Combined, Single-Anchor Subscapularis Tendon Repair and Proximal Biceps Tenodesis Leads to Improved Function and Decreased Pain at 1 Year.

Purpose: To evaluate the 1-year clinical outcomes of patients treated with combined proximal biceps tenodesis and repair of type II to III subscapularis tendon (SST) injuries according to Lafosse et al., using the Loop 'N' Tack (LNT) technique. Methods: All patients undergoing proximal biceps tenodesis and rotator cuff repair between March 1, 2020, and January 30, 2022, were retrospectively identified. Only patients undergoing combined proximal biceps tenodesis and repair of grade II or III SST injuries with a minimum follow-up of 1 year were included. All patients underwent combined single-anchor proximal biceps tenodesis and SST repair using the LNT technique. The following outcome scores were recorded at a final follow-up of 1 year postoperatively and compared with baseline, preoperative values: American Shoulder and Elbow Score (ASES), Single Assessment Numerical Evaluation (SANE), Veterans Rand 12 Item Health Survey (VR-12), and visual analog scale (VAS). The minimal clinically important difference (MCID) for all outcome indices was determined with a distribution-based method. Results: A total of 41 consecutive patients were included. The MCID values for VAS pain, ASES, SANE, and VR-12 mental scores were 0.97, 8.5, 10.9, and 6.0 respectively. At 1-year final follow-up, approximately 95% (39/41) of patients exceeded the MCID for VAS pain scores, 90% (37/41) of patients for ASES scores, 85.4% (34/41) of patients for SANE scores, and 75.6% (31/41) of patients for VR-12 mental health scores. On average, ASES and SANE scores improved by 37 (preoperatively: 45.2, 1 year: 82.4, P < .001) and 38 points (preoperatively: 38.0, 1 year: 75.7, P < .001), respectively, while VAS scores decreased by 4 points (preoperatively: 5.49, 1 year: 1.48, P < .001). Approximately 88% (36/41) of patients were satisfied at 1 year postoperatively. Treatment failure was observed in 1 patient (2.4%). Conclusions: Patients treated with combined, single-anchor SST repair and LNT proximal biceps tenodesis achieved significant improvements in function, high satisfaction, and low rates of reoperation at 1 year postoperatively. Additionally, 76% to 95% of patients met the MCID for VAS pain, ASES, SANE, and VR-12 mental health scores. Level of Evidence: Level IV, retrospective case series.

Intraobserver and Interobserver Reliability of the Snyder and Expanded SLAP Classification System: A Video Study.

Background: Superior labral anterior and posterior (SLAP) tears are a common finding in overhead athletes. The original classification system produced by Snyder in 1990 contained 4 types of SLAP tears and was later expanded to 10 types. The classification has been challenging because of inconsistencies between surgeons making diagnoses and treatments based on the diagnosis. Furthermore, patient factors-such as age and sports played-affect the treatment algorithms, even across similarly classified SLAP tears. Purpose: To (1) assess the interobserver and intraobserver reliability of the Snyder and expanded SLAP (ESLAP) classification systems and (2) determine the consistency of treatment for a given SLAP tear depending on different clinical scenarios. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: A total of 20 arthroscopic surgical videos and magnetic resonance imaging scans of patients with SLAP tears were sent to 20 orthopaedic sports medicine surgeons at various stages of training. Surgeons were asked to identify the type of SLAP tear using the Snyder and ESLAP classifications. Surgeons were then asked to determine the treatment for a SLAP tear using 4 clinical scenarios: (1) in the throwing arm of an 18-year-old pitcher; (2) in the dominant arm of an 18-year-old overhead athlete; (3) a 35-year-old overhead athlete; (4) or a 50-year-old overhead athlete. Responses were recorded, and the cases were shuffled and sent back 6 weeks after the initial responses. Results were then analyzed using the Fleiss kappa coefficient (κ) to determine interobserver and intraobserver degrees of agreement. Results: There was moderate intraobserver reliability in both the Snyder and ESLAP classifications (κ = 0.52) and fair interobserver reliability for both classification systems (Snyder, κ = 0.31; ESLAP, κ = 0.30; P < .0001) among all surgeons. Additionally, there was only fair agreement (κ = 0.30; P < .0001) for the treatment modalities chosen by the reviewers for each case. Conclusion: This study demonstrated that SLAP tears remain a challenging problem for orthopaedic surgeons in diagnostics and treatment plans. Therefore, care should be taken in the preoperative discussion with the patient to consider all the possible treatment options because this may affect the postoperative recovery period and patient expectations.

Biomechanical Analysis of Ideal Knee Flexion Angle for ACL Graft Tensioning Utilizing Multiple Femoral and Tibial Tunnel Locations.

Anterior cruciate ligament (ACL) graft failure rate has been reported to be greater than 5% at 5 years. Our study evaluated ACL excursion with anatomic and nonanatomic femoral and tibial tunnels to determine optimal flexion angle to tension the ACL to minimize excursion. Ten cadaveric knee specimens were used. The ACL was sectioned and the femoral and tibial attachments were marked. A 1/16-inch drill created a tunnel in the center of the ACL footprint on the tibia and femur and additional tunnels were made 5 mm from this. A suture was passed through each tunnel combination and attached to a string potentiometer. The knee was ranged from full extension to 120 degrees of flexion for 10 cycles while mounted in a custom fixture. The change in length (excursion) of the suture during movement was recorded for each combination of femoral and tibial tunnels. Anatomic reconstruction of the ACL with tunnel placement in the center of the femoral and tibial footprint did not result in an isometric graft, with excursion of the ACL during knee motion of 7.46 mm (standard deviation [SD]: 2.7mm), greatest at 2.84 degrees of flexion (SD: 4.22). The tunnel combination that resulted in the least excursion was a femoral footprint 5 mm anterior to the femoral and 5 mm posterior to the tibial footprint (4. 2mm, SD: 1.37 mm). The tunnel combination that resulted in the most excursion utilized femoral footprint 5 mm proximal to the femoral and 5 mm posterior to the tibial footprint (9.81 mm, SD: 2.68 mm). Anatomic ACL reconstruction results in significant excursion of the ACL throughout motion. If not tensioned properly, the ACL can stretch during range of motion, potentially leading to rerupture. To prevent stretching of the graft, the current biomechanical study recommends tensioning an anatomic ACL reconstruction at its point of maximal excursion, or between 0 and 5 degrees of flexion. The level of evidence is IV.

Measurements of Tendon Movement Within the Bicipital Groove After Suprapectoral Intra-articular Biceps Tenodesis in a Cadaveric Model.

BACKGROUND: Lesions of the long head of the biceps can be successfully treated with biceps tenotomy or tenodesis when surgical management is elected. The advantage of a tenodesis is that it prevents the potential development of a cosmetic deformity or cramping muscle pain. Proponents of a subpectoral tenodesis believe that "groove pain" may remain a problem after suprapectoral tenodesis as a result of persistent motion of the tendon within the bicipital groove. PURPOSE/HYPOTHESIS: To evaluate the motion of the biceps tendon within the bicipital groove before and after a suprapectoral intra-articular tenodesis. The hypothesis was that there would be minimal to no motion of the biceps tendon within the bicipital groove after tenodesis. STUDY DESIGN: Controlled laboratory study. METHODS: Six fresh-frozen cadaveric arms were dissected to expose the long head of the biceps tendon as well as the bicipital groove. Inclinometers and fiducials (optical markers) were used to measure the motions of the scapula, forearm, and biceps tendon through a full range of shoulder and elbow motions. A suprapectoral biceps tenodesis was then performed, and the motions were repeated. The motion of the biceps tendon was quantified as a function of scapular or forearm motion in each plane, both before and after the tenodesis. RESULTS: There was minimal motion of the native biceps tendon during elbow flexion and extension but significant motion during all planes of scapular motion before tenodesis, with the most motion occurring during shoulder flexion-extension (20.73 ± 8.21 mm). The motion of the biceps tendon after tenodesis was significantly reduced during every plane of scapular motion compared with the native state (P < .01 in all planes of motion), with a maximum motion of only 1.57 mm. CONCLUSION: There was a statistically significant reduction in motion of the biceps tendon in all planes of scapular motion after the intra-articular biceps tenodesis. The motion of the biceps tendon within the bicipital groove was essentially eliminated after the suprapectoral biceps tenodesis. CLINICAL RELEVANCE: This arthroscopic suprapectoral tenodesis technique can significantly reduce motion of the biceps tendon within the groove in this cadaveric study, possibly reducing the likelihood of groove pain in the clinical setting.

The Use of Suture Augmentation for Graft Protection in ACL Reconstruction: A Biomechanical Study in Porcine Knees.

PURPOSE: To biomechanically evaluate the use of the suture augmentation construct at time 0 of ACL reconstruction. METHODS: Eighty porcine knees underwent ACL reconstruction using 2 techniques for graft fixation: a single suspensory construct (SSC), performed with a femoral button and tibial interference screw; and a double suspensory construct (DSC), with a femoral and tibial button. Each fixation technique was performed on 40 porcine knees divided into 4 subgroups. The first group had a nonaugmented ACL reconstruction, the second group had an ACL reconstruction with suture augmentation, and the third and fourth groups were the same as the first and second groups, with the graft resected 80% to simulate graft weakening. Ultimate load, yield load, stiffness, cyclic displacement values, and mode of failure were recorded for each graft. RESULTS: In a weakened graft model with 80% graft resection, there was a significant increase in ultimate strength (P < .001), yield strength (P < .001), and cyclic displacement (P < .001) with suture augmentation. There was no significant increase in stiffness with suture augmentation with either construct (P = .278). In the setting of an intact graft, there were no differences in either SSC or DCS groups with or without suture augmentation. CONCLUSIONS: The addition of a suture to ACL reconstruction techniques resulted in minimal changes in baseline biomechanical characteristics while improving ultimate load, yield load, and cyclic displacement in a weakened graft model. CLINICAL RELEVANCE: Suture augmentation of ACL reconstruction may confer improved integrity of the graft and is worth consideration and future clinical study.

The Loop 'N' Tack Biceps Tenodesis: An All-Arthroscopic, Intra-Articular Technique.

Tenodesis and tenotomy of the long head of the biceps are treatment options for a wide range of pathologies without clear superior technique or site of fixation. Clinical outcomes comparing numerous techniques for tenotomy versus tenodesis have resulted in similar pain relief; however, tenotomy may result in a cosmetic "Popeye" deformity and fatigue pain. We present a quick, simple, and knotless technique for tenodesis of the long head of the biceps at the proximal aspect of the bicipital grove that can be completed entirely arthroscopically. This technique uses suture to secure a tenotomized proximal biceps tendon to a knotless anchor just proximal to the subscapularis tendon at the proximal biceps groove. The tensionless repair allows the biceps to scar within the biceps groove, thereby reducing subsidence and formation of a "Popeye" deformity and fatigue pain in the biceps seen with tenotomy alone while eliminating the ability to overtension.

The Loop 'n' Tack Knot: Biomechanical Analysis of a Novel Suture Technique for Proximal Biceps Tenodesis.

BACKGROUND: Secure tendon grasping is critical to the success of any tenodesis procedure. Several techniques currently used for tendon grasping can result in longitudinal splitting of the tendon, causing construct failure and failure of the tenodesis. PURPOSE: To compare the Loop 'n' Tack knot as a tendon-grasping technique with other common suture techniques. We investigated the biomechanical strength and mode of failure. STUDY DESIGN: Controlled laboratory study. METHODS: Eleven matched pairs of proximal biceps were harvested from fresh-frozen cadaveric shoulders. One tendon from each pair was stitched using 1 of 4 different techniques. The suture techniques evaluated included the Loop 'n' Tack with 2 different types of high-strength nonabsorbable suture, a double half-racking stitch, and a Krakow stitch. Samples were cyclically loaded between 5 and 20 N for 100 cycles, followed by a pull to failure at 33 mm/s. RESULTS: The Loop 'n' Tack techniques were equivalent to the double half-racking and Krakow techniques for load to ultimate failure (P = .817 and P = .984, respectively). The double half-racking technique was the stiffest construct, which was significantly greater than the second-stiffest group, the Loop 'n' Tack method with both FiberLink suture (P = .012) and SutureTape (P = .002), which had greater stiffness than the Krakow group (P < .001). The most common failure mode for the Loop 'n' Tack stitch was suture breakage compared with the Krakow and double half-racking methods, where the most common mode of failure was suture pullout from the tendon (P < .001). CONCLUSION: Biomechanical testing found that the Loop 'n' Tack techniques had similar ultimate load to failure values when compared with the double half-racking and Krakow methods. Mode-of-failure analysis showed that the Loop 'n' Tack construct typically failed by suture breakage, whereas the other techniques failed by suture pullout. CLINICAL RELEVANCE: The Loop 'n' Tack technique allows for secure grasping of tissue without the need for externalization of the tendon. This technique may be beneficial in compromised or poor-quality tissue without reducing overall pullout strength when compared with a standard half-racking or Krakow stitch.

Bone Marrow Edema, Clinical Significance, and Treatment Options: A Review.

Bone marrow edema (BME) is a descriptive term used to describe high-signal intensity changes detected on magnetic resonance fluid-sensitive sequences that could be attributed to a number of underlying pathologies. Regardless of the cause, physiologic remodeling of the subchondral bone can be limited because of ongoing joint forces, increased focalization of stress, and reduced healing capacity of the subchondral bone. BME is a known prognostic factor associated with pain, dysfunction, and progressive cartilage damage. This review summarizes the current known causes of BMEs, theories related to histopathological changes, and current treatment options including novel biologic surgical options.

Investigating the Bias in Orthopaedic Patient-reported Outcome Measures by Mode of Administration: A Meta-analysis.

BACKGROUND: Patient-reported outcome measures (PROMs) are critical and frequently used to assess clinical outcomes to support medical decision-making. QUESTIONS/PURPOSE: The purpose of this meta-analysis was to compare differences in the modes of administration of PROMs within the field of orthopaedics to determine their impact on clinical outcome assessment. PATIENTS AND METHODS: The PubMed database was used to conduct a review of literature from 1990 to 2018 with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol. All articles comparing PROMs for orthopaedic procedures were included and classified by the mode of administration. Each specific survey was standardized to a scale of 0 to 100, and a repeated random effectsmodel meta-analysis was conducted to determine the mean effect of each mode of survey. RESULTS: Eighteen studies were initially included in the study, with 10 ultimately used in the meta-analysis that encompassed 2384 separate patient survey encounters. Six of these studies demonstrated a statistically notable difference in PROM scores by mode of administration. The meta-analysis found that the standardized mean effect size for telephone-based surveys on a 100-point scale was 71.7 (SE 5.0) that was significantly higher (P , 0.0001) than survey scores obtained via online/tech based (65.3 [SE 0.70]) or self-administered/paper surveys (61.2 [SE 0.70]). CONCLUSIONS: Overall, this study demonstrated that a documented difference exists in PROM quality depending on the mode of administration. PROM scores obtained via telephone (71.7) are 8.9% higher than scores obtained online (65.3, P , 0.0001), and 13.8% higher than scores obtained via self-administered on paper (61.8, P , 0.0001). Few studies have quantified statistically notable differences between PROM scores based solely on the mode of acquisition in orthopaedic.

Can We Accurately Predict the Quadruple Hamstring Graft Diameter From Preoperative Magnetic Resonance Imaging?

BACKGROUND: Anterior cruciate ligament (ACL) reconstruction with a quadruple hamstring (QH) autograft is a widely utilized procedure with good outcomes. A graft diameter less than 8 mm, however, has been associated with higher revision rates. Accurately determining the diameter of the hamstring tendon preoperatively can help surgeons plan accordingly. PURPOSE/HYPOTHESIS: The purpose of our study was to determine whether QH graft size can be reliably predicted from preoperative magnetic resonance imaging (MRI) measurements. We hypothesized that we can achieve a high predicted QH graft size correlation with regard to preoperative and intraoperative measurements. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: We evaluated patients undergoing ACL reconstruction using QH autografts. At the time of surgery, the semitendinosus tendon (ST) and gracilis tendon (GT) were harvested and sized and then sized as a QH graft. Preoperative individual ST and GT sizes were determined from T2-weighted fat-saturated MRI at 3 cm above the joint line using correlating axial and coronal images. We then used a predictive chart to predict what the size of the QH graft would be and compared this with the actual measurements. Pearson correlation coefficients between predicted and actual graft sizes were calculated. RESULTS: The predicted GT graft size was within 0.5 mm of the actual size in 45 of 60 (75%) patients and within 1 mm of the actual graft size in 59 of 60 (98%) patients. The predicted GT graft size from MRI measurements correlated with the actual GT graft size (r = 0.62, P < .00001). The predicted ST graft size was within 0.5 mm of the actual size in 45 of 60 (75%) patients and within 1 mm of the actual graft size in 56 of 60 (93%) patients. The predicted ST graft size from MRI measurements correlated with the actual ST graft size (r = 0.71, P < .00001). The predicted QH graft size was within 0.5 mm of the actual size in 52 of 60 (87%) patients and within 1 mm of the actual graft size in 60 of 60 (100%) patients. The predicted QH graft size from MRI measurements correlated with the actual QH graft size (r = 0.81, P < .00001). CONCLUSION: The current technique can reliably predict the size of a QH graft within 1 mm of the final graft size.

Short-Term Outcomes for the Biologic Treatment of Bone Marrow Edema of the Knee Using Bone Marrow Aspirate Concentrate and Injectable Demineralized Bone Matrix.

PURPOSE: To evaluate short-term outcomes for the biologic treatment of bone marrow edema (BME) of the knee using bone marrow aspirate concentrate (BMAC) and injectable demineralized bone matrix (iDBM). METHODS: We performed a review of prospectively collected data from patients who underwent treatment for bone marrow lesions (BMLs) of the knee using BMAC and iDBM (IntraOsseous BioPlasty; Arthrex, Naples, FL) between May 2017 and December 2018. Inclusion criteria included patients aged 18 to 65 years with the presence of BME on T2-weighted magnetic resonance imaging in the subchondral weightbearing region of the tibia or femoral condyle, with pain corresponding to the same compartment. The International Knee Documentation Committee (IKDC), pain visual analog scale (VAS), and 12-Item Short Form Health Survey (SF-12) scores were used to evaluate clinical outcomes. RESULTS: We evaluated 20 patients who were treated at a single academic medical institution over a mean 14.5-month follow-up (median, 14 months; range, 6-25 months). The average patient age was 51.7 years (range 38-62 years). Compared with preoperative values, the visual analog scale decreased from 7.0 to 1.3 (P = .008). The mean International Knee Documentation Committee scores improved from 29.2 to 66.1 (P = .063). Both the Physical and Mental Component Scores of the 12-Item Short Form Health Survey also showed improvement (Physical Component Score, P = .438; Mental Component Score, P = .563). Based on postoperative magnetic resonance imaging, 75% (3 of 4) of the BMLs demonstrated complete healing. The survival rate was 93% at 1-year follow-up. CONCLUSION: Biologic treatment of BME of the knee using BMAC and iDBM is an effective adjunct to arthroscopy that provides short-term pain relief for BMLs associated with degenerative conditions of the knee. This procedure is associated with clinically significant improvements in knee pain and function at a short-term follow-up. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Oculomotor, Vestibular, and Reaction Time Effects of Sports-Related Concussion: Video-Oculography in Assessing Sports-Related Concussion.

OBJECTIVE: The purpose of the study was to test the ability of oculomotor, vestibular, and reaction time (OVRT) metrics to serve as a concussion assessment or diagnostic tool for general clinical use. SETTING AND PARTICIPANTS: Patients with concussion were high school-aged athletes clinically diagnosed in a hospital setting with a sports-related concussion (n = 50). Control subjects were previously recruited male and female high school student athletes from 3 local high schools (n = 170). DESIGN: Video-oculography was used to acquire eye movement metrics during OVRT tasks, combined with other measures. Measures were compared between groups, and a subset was incorporated into linear regression models that could serve as indicators of concussion. MEASURES: The OVRT test battery included multiple metrics of saccades, smooth pursuit tracking, nystagmoid movements, vestibular function, and reaction time latencies. RESULTS: Some OVRT metrics were significantly different between groups. Linear regression models distinguished control subjects from concussion subjects with high accuracy. Metrics included changes in smooth pursuit tracking, increased reaction time and reduced saccade velocity in a complex motor task, and decreased optokinetic nystagmus (OKN) gain. In addition, optokinetic gain was reduced and more variable in subjects assessed 22 or more days after injury. CONCLUSION: These results indicate that OVRT tests can be used as a reliable adjunctive tool in the assessment of concussion and that OKN results appear to be associated with a prolonged expression of concussion symptoms.

Interobserver and Intraobserver Reliability of an MRI-Based Classification System for Injuries to the Ulnar Collateral Ligament.

BACKGROUND: Despite improvements in understanding biomechanics and surgical options for ulnar collateral ligament (UCL) tears, there remains a need for a reliable classification of UCL tears that has the potential to guide clinical decision making. PURPOSE: To assess the intra- and interobserver reliability of the newly proposed magnetic resonance imaging (MRI)-based classification for UCL tears. Secondary objectives included assessing the effect of additional views, discrimination between distal and nondistal tears, and correlation of imaging reads with intraoperative findings of the UCL. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: Nine fellowship-trained specialists from 7 institutions independently completed 4 surveys consisting of 60 elbow MRI scans with UCL tears using a newly proposed 6-stage classification system. The first and third surveys contained 60 coronal images, while the second and fourth contained the same images with coronal and axial views presented in a random order to assess intraobserver variability via the weighted kappa value and the effect of additional imaging views. Weighted kappa values were also calculated for each of the 4 surveys to acquire interobserver reliability. Reliability analysis was repeated through a 2-group classification analysis for distal and nondistal tears. Observer readings were compared with intraoperative UCL findings. RESULTS: For the newly proposed 6-stage MRI-based classification, intra- and interobserver reliability demonstrated near perfect and substantial agreement, respectively. These values increased only when substratified into the 2-group distal and nondistal tear classification ( P < .05). The additional axial view did not statistically improve the agreement within and among readers. When compared with intraoperative findings from 30 elbows, observer readings were accurate for tear grade (partial and complete), proximal location, and distal location but not midsubstance tears. CONCLUSION: The newly proposed 6-stage MRI-based classification utilizing grade and location of the injury had substantial to near perfect agreement among and within fellowship-trained observers.

Clinical Evaluation of an Arthroscopic Knotless Suprapectoral Biceps Tenodesis Technique: Loop 'n' Tack Tenodesis.

BACKGROUND: Pathology of the long head of the biceps tendon is a well-known cause of shoulder pain that is commonly managed with arthroscopic suprapectoral biceps tenodesis when conservative treatment fails. PURPOSE: To present an arthroscopic knotless suprapectoral biceps tenodesis technique known as "Loop 'n' Tack" tenodesis and to report the clinical outcomes of patients with a minimum 2 years of follow-up. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective review of all patients who had undergone Loop 'n' Tack tenodesis between January 2009 and May 2014 was completed. Charts were reviewed, and patients were contacted for demographic data, time from surgery, concomitant procedures, and workers' compensation status, as well as visual analog scale for pain, American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation, and University of California, Los Angeles (UCLA) scores. RESULTS: Complete follow-up evaluations were performed for 59 of 68 patients (87%). Mean follow-up was 43 months. A majority (88%) of patients had at least 1 additional procedure performed at the time of biceps tenodesis. The mean ASES shoulder score improved from 42.6 preoperatively to 91.0 postoperatively (P < .001), and 54 of 59 patients (91.5%) had a good/excellent outcome, with a UCLA shoulder score >27 and ASES shoulder score >70. Three patients (5%) reported biceps cramping pain with overuse, and 2 (3.3%) reported intermittent anterior shoulder pain. No patients had developed a "Popeye" deformity at final clinical examination, and 97% reported that they were overall satisfied with the procedure. CONCLUSION: The Loop 'n' Tack tenodesis technique results in a high rate of patient satisfaction, significant improvement in shoulder outcome scores, and a low incidence of postoperative pain, with no reoperations for biceps-related pathology.

An Algorithm for Diagnosing and Treating Primary and Recurrent Patellar Instability.

Major anatomic risk factors for recurrent patellar instability include trochlear dysplasia, patella alta, a lateralized tibial tuberosity, and medial patellofemoral ligament insufficiency. Acute first-time patellar dislocation may be treated nonoperatively in the absence of osteochondral injury. Recurrent patellar instability often requires medial patellofemoral ligament reconstruction, with osseous procedures reserved for patients with substantial underlying anatomic abnormalities. Surgical treatment of patellar instability is complex and should be individualized to address the needs of each patient.

Quadrupled Hamstring Graft Strength as a Function of Clinical Sizing.

PURPOSE: This study sought to compare the strength of quadrupled hamstring tendon (QHT) grafts of 6 to 9.5 mm in clinical diameter with that of 10-mm bone-patellar tendon-bone (BPTB) grafts. METHODS: Twenty cadaveric semitendinosus and gracilis tendons were combined into QHT grafts. These were sized using a standard graft-sizing device and an area micrometer, yielding grafts ranging from 6 to 9.5 mm in diameter. The grafts were tested to failure. Five 10-mm BPTB grafts were also sized and tested. RESULTS: Clinical sizing did predict the strength of the graft but not profoundly. As a material alone, without consideration of fixation in bone tunnels, QHT grafts were stronger than BPTB grafts. Graft strength decreased with size, but a linear relation between strength and diameter (r(2) = 0.715, P < .001) was found to be as good as the expected quadratic fit (r(2) = 0.709). Compared with BPTB grafts, even the smallest QHT grafts (diameter <6.5 mm) were still significantly stronger than 10-mm BPTB grafts (P = .004). The elastic moduli of the QHT and BPTB grafts were 761 ± 187 MPa and 615 ± 403 MPa, respectively; elongations at failure were 12.0% ± 2.0% and 7.5% ± 1.6%, respectively; and failure stresses were 105 ± 18 MPa and 50 ± 14 MPa, respectively. CONCLUSIONS: This work shows that a clinical size of QHT grafts of 6 mm in diameter is not a concern regarding the strength itself. For a possible lower-end prediction of acceptable size, assuming that a gracilis-semitendinosus graft would have only the stress of the weakest measured QHT graft of 88 MPa, a graft of 5.5 mm in diameter would suffice, having more strength in newtons than the average patellar tendon. CLINICAL RELEVANCE: Clinically sized QHT grafts have a higher failure strength than 10-mm patellar tendon grafts. Therefore the strength of the graft cannot account for the higher clinical failure rates of smaller hamstring grafts in active patients in clinical studies.

Technique for creating the anterior cruciate ligament femoral socket: optimizing femoral footprint anatomic restoration using outside-in drilling.

PURPOSE: The purpose of this study was to investigate and optimize anterior cruciate ligament (ACL) femoral outside-in drilling technique with a goal of anatomic restoration of the footprint morphologic length, width, area, and angular orientation. METHODS: Ex vivo, computer navigation was used to create virtual 3-dimensional maps of femoral bone tunnels for ACL drill guide pin insertion paths on small, medium, and large models of averaged femora considering various pin insertion angles to the femur. We then determined which pin insertion angle resulted in an ACL femoral footprint optimally matching normal human anatomic length, width, area, and angular orientation of the footprint long axis. RESULTS: During outside-in drilling of the ACL femoral socket, a guide pin entrance angle of 60° to a line perpendicular to the femoral anatomic axis, combined with a guide pin entrance angle of 20° to the transepicondylar axis, results in the closest approximation of the gold standard of normal anatomic morphology of the human knee ACL femoral footprint length, width, area, and angular orientation. CONCLUSIONS: During outside-in drilling of the ACL femoral socket, a guide pin entrance angle of 60° to a line perpendicular to the femoral anatomic axis, combined with a guide pin entrance angle of 20° to the transepicondylar axis, results in optimal reconstruction of the normal human anatomic ACL femoral footprint length, width, area, and angular orientation. CLINICAL RELEVANCE: We describe arthroscopic landmarks for anatomic ACL femoral socket creation that may be considered by practicing arthroscopic surgeons in the operating room, without open dissection or fluoroscopy and unaffected by type of drill guide or variations in the thickness of the femoral soft-tissue envelope.

Understanding bony safety zones in the posterior iliac crest: an anatomic study from the Hamann-Todd collection.

STUDY DESIGN: Morphometric analysis of the human ilia obtained from the Hamann-Todd Collection at Cleveland Museum of Natural History. OBJECTIVE: To identify whether gender and pelvis size affect the distances between anatomic landmarks of the posterior pelvis. SUMMARY OF BACKGROUND DATA: The iliac crest bone harvest is commonly performed in orthopedic, neurosurgic, and maxillofacial surgery. Morbidity from the bone graft harvest is well described (Arrington et al, Clin Orthop Relat Res 1996:300-9; Ebraheim et al, J Am Acad Orthop Surg 2001;9:210-8; Hu and Bohlman, Clin Orthop Relat Res 1994;208-13; Kahn, Clin Orthop Relat Res 1979;204-7; Kurz et al, Spine 1989;14:1324-31; Lim et al, Spine 1996;21:2376-8; Sasso et al, J Bone Joint Surg Am 1998;80:631-5; St. John et al, A J Orthop (Belle Mead NJ) 2003;32:18-23; Summers and Eisenstein, J Bone Joint Surg Br 1989;71:677-80). Several studies have advanced our understanding of the bony, vascular, and neurologic anatomy of the posterior iliac crest (Ebraheim et al, J Am Acad Orthop Surg 2001;9:210-8; Xu et al, Spine 1996;21:1017-20). There is no literature documenting the measurement of this region on a large, statistically significant scale. METHODS: An anatomic study was undertaken using the Hamann-Todd collection. The bilateral human ilia were examined from 50 men and 50 women between 18 and 80 years of age. Age, gender, and side were recorded. Four parameters were recorded: the shortest distance from the posterior superior iliac spine to the sciatic notch (PN), the shortest distance from posterior superior iliac spine to the sacroiliac joint (PS), the anterior-posterior length of the sciatic notch (P90), and the maximum length of the sacroiliac joint (SI). RESULTS: The right and left ilia were compared, and no significant difference was found. The mean for all 4 measurements was slightly larger in men and statistically significant (PN: men 43.7 +/- 4.6 mm vs. women 39.7 +/- 5.8 mm; PS: 21.5 +/- 7.8 mm vs. 16.9 +/- 5.3 mm; P90: 16.7 +/- 3.8 mm vs. 15.3 +/- 3.6 mm; SI: 60.0 +/- 5.9 mm vs. 55.2 +/- 5.8 mm). The ranges and distribution of data within the ranges were compared. Men had higher maximum limits although the lower limits were similar (PN: men 28.7-62.7 mm vs. women 28.0-51.0 mm; PS: 7.3-43.3 mm vs. 4.7-34.3 mm; P90: 9-25.3 mm vs. 7.7-22.7 mm; SI: 42.3-69 mm vs. 50.0-79.0 mm). CONCLUSION: This study defines distances in the posterior iliac crest beyond which the risk of injuring important structures is present (2.80 cm for 100% of the population or 3.00 cm for > or = 90%).

Complications of anterior cruciate ligament reconstruction.

Anterior cruciate ligament reconstruction has become one of the most common arthroscopic knee procedures, and it has excellent success rates. Intraoperative technical complications are uncommon but can be devastating to knee function. Each of the multiple steps in the reconstruction has associated complications.