Technical Pearls for Arthroscopic Labral Augmentation of the Hip.

Our recent understanding of the importance of the acetabular labral suction seal has placed preserving labral integrity as a guiding principle in hip preservation surgery. In cases with a hypoplastic labrum and intact chondrolabral junction, labral augmentation presents as a viable alternative and an often preferred treatment option over labral reconstruction. At this time, there are few studies that have described the technical pearls of performing labral augmentation of the hip. In this technique guide, we describe, in detail, the kite technique for the introduction, control, and acetabular fixation of a hip labral augmentation graft. Comparable to flying a kite with 2 fly lines and to the previously described kite technique for hip labral reconstruction, the kite technique for labral augmentation is based on the principle that the use of 2 control sutures in a pulley system creates an efficient method to accurately and reproducibly facilitate graft passage and fixation during arthroscopic labral augmentation procedures.

Capsular Reconstruction of the Hip Using Modified Kite Technique: A Technical Guide for Efficient Graft Management and Fixation.

Preserving capsular integrity has become an important principle of hip preservation surgery given the increasingly recognized deleterious effects of instability in cases of capsular insufficiency. When capsular tissue is deficient, capsular reconstruction may be indicated to restore function of the iliofemoral ligament and improve hip biomechanics. To date, few studies have presented technical guidance on performing arthroscopic capsular reconstruction of the hip. In this Technical Note, we introduce a modified kite technique for arthroscopic entry, control, and fixation of a capsular reconstruction graft. Similar to flying a kite with multiple fly lines, and to the previously described kite technique for hip labral reconstruction, the principles of this method are founded on the belief that control sutures within a pulley system facilitate safe and efficient graft management during capsular reconstruction procedures.

The Utility of Obtaining a Complete Blood Count After Total Knee Arthroplasty in the Era of Tranexamic Acid.

Questioning the routine use of postoperative laboratory tests is a strategy to combat rising health care costs. The goal of this study was to determine the utility and cost of routine postoperative complete blood count (CBC) testing after primary total knee arthroplasty (TKA) in the era of tranexamic acid (TXA). This retrospective chart review identified patients who underwent primary TKA performed by a single surgeon at a single private institution during a 2-year period. All patients received TXA intraoperatively. Exact tests were used to determine whether there was a significant difference in transfusion rates between patients with and without preoperative anemia. Of 628 primary TKA procedures, 390 patients (62.10%) had anemia postoperatively. However, only 1 patient (0.16%) required transfusion. A total of 956 CBC tests were performed without intervention, at a total cost of $116,804.08. In addition, 1 of 26 patients with preoperative anemia vs 0 of 602 patients without preoperative anemia required transfusion (P=.04). Healthy patients undergoing primary TKA who receive TXA do not require postoperative CBC. This change has the potential to reduce this laboratory cost by more than 97% compared with the current practice of obtaining postoperative CBC testing for every patient undergoing TKA. Only patients with preoperative anemia should undergo postoperative CBC testing to help to identify those who require transfusion. The potential health care savings associated with eliminating routine postoperative CBC testing are substantial and should be considered by arthroplasty surgeons. [Orthopedics. 2021;44(1):e26-e30.].

Successful Hip Arthroscopy Using Postless Distraction in a Professional Basketball Player: A Case Report.

CASE: A 36-year-old 7'0' male professional basketball player presented with hip pain and radiographic imaging consistent with femoroacetabular impingement syndrome and a labral tear. Hip arthroscopy was performed with the patient positioned supine on a postless distraction table to negate the risk of pudendal nerve and perineal skin complications. Hip distraction was achieved with only 40 lbs (18.14 kg) of distraction force. Labral repair and cam osteochondroplasty were safely performed without complication. CONCLUSIONS: This case is the first to demonstrate that postless distraction may be considered for patients at end ranges of height that exceed the limitations of common hip arthroscopy tables.

Kite Measurement Technique for Enhanced Accuracy and Technical Proficiency of Graft Preparation in Segmental Labral Reconstruction of the Hip.

Preserving labral integrity has become a guiding principle in hip preservation surgery given the recent understanding of the importance of the acetabular labral suction seal. When labral tissue is deficient, a labral reconstruction may be indicated to re-create the suction seal and improve hip biomechanics. One of the main challenges of segmental labral reconstruction techniques is obtaining an accurate measurement of the defect because incorrect sizing of the graft could result in incomplete restoration of the labral seal or an oversized graft that requires amputation. In this report, we present a kite measurement technique that allows for easy, accurate measurement of the segmental defect during segmental labral reconstruction.

Hip Labral Reconstruction: The "Kite Technique" for Improved Efficiency and Graft Control.

Although the merits of labral reconstruction have been well established, the technical difficulty of presently used reconstruction techniques-particularly with graft passage and fixation-limit its efficacy and potentiates the risk of iatrogenic damage within the hip joint. The unwieldy nature of a floating labral graft anchored on one end may impede accurate fixation of the other end, which is critical for restoration of the fluid hip seal and preservation of graft integrity. In this technique narrative, we present a "kite technique" for introduction, control, and efficient fixation of a labral reconstruction graft. The principles of this method are founded on the belief that a soft-tissue graft in an arthroscopic environment is much easier to guide into position with 2 control sutures using a pulley system similar to flying a kite with 2 fly lines. Although we herein detail the technique as it applies to labral reconstruction in the hip, the concept of the kite technique may also be employed in arthroscopic-assisted soft-tissue reconstructions of other joints.

Chronic rupture of the long head of the biceps tendon: comparison of 2-year results following primary versus revision open subpectoral biceps tenodesis.

INTRODUCTION: The purpose of this study was to evaluate the clinical results of surgical repair for proximal long head of the biceps (LHB) tendon ruptures comparing chronic primary and postsurgical revision LHB tendon ruptures. MATERIALS AND METHODS: Patients who underwent subpectoral LHB tenodesis for chronic ruptures with a minimum of 2 years from surgery were identified. ASES and SF-12 PCS scores and surgical and demographic data were collected prospectively. At final follow-up, patients were interviewed regarding symptoms related to their biceps. Symptoms were converted into a Subjective Proximal Biceps Score (SPBS). RESULTS: Twenty-seven patients (22 males, 5 females) with a mean age of 61 years (range 40-76 years) underwent LHB tenodeses. Twenty patients (74.1 %) were primary repairs for chronic ruptures and seven patients (25.9 %) were revision repairs after failed prior LHB tenodesis. Twenty-five patients (92.6 %; n = 18 primary; n = 7 revision) were available for follow-up a mean of 3.8 years (range 2-6.1). The overall median postoperative SPBS showed significant improvement over the preoperative baseline (p < 0.001). Individual components of the SPBS showed substantial improvements. The SPBS significantly correlated with the postoperative ASES score (r = -0.478; p = 0.038). There were no differences in postoperative SPBSs between the primary and revision tenodesis groups. The mean postoperative ASES score was 90.3 and SF-12 PCS was 52.6. CONCLUSIONS: Open subpectoral LHB tenodesis was a safe and effective method for the treatment of chronic LHB tendon ruptures and for the revision of failed post-surgical LHB ruptures. Patients had less pain, cramping, and deformity after LHB tenodesis. The SPBS, ASES, and SF-12 PCS scores significantly improved among this group of patients. LEVEL OF EVIDENCE: Level III; Retrospective comparative study.

Intramedullary Tibial Nailing Reduces the Attachment Area and Ultimate Load of the Anterior Medial Meniscal Root: A Potential Explanation for Anterior Knee Pain in Female Patients and Smaller Patients.

BACKGROUND: Intramedullary (IM) nailing is the treatment of choice among orthopaedic surgeons for tibial shaft fractures. However, because of the close proximity of the nail's insertion site to the anterior medial (AM) meniscal root on the tibial plateau, there is increased risk of iatrogenic injury to the meniscal root during nailing. PURPOSE: To quantify the area of the AM meniscal root footprint damaged by IM tibial reaming and determine its subsequent effects on the ultimate failure load in female versus male knees. STUDY DESIGN: Controlled laboratory study. METHODS: Twelve matched pairs (6 male and 6 female pairs; average age, 50.2 years) of human cadaveric knees were randomly assigned to native and reamed groups. In the reamed group, knees were reamed within the "safe zone" according to current guidelines for IM tibial nail insertion (3 mm lateral to the center of the tibial tubercle and adjacent to the anterior margin of the tibial plateau). The attachment areas and ultimate failure load were quantified and compared with paired knees in the native group. RESULTS: Intra-articular reaming within the "safe zone" for IM tibial nail insertion did not significantly decrease the AM root attachment area or ultimate failure load in male specimens, as only 2 of the 6 knees were damaged by reaming. In contrast, all 6 of the AM roots in the female knees were damaged by reaming, and on average, reaming decreased the female AM root attachment area by 19% and significantly decreased ultimate failure load by 37% (P = .028). There was a strong negative correlation (R(2) = 0.77) between reamed tunnel-AM root overlap area and medial-lateral width in female but not in male knees. CONCLUSION: Standard reaming for an IM tibial nail induced significant damage to the AM meniscal root in smaller, female specimens, whereas larger, male specimens were not affected. CLINICAL RELEVANCE: These findings may suggest that improvements in current guidelines and surgical techniques are warranted to prevent iatrogenic injury to the AM meniscal root during intramedullary reaming for tibial shaft fractures in females and in smaller patients.

Return to play following anterior cruciate ligament reconstruction.

In athletes, significant advances in anterior cruciate ligament reconstruction techniques and rehabilitation have led to improved surgical outcomes and increased expectations for return to play. Although an expeditious return to sport has become an achievable and often realistic goal, the factors that most influence safe, timely, and successful return to play remain unknown. The literature offers mainly anecdotal evidence to guide the team physician in the decision-making process, with a paucity of criteria and consensus guidelines available to help determine return to sport. Attempts have been made to introduce criteria-based progression in the rehabilitation process, but validation of subjective and objective criteria has been difficult. Nevertheless, several pertinent factors in the preoperative, intraoperative, and postoperative periods may affect return to play following anterior cruciate ligament reconstruction. Further research is warranted to validate reliable, consensus guidelines with objective criteria to facilitate the return to play process.

Environmental disruption of circadian rhythm predisposes mice to osteoarthritis-like changes in knee joint.

Circadian rhythm dysfunction is linked to many diseases, yet pathophysiological roles in articular cartilage homeostasis and degenerative joint disease including osteoarthritis (OA) remains to be investigated in vivo. Here, we tested whether environmental or genetic disruption of circadian homeostasis predisposes to OA-like pathological changes. Male mice were examined for circadian locomotor activity upon changes in the light:dark (LD) cycle or genetic disruption of circadian rhythms. Wild-type (WT) mice were maintained on a constant 12 h:12 h LD cycle (12:12 LD) or exposed to weekly 12 h phase shifts. Alternatively, male circadian mutant mice (Clock(Δ19) or Csnk1e(tau) mutants) were compared with age-matched WT littermates that were maintained on a constant 12:12 LD cycle. Disruption of circadian rhythms promoted osteoarthritic changes by suppressing proteoglycan accumulation, upregulating matrix-degrading enzymes and downregulating anabolic mediators in the mouse knee joint. Mechanistically, these effects involved activation of the PKCδ-ERK-RUNX2/NFκB and ß-catenin signaling pathways, stimulation of MMP-13 and ADAMTS-5, as well as suppression of the anabolic mediators SOX9 and TIMP-3 in articular chondrocytes of phase-shifted mice. Genetic disruption of circadian homeostasis does not predispose to OA-like pathological changes in joints. Our results, for the first time, provide compelling in vivo evidence that environmental disruption of circadian rhythms is a risk factor for the development of OA-like pathological changes in the mouse knee joint.

Systematic technique-dependent differences in CT versus MRI measurement of the tibial tubercle-trochlear groove distance.

BACKGROUND: The tibial tubercle-trochlear groove (TTTG) distance is used to quantify the degree of lateralization of the patellar tendon insertion on the tibial tubercle relative to the deepest part of the trochlear groove. Disagreement exists as to whether the TTTG distance measured on computed tomography (CT) and magnetic resonance imaging (MRI) can be considered equivalent. PURPOSE: To compare TTTG distance as measured on axial CT and MRI and to investigate the potential effect of patient positioning between modalities. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: Patients who received both CT and MRI of the same knee for any indication from August 2010 to April 2014 were included in this study. The TTTG distances were measured twice by 2 raters in a randomized order, with at least 30 days between ratings to minimize recall bias. Inter- and intrarater reliability of CT and MRI measurements and intermethod reliability were assessed with intraclass correlation coefficients (ICCs). Bland-Altman plots were also created to assess agreement. Differences in patient positioning were investigated to determine its effect on the TTTG distance. RESULTS: Fifty-nine patients (age, 32.8 ± 12.9 years) were included. Interrater ICCs were excellent for both CT and MRI measurements. Intrarater ICCs were excellent for both raters. Absolute agreement ICCs for intermethod reliability were fair to good, but consistency type agreement was excellent. A systematic bias of lower MRI distances (bias = -2.8 mm) compared with CT was observed. The investigation of CT versus MRI imaging techniques demonstrated that the standard MRI examination places the knee in approximately 4.6° of relative varus alignment compared with CT. CONCLUSION: A systematic bias toward lower TTTG distances on MRI compared with CT was found. This finding is likely dependent on imaging technique, including patient positioning. Patient knees were positioned in varus on the MRI compared with the CT examination, with resulting lower TTTG distances on MRI compared with CT. The TTTG distances on CT and MRI vary with imaging technique, which may be attributable to patient positioning and result in differences among imaging centers.

Cyclic displacement after meniscal root repair fixation: a human biomechanical evaluation.

BACKGROUND: Recent biomechanical evidence suggests that the meniscus-suture interface contributes the most displacement to the transtibial pull-out repair for meniscal root tears. Therefore, optimization of surgical technique at the meniscus-suture interface may minimize displacement and improve the strength of meniscal root repairs. PURPOSE/HYPOTHESIS: The purpose of this study was to investigate the cyclic displacement and ultimate failure loads of 4 different meniscus-suture fixation techniques for posterior medial meniscal root repairs in human meniscus tissue. The hypothesis was that there would be no significant difference between the two simple sutures (TSS) technique and 3 other techniques in cyclic displacement or ultimate failure load. STUDY DESIGN: Controlled laboratory study. METHODS: A total of 32 fresh-frozen, human, medial meniscal transplant specimens were randomly assigned to 4 meniscus-suture fixation techniques used for transtibial pull-out repair in posterior medial meniscal root tears (n = 8 per group). The suture techniques studied were (1) TSS, (2) modified Mason-Allen (MMA), (3) single double-locking loop (S-DLL), and (4) double double-locking loop (D-DLL). The menisci were subjected to a cyclic tensioning protocol representative of postoperative rehabilitation (10-30 N for 1000 cycles) and pulled to failure at a rate of 0.5 mm/s. RESULTS: After 1000 cycles, the TSS group displaced the least (mean ± SD, 1.78 ± 0.64 mm), followed by the MMA (2.14 ± 0.65 mm), D-DLL (2.97 ± 0.57 mm), and S-DLL (3.81 ± 0.78 mm) groups. After 100, 500, and 1000 cycles, suture displacements using the TSS and MMA techniques were not significantly different (P > .13), while the TSS technique resulted in significantly less displacement than the S-DLL and D-DLL (P < .03) techniques. The ultimate failure loads of the MMA (325 ± 77 N) and D-DLL (320 ± 50 N) techniques were significantly greater than those of the TSS (192 ± 52 N) and S-DLL (217 ± 51 N) techniques (P < .05). CONCLUSION: The TSS and MMA fixation techniques were not significantly different, while the TSS was significantly better at resisting displacement when compared with the S-DLL and D-DLL stitch configurations. The MMA and D-DLL techniques exhibited significantly greater failure loads than did the TSS and S-DLL techniques; however, all techniques demonstrated ultimate failure loads above the currently accepted rehabilitation force threshold. CLINICAL RELEVANCE: The TSS fixation technique combines the lowest technical difficulty and the ability to resist displacement at time zero. The MMA technique, although more technically challenging, may provide an alternative means to resist displacement while enhancing the failure load.

Anterior meniscus root avulsion following intramedullary nailing for a tibial shaft fracture.

UNLABELLED: This paper presents the first reported case of iatrogenic injury to the anterior medial meniscal root attachment following intramedullary nailing for a tibial shaft fracture. The patient experienced a closed right tibia-fibula fracture 7 years prior to presentation, which was treated with a reamed intramedullary nail. The nail was removed 3 years after the index surgery due to chronic anterior knee pain, which persisted following hardware removal. At presentation, the patient was diagnosed with an anterior horn medial meniscal root tear likely secondary to insertion of the intramedullary nail through the anatomic footprint of the anterior medial root. After undergoing a medial meniscus anterior horn root repair, the patient was asymptomatic and resumed normal activities. LEVEL OF EVIDENCE: Case report, Level IV.

Biomechanical evaluation of a transtibial pull-out meniscal root repair: challenging the bungee effect.

BACKGROUND: A common treatment for posterior meniscal root tears is transtibial pull-out repair, which has been biomechanically reported to restore tibiofemoral contact mechanics to those of the intact knee. Biomechanical data suggest that there is significant displacement of the repaired meniscal root with cyclic loading, which may be responsible for the poor healing and meniscal extrusion demonstrated in some clinical studies. HYPOTHESIS/PURPOSE: The purpose of this study was to quantify the time-zero displacement of the posterior meniscal root in response to cyclic loading after transtibial pull-out repair and to quantify the individual contributions to displacement of the following: (1) suture elongation, (2) button-bone interface, and (3) meniscus-suture interface. The meniscus-suture interface was hypothesized to result in significantly more displacement than the button-bone interface or suture elongation. STUDY DESIGN: Descriptive laboratory study. METHODS: Transtibial pull-out repair of the posterior medial meniscal root was performed in 6 porcine knees, and cyclic displacement was measured using a loading protocol representative of postoperative rehabilitation. Displacement from (1) suture elongation, (2) the button-bone interface, and (3) the meniscus-suture interface was determined by cyclically loading 6 specimens for each construct using the same loading protocol to determine the contribution of each component to the overall displacement of the repair construct. RESULTS: After 1000 cycles, the repair construct displaced by a mean of 3.28 mm (95% CI, 2.07-4.49). The meniscus-suture component (mean, 2.52 mm; 95% CI, 2.21-2.83) displaced significantly more than the button-bone component (mean, 0.90 mm; 95% CI, 0.64-1.15; P = .006) and suture elongation component (mean, 0.71 mm; 95% CI, 0.36-1.06; P = .006) after 1000 cycles. Displacement of the button-bone and suture elongation components was not significantly different after 1000 cycles (P = .720). CONCLUSION: There was substantial displacement of the posterior medial meniscal root repaired with the transtibial pull-out technique under a cyclic loading protocol simulating postoperative rehabilitation. The meniscus-suture interface contributed to significantly more displacement than the button-bone interface and suture elongation in the transtibial pull-out repair construct. CLINICAL RELEVANCE: The results provide a framework for optimizing the transtibial pull-out repair technique. Future studies should focus on improving suture fixation strength within the meniscus-suture interface.

Anatomy of the anterior root attachments of the medial and lateral menisci: a quantitative analysis.

BACKGROUND: While the biomechanical importance of the meniscal roots has been demonstrated, the anatomy of the anterior meniscal roots remains largely unknown. Defining the quantitative anatomy of the anterior meniscal root attachments is essential for developing improved diagnostic and surgical techniques. HYPOTHESIS: The anterior medial (AM) and anterior lateral (AL) meniscal roots could be quantitatively defined relative to open and arthroscopic surgical landmarks. STUDY DESIGN: Descriptive laboratory study. METHODS: Twelve nonpaired human cadaveric knees were used (average age, 51.3 years). A coordinate measuring device quantified the anatomic relationships of the AM and AL root attachments to open and arthroscopic surgical landmarks. The tibial attachments of both anterior roots were defined and quantified by categorizing the fibers of the root as either central, dense attachments or peripheral, supplemental attachments. RESULTS: The center of the tibial tuberosity and the medial tibial eminence apex were 27.0 mm lateral and distal and 27.5 mm posterior to the center of the AM root, respectively. The center of the anterior cruciate ligament (ACL) and the lateral tibial eminence apex were 5.0 mm posteromedial and 14.4 mm posterolateral to the center of the AL root, respectively. The AM root attachment had a mean area of 110.4 mm(2) (95% CI, 92.2-128.5) with a central attachment of 56.3 mm(2) (95% CI, 46.9-65.8). The AL root attachment had a mean area of 140.7 mm(2) (95% CI, 121.6-159.8) and inserted deeply beneath the ACL in all specimens. The overlap of the ACL on the AL root averaged 88.9 mm(2) (95% CI, 63.3-114.6), comprising 63.2% of the AL root attachment. CONCLUSION: The anterior meniscal roots were identified in relation to pertinent open and arthroscopic landmarks. The extended overlap between the AL root and ACL attachment revealed a more intimate tibial attachment relationship than previously recognized. CLINICAL RELEVANCE: Quantitative descriptions of the anterior meniscal roots elucidate the relationship between the root attachments and pertinent surgical landmarks. In addition, the supplemental attachments of both menisci may contribute to native meniscal function, and further investigation is recommended.

Radiographic identification of the anterior and posterior root attachments of the medial and lateral menisci.

BACKGROUND: Anatomic root placement is necessary to restore native meniscal function during meniscal root repair. Radiographic guidelines for anatomic root placement are essential to improve the accuracy and consistency of anatomic root repair and to optimize outcomes after surgery. PURPOSE: To define quantitative radiographic guidelines for identification of the anterior and posterior root attachments of the medial and lateral menisci on anteroposterior (AP) and lateral radiographic views. STUDY DESIGN: Descriptive laboratory study. METHODS: The anterior and posterior roots of the medial and lateral menisci were identified in 12 human cadaveric specimens (average age, 51.3 years; age range, 39-65 years) and labeled using 2-mm radiopaque spheres. True AP and lateral radiographs were obtained, and 2 raters independently measured blinded radiographs in relation to pertinent landmarks and radiographic reference lines. RESULTS: On AP radiographs, the anteromedial and posteromedial roots were, on average, 31.9 ± 5.0 mm and 36.3 ± 3.5 mm lateral to the edge of the medial tibial plateau, respectively. The anterolateral and posterolateral roots were, on average, 37.9 ± 5.2 mm and 39.3 ± 3.8 mm medial to the edge of the lateral tibial plateau, respectively. On lateral radiographs, the anteromedial and anterolateral roots were, on average, 4.8 ± 3.7 mm and 20.5 ± 4.3 mm posterior to the anterior margin of the tibial plateau, respectively. The posteromedial and posterolateral roots were, on average, 18.0 ± 2.8 mm and 19.8 ± 3.5 mm anterior to the posterior margin of the tibial plateau, respectively. The intrarater and interrater intraclass correlation coefficients (ICCs) were >0.958, demonstrating excellent reliability. CONCLUSION: The meniscal root attachment sites were quantitatively and reproducibly defined with respect to anatomic landmarks and superimposed radiographic reference lines. The high ICCs indicate that the measured radiographic relationships are a consistent means for evaluating meniscal root positions. CLINICAL RELEVANCE: This study demonstrated consistent and reproducible radiographic guidelines for the location of the meniscal roots. These measurements may be used to assess root positions on intraoperative fluoroscopy and postoperative radiographs.