, 19 to 120 months). The overall follow-up rate was 93% (595 of 644). The mean age was 37 years (range, 20 to 62 years), and 303 patients (63%) were men. The methods of procurement and storage time included fresh (61%), prolonged fresh (24%), and fresh frozen (15%). With regard to etiology, the most common indications for transplantation included post-traumatic (38%), osteochondritis dissecans (30%), osteonecrosis from all causes (12%), and idiopathic (11%). Forty-six percent of patients had concomitant procedures, and the mean defect size across studies was 6.3 cm(2). The overall satisfaction rate was 86%. Sixty-five percent of patients (72 of 110) showed little to no arthritis at final follow-up. The reported short-term complication rate was 2.4%, and the overall failure rate was 18%. Heterogeneity in functional outcome measures precluded a meta-analysis; a qualitative synthesis allowed for the identification of several positive and negative prognostic factors. CONCLUSIONS: Osteochondral allograft transplantation for focal and diffuse (single-compartment) chondral defects results in predictably favorable outcomes and high satisfaction rates at intermediate follow-up. Patients with osteochondritis dissecans and traumatic and idiopathic etiologies have more favorable outcomes, as do younger patients with unipolar lesions and short symptom duration. Future studies should include comparative control groups and use established outcome instruments that will allow for pooling of data across studies. LEVEL OF EVIDENCE: Level IV, systematic review of Level IV studies.

Assessment of 30 Years of Randomized Controlled Trials in The American Journal of Sports Medicine: 1990-2020.

Background: Randomized controlled trials (RCTs) stand atop the evidence-based hierarchy of study designs for their ability to arrive at results with the lowest risk of bias. Even for RCTs, however, critical appraisal is essential before applying results to clinical practice. Purpose: To analyze the quality of reporting of RCTs published in The American Journal of Sports Medicine (AJSM) from 1990 to 2020 and to identify trends over time and areas of improvement for future trials. Study Design: Systematic review; Level of evidence, 1. Methods: We queried the AJSM database for RCTs published between January 1990 and December 2020. Data pertaining to study characteristics were recorded. Quality assessments were conducted using the Detsky quality-of-reporting index and the modified Cochrane risk-of-bias (mROB) tool. Univariate and multivariable models were generated to establish factors with associations to study quality. The Fragility Index was calculated for eligible studies. Results: A total of 277 RCTs were identified with a median sample size of 70 patients. A total of 19 RCTs were published between 1990 and 2000 (t1); 82 RCTs between 2001 and 2010 (t2); and 176 RCTs between 2011 and 2020 (t3). From t1 to t3, significant increases were observed in the overall mean-transformed Detsky score (from 68.2% ± 9.8% to 87.4% ± 10.2%, respectively; P < .001) and mROB score (from 4.7 ± 1.6 to 6.9 ± 1.6, respectively; P < .001). Multivariable regression analysis revealed that trials with follow-up periods of <5 years clearly stated primary outcomes, and a focus on the elbow, shoulder, or knee were associated with higher mean-transformed Detsky and mROB scores. The median Fragility Index was 2 (interquartile range, 0-5) for trials with statistically significant. Studies with small sample sizes (<100 patients) were more likely to have low Fragility Index scores and less likely to have a statistically significant finding in any outcome. Conclusion: The quantity and quality of published RCTs published in AJSM increased over the past 3 decades. However, single-center trials with small sample sizes were prone to fragile results.

Risk factors for peroneal nerve injury and recovery in knee dislocation.

BACKGROUND: Acute knee dislocation is rare but has a high rate of associated neurovascular injuries and potentially limb-threatening complications. These include the substantial morbidity associated with peroneal nerve injury: neuropathic pain, decreased mobility, and considerably reduced function, which not only impairs patient function but complicates treatment. QUESTIONS/PURPOSES: We therefore identified and quantified the risks associated with specific factors for peroneal nerve injury and recovery in patients with knee dislocations. PATIENTS AND METHODS: We retrospectively reviewed the charts of 26 patients, from among a cohort of all 91 knee dislocations, with a peroneal nerve palsy over a 5-year period. We then used univariable and multivariable statistics to identify risk factors predicting peroneal nerve injury and recovery. RESULTS: Gender (odds ratio, 5.47), body mass index (odds ratio, 1.14), and fibular head fracture (odds ratio, 4.77) were associated with peroneal nerve injury. Only younger age was associated with peroneal nerve recovery. CONCLUSIONS: Knowledge of the risk factors for peroneal nerve injury and the predictors of recovery in knee dislocation allows the treating surgeon to have a better understanding of the nature of the neurologic injury and modify management based on the anticipated return of nerve function. LEVEL OF EVIDENCE: Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Anatomic Bankart repair compared with nonoperative treatment and/or arthroscopic lavage for first-time traumatic shoulder dislocation.

PURPOSE: The objective of this systematic review was to determine the efficacy of anatomic Bankart repair in patients with a first-time shoulder dislocation compared with either arthroscopic lavage or traditional sling immobilization. METHODS: We searched the Cochrane Central Register of Controlled Trials, Medline, Embase, CINAHL, Web of Science, LILACS, and a clinical trials registry for ongoing and completed randomized or quasi-randomized controlled trials comparing anatomic Bankart repair with either rehabilitation or arthroscopic lavage. Two reviewers selected studies for inclusion, assessed methodologic quality, and extracted data. Pooled analyses were performed by use of a random-effects model, and risk ratio (RR) and 95% confidence intervals (CIs) were computed. RESULTS: We included 3 randomized trials and 1 quasi-randomized trial comprising 228 patients. Of the included trials, 2 compared anatomic Bankart repair with sling immobilization whereas 2 compared Bankart repair with arthroscopic lavage. A meta-analysis of all 4 trials showed that the rate of recurrent instability was significantly lower among participants undergoing anatomic Bankart repair compared with those undergoing either immobilization or arthroscopic lavage (RR, 0.18; 95% CI, 0.10 to 0.33). Subgroup analysis showed that this effect persisted when Bankart repair was compared with arthroscopic lavage alone (2 studies) (RR, 0.14; 95% CI, 0.06 to 0.31) or sling immobilization alone (2 studies) (RR, 0.26; 95% CI, 0.10 to 0.67). Western Ontario Shoulder Instability scores were better with anatomic Bankart repair compared with either arthroscopic lavage or immobilization (2 studies) (mean difference, -232; 95% CI, -317 to -146). CONCLUSIONS: There is evidence to suggest treatment of young patients with a first-time shoulder dislocation with anatomic Bankart repair with the goal of lowering the rate of recurrent instability over the long-term and improving short-term quality of life. LEVEL OF EVIDENCE: Level II, systematic review of Level I and II studies.

The role of platelet-rich plasma in arthroscopic rotator cuff repair: a systematic review with quantitative synthesis.

PURPOSE: Despite the theoretic basis and interest in using platelet-rich plasma (PRP) to improve the potential for rotator cuff healing, there remains ongoing controversy regarding its clinical efficacy. The objective of this systematic review was to identify and summarize the available evidence to compare the efficacy of arthroscopic rotator cuff repair in patients with full-thickness rotator cuff tears who were concomitantly treated with PRP. METHODS: We searched the Cochrane Central Register of Controlled Trials, Medline, Embase, and PubMed for eligible studies. Two reviewers selected studies for inclusion, assessed methodologic quality, and extracted data. Pooled analyses were performed using a random effects model to arrive at summary estimates of treatment effect with associated 95% confidence intervals. RESULTS: Five studies (2 randomized and 3 nonrandomized with comparative control groups) met the inclusion criteria, with a total of 261 patients. Methodologic quality was uniformly sound as assessed by the Detsky scale and Newcastle-Ottawa Scale. Quantitative synthesis of all 5 studies showed that there was no statistically significant difference in the overall rate of rotator cuff retear between patients treated with PRP and those treated without PRP (risk ratio, 0.77; 95% confidence interval, 0.48 to 1.23). There were also no differences in the pooled Constant score; Simple Shoulder Test score; American Shoulder and Elbow Surgeons score; University of California, Los Angeles shoulder score; or Single Assessment Numeric Evaluation score. CONCLUSIONS: PRP does not have an effect on overall retear rates or shoulder-specific outcomes after arthroscopic rotator cuff repair. Additional well-designed randomized trials are needed to corroborate these findings. LEVEL OF EVIDENCE: Level III, systematic review of Level I, II, and III studies.

Treatment of periprosthetic fractures around hip resurfacings with cephalomedullary nails.

We describe 2 cases of proximal femoral fractures, 1 intertrochanteric and 1 subtrochanteric, distal to hip resurfacing implants that were managed successfully via internal fixation with trochanteric start point cephalomedullary nails. Both patients had pain-free, well-functioning implants with radiographically healed fractures at their 1-year follow-up. This novel approach offers several advantages over previously described techniques for these rare and difficult-to-treat fractures.