Repair of Quadriceps and Patellar Tendon Tears.

Tears of the quadriceps or patellar tendon usually occur after a sudden eabccentric contraction and are diagnosed by a palpable gap at the injury site combined with an inability to perform a straight leg raise. Bilateral knee radiographs may demonstrate patella alta with patellar tendon tears and patella baja with quadriceps tendon tears compared with the uninjured knee. Ultrasound and magnetic resonance imaging can be helpful when there is uncertainty in the diagnosis. Surgical treatment is indicated for complete tears and some high-grade, partial tears. Nonabsorbable high-strength sutures or suture tape are placed in running locking fashion along the injured tendon and secured to the patella with bone tunnels (i.e., transosseous) or suture anchors. The transosseous technique requires exposure of the length of the patella to drill 3 bone tunnels to shuttle the sutures and tie over either pole of the patella. The suture anchor technique allows for a smaller incision and less soft-tissue dissection and may use a knotted or knotless technique. Biomechanical testing with load to failure is not statistically different between the transosseous and anchor techniques, although anchors have been shown to have less gap formation at the repair site. Repair augmentation with a graft may be beneficial in mid-substance injuries, chronic tears, and in cases of compromised tissue quality. Rehabilitation usually can be initiated immediately with protected weight-bearing in an orthosis, safe-zone knee passive range of motion, and avoidance of active extension. After a period of 6 weeks, rehabilitation can progress with full range of motion and a concentric strengthening program.

Radiographic and Dynamic Assessment for Resection of Cam Lesions in Patients With Femoroacetabular Impingement.

Cam-type femoroacetabular impingement is characterized by a pathologic asphericity of the femoral head-neck junction, and arthroscopic femoral osteoplasty is indicated to correct the bony abnormality and restore normal hip mechanics when symptomatic. Residual femoroacetabular impingement deformity after arthroscopy is a leading cause of failure, and it is therefore critical to perform a thorough fluoroscopic and dynamic assessment when addressing cam deformities arthroscopically. The fluoroscopic assessment uses 6 anteroposterior views, including 3 in hip extension (30° internal rotation, neutral rotation, and 30° external rotation) and 3 in 50° flexion (neutral rotation, 40° external rotation, 60° of external rotation), performed before, during, and after the femoral resection. The dynamic assessment includes evaluation of impingement-free range of motion and "end feel" (a subjective description of the tactile feedback during assessment of hip motion), and should be performed before and after the femoral resection in 3 specific positions (extension/abduction, flexion/abduction, and flexion/internal rotation). Although the anterior aspect of the head-neck junction is readily accessed through standard arthroscopic portals with the hip in 30 to 50° of flexion, the posterolateral, posteromedial, and posterior extent of the femoral head-neck junction are challenging to address. The natural external rotation of the proximal femur during flexion and internal rotation during extension can be used to gain posterior lateral and medial access. Antero/posteromedial femoral access can be obtained with >50° of hip flexion with the burr in the anteromedial portal. Posterolateral femoral access is achieved with hip extension with the burr in the anterolateral portal, and further posterolateral access can be achieved with the addition of traction, allowing resection of posterolateral deformities extending beyond the lateral retinacular vessels while remaining proximal to the vessels. This comprehensive intraoperative fluoroscopic and dynamic assessment and surgical technique can lead to a predictable correction of most cam-type deformities.

Editorial Commentary: Both Femoral Acetabular Anteversion and Retroversion May Contribute to the Effect of Femoroacetabular Impingement: What's Your Version?

Femoral anteversion may be a protective factor for hip impingement, whereas hip arthroscopy outcomes are worse for patients with femoral retroversion. Changes in version also affect the location of impingement. The association of increased anteversion with cam lesions may also explain the high number of patients with asymptomatic cam lesions. Thus, some patients may have large α angles but be asymptomatic. Finally, although femoral version is important, it must be considered in the setting of the patient's acetabular morphology. There is a complex interplay of femoral and acetabular morphologies.

Editorial Commentary: Hip Femoroacetabular Impingement Emotional Impact and Mental Health: An Arthroscope Can't Fix Everything.

Arthroscopic treatment of femoroacetabular impingement is increasingly common with established clinical success. As with other chronic injuries, there is an emotional impact that can affect recovery, particularly in competitive athletes. As this emotional aspect of injury is more recognized, it will be important to determine comprehensive means of treating both an athlete's physical and mental health. It is important to establish preoperative expectations. For certain patients, psychological evaluation and treatment is indicated early in the diagnosis and recovery to ensure mental fitness, and this may be especially true for adolescents. A comprehensive and personalized approach to injury recovery is optimal.

Editorial Commentary: Hip Traumatic Labrum Tears: Does Femoroacetabular Impingement Syndrome Make a Difference in Outcome?

It is well known that key features of femoral acetabular impingement syndrome include labrum tears. These tears often are caused by elevation of the labrum off the acetabulum. However, another common cause of labrum tears is traumatic injuries from either low- or high-energy mechanisms. It is commonly thought that traumatic labrum tears may have different outcomes than the atraumatic tears. However, recent studies now show that traumatic labrum tears have equivalent outcomes to atraumatic groups even when including the worker's compensation population.

Editorial Commentary: When Your Golf Game Is Handicapped by Your Hip.

Golf is a common recreational and competitive sport that requires full hip rotation to allow for a smooth and effective swing. Therefore hip impingement and hip osteoarthritis, by limiting rotation, could cause pain in golfers and even encourage them to discontinue the sport. In my opinion, the lead hip in golfers is likely what generally drives the symptoms in the hip, back, or knee. After surgical correction, golfers are able to get back to golf and many experience improved performance.

Editorial Commentary: Hip Arthroscopy in Hip Dysplasia: Just Because You Are Doing It, Should You?

As surgeons advance the field of hip arthroscopy and perform more hip arthroscopy in patients with hip dysplasia and associated femoroacetabular impingement, we need to publish more outcome studies to determine this procedure's success and safety in this specific group of patients.

Research Pearls: The Significance of Statistics and Perils of Pooling. Part 1: Clinical Versus Statistical Significance.

Patient-reported outcomes (PROs) are increasingly being used in today's rapidly evolving health care environment. The value of care provision emphasizes the highest quality of care at the lowest cost. Quality is in the eye of the beholder, with different stakeholders prioritizing different components of the value equation. At the center of the discussion are the patients and their quantification of outcome via PROs. There are hundreds of different PRO questionnaires that may ascertain an individual's overall general health, quality of life, activity level, or determine a body part-, joint-, or disease-specific outcome. As providers and patients increasingly measure outcomes, there exists greater potential to identify significant differences across time points due to an intervention. In other words, if you compare groups enough, you are bound to eventually detect a significant difference. However, the characterization of significance is not purely dichotomous, as a statistically significant outcome may not be clinically relevant. Statistical significance is the direct result of a mathematical equation, irrelevant to the patient experience. In clinical research, despite detecting statistically significant pre- and post-treatment differences, patients may or may not be able to perceive those differences. Thresholds exist to delineate whether those differences are clinically important or relevant to patients. PROs are unique, with distinct parameters of clinical importance for each outcome score. This review highlights the most common PROs in clinical research and discusses the salient pearls and pitfalls. In particular, it stresses the difference between statistical and clinical relevance and the concepts of minimal clinically important difference and patient acceptable symptom state. Researchers and clinicians should consider clinical importance in addition to statistical significance when interpreting and reporting investigation results.

The role of arthroscopy in the management of glenohumeral osteoarthritis: a Markov decision model.

PURPOSE: The purposes of this study were (1) to construct a theoretical Markov decision model to compare the total remaining quality-adjusted life-years following either arthroscopic management (AM) or total shoulder arthroplasty (TSA) for the treatment of glenohumeral osteoarthritis and (2) to determine the possible effects of age on the preferred treatment strategy. METHODS: A Markov decision model was constructed to compare AM and TSA in patients with glenohumeral osteoarthritis. The rates of surgical complications, revision surgery, and death were derived from the literature and analyzed. The principal outcome measure was the mean total remaining quality-adjusted life-years after each treatment strategy. Sensitivity analyses were performed for age at the initial procedure, utilities, and transition probabilities. RESULTS: This theoretical decision model showed that AM was the preferred strategy for patients younger than 47 years, TSA was the preferred strategy for patients older than 66 years, and both treatment strategies were reasonable for patients aged between 47 and 66 years. The model was highly sensitive to age at the index surgery, utilities of wellness states, survivorship, and the probability of failure after either AM or TSA. CONCLUSIONS: According to this theoretical decision model, AM was the preferred treatment strategy for patients younger than 47 years, primary TSA was the preferred treatment strategy for patients older than 66 years, and both treatment options were reasonable for patients aged between 47 and 66 years. LEVEL OF EVIDENCE: Level II, economic and decision analysis.

The history of radiofrequency energy and Coblation in arthroscopy: a current concepts review of its application in chondroplasty of the knee.

Radiofrequency energy has had widespread use for a variety of surgical procedures. Its application in orthopedic surgery initiated with shoulder instability. Over the last couple decades it has been applied as surgical tool for cartilage treatment as well. There have been significant gains in its technology and our understanding of its potential benefits. We address its history and advancements in becoming a surgical tool for cartilage lesions along with a review of recent long-term follow up studies.

Meniscus Root Repair vs Meniscectomy or Nonoperative Management to Prevent Knee Osteoarthritis After Medial Meniscus Root Tears: Clinical and Economic Effectiveness.

BACKGROUND: Medial meniscus root tears are a common knee injury and can lead to accelerated osteoarthritis, which might ultimately result in a total knee replacement. PURPOSE: To compare meniscus repair, meniscectomy, and nonoperative treatment approaches among middle-aged patients in terms of osteoarthritis development, total knee replacement rates (clinical effectiveness), and cost-effectiveness. STUDY DESIGN: Meta-analysis and cost-effectiveness analysis. METHODS: A systematic literature search was conducted. Progression to osteoarthritis was pooled and meta-analyzed. A Markov model projected strategy-specific costs and disutilities in a cohort of 55-year-old patients presenting with a meniscus root tear without osteoarthritis at baseline. Failure rates of repair and meniscectomy procedures and disutilities associated with osteoarthritis, total knee replacement, and revision total knee replacement were accounted for. Utilities, costs, and event rates were based on literature and public databases. Analyses considered a time frame between 5 years and lifetime and explored the effects of parameter uncertainty. RESULTS: Over 10 years, meniscus repair, meniscectomy, and nonoperative treatment led to 53.0%, 99.3%, and 95.1% rates of osteoarthritis and 33.5%, 51.5%, and 45.5% rates of total knee replacement, respectively. Meta-analysis confirmed lower osteoarthritis and total knee replacement rates for meniscus repair versus meniscectomy and nonoperative treatment. Discounted 10-year costs were $22,590 for meniscus repair, as opposed to $31,528 and $25,006 for meniscectomy and nonoperative treatment, respectively; projected quality-adjusted life years were 6.892, 6.533, and 6.693, respectively, yielding meniscus repair to be an economically dominant strategy. Repair was either cost-effective or dominant when compared with meniscectomy and nonoperative treatment across a broad range of assumptions starting from 5 years after surgery. CONCLUSION: Repair of medial meniscus root tears, as compared with total meniscectomy and nonsurgical treatment, leads to less osteoarthritis and is a cost-saving intervention. While small confirmatory randomized clinical head-to-head trials are warranted, the presented evidence seems to point relatively clearly toward adopting meniscus repair as the preferred initial intervention for medial meniscus root tears.

Posterior Surgical Approach to the Knee.

Posterior knee approaches are reliable techniques to address the treatment of various pathologies of the posterior region of the knee, including Baker cyst excision, tibial plateau fracture fixation, posterior cruciate ligament avulsions and inlay reconstructions, femoral condyle cartilage procedures, posterior meniscal repair and loose body removal among others. Surgery in the posterior knee region can be challenging because of the presence of neurovascular structures including the tibial nerve, popliteal artery and vein, and common peroneal nerve; thus, it is less commonly performed. The purpose of this Technical Note is to describe the posteromedial approach to the knee, its anatomic considerations, and how to avoid complications related to the surgical approach.

Posterior cruciate ligament graft fixation angles, part 2: biomechanical evaluation for anatomic double-bundle reconstruction.

BACKGROUND: Prior studies have suggested that anatomic double-bundle (DB) posterior cruciate ligament reconstruction (PCLR) reduces residual laxity compared with the intact state better than single-bundle PCLR. Although the anterolateral bundle (ALB) and posteromedial bundle (PMB) reportedly act codominantly, few studies have compared commonly used graft fixation angles and the influence that graft fixation angles have on overall graft forces and knee laxity. HYPOTHESIS: Graft fixation angle combinations of 0°/75° (PMB/ALB), 0°/90°, 0°/105°, 15°/75°, 15°/90°, and 15°/105° would significantly reduce knee laxity from the sectioned PCL state while preventing in vitro graft forces from being overloaded between any of the graft fixation angles. STUDY DESIGN: Controlled laboratory study. METHODS: Nine cadaveric knees were evaluated for the kinematics of the intact, PCL-sectioned, and DB PCLR techniques. The DB technique was varied by fixing the PMB and ALB grafts at the following 6 randomly ordered fixation angle combinations: 0°/75° (PMB/ALB), 0°/90°, 0°/105°, 15°/75°, 15°/90°, and 15°/105°. A 6 degrees of freedom robotic testing system subjected each specimen to an applied 134-N posterior tibial load at 0° to 120° of flexion and 5-N·m external, 5-N·m internal, and 10-N·m valgus rotation torques applied at 60°, 75°, 90°, 105°, and 120° of flexion. The ALB and PMB grafts were fixed to load cells that concurrently measured graft forces throughout kinematic testing. t tests compared the kinematics between groups, and 2-factor models assessed the contribution of ALB and PMB grafts after DB PCLR (P < .05). RESULTS: Consistently, DB PCLR significantly reduced posterior translation compared with the sectioned PCL and was comparable with the intact state during applied posterior tibial loads at flexion angles of greater than 90°; a mean residual laxity of 1.5 mm remained compared with the intact state during applied posterior tibial loads. Additionally, fixing the PMB graft at 15° resulted in significantly larger PMB graft forces compared with fixation at 0° during applied posterior loading, internal rotation, external rotation, and valgus rotation. Similarly, fixing the ALB graft at 75° resulted in significantly larger ALB graft forces compared with fixation of the ALB graft at 90° or 105° during all loading conditions. CONCLUSION: Fixation of the PMB graft at 0° to 15° and the ALB graft at 75° to 105° during DB PCLR were successful in significantly reducing knee laxity from the sectioned state. However, fixation of the PMB graft at 15° versus 0° resulted in significantly increased loads through the PMB graft, and fixation of the ALB graft at 75° versus 90° or 105° resulted in significantly increased loads through the ALB graft. CLINICAL RELEVANCE: This study found that all 6 fixation angle combinations significantly improved knee kinematics compared with the sectioned state at time zero; however, it is recommended that fixation of the PMB graft be performed at 0° because of the significant increases in PMB graft loading that occur with fixation at 15° and that fixation of the ALB graft be performed at 90° or 105° rather than 75° to minimize ALB graft forces, which could lead to graft attenuation or failure over time.

Posterior cruciate ligament graft fixation angles, part 1: biomechanical evaluation for anatomic single-bundle reconstruction.

BACKGROUND: Currently, no consensus exists for the optimal graft fixation angle for anatomic single-bundle (SB) posterior cruciate ligament reconstructions (PCLRs). Additionally, direct graft forces have not been measured. Alternative graft fixation angles and the resultant graft forces should be investigated to optimize the stability of SB PCLRs without overconstraining the knee. HYPOTHESIS: Graft fixation angles of 75°, 90°, and 105° for SB PCLR were hypothesized to improve knee stability compared with the sectioned posterior cruciate ligament state with no evidence of knee overconstraint. STUDY DESIGN: Controlled laboratory study. METHODS: Nine fresh-frozen human cadaveric knees were biomechanically evaluated for the intact, sectioned, and SB PCLR states with the anterolateral bundle graft fixed at 75°, 90°, and 105°. A 6 degrees of freedom robotic system assessed knee laxity with a 134-N posterior load applied at 0° to 120° and 5-N·m external, 5-N·m internal, and 10-N·m valgus rotation torques applied at 60° to 120°. By securing the graft to an external load cell, graft forces were measured throughout kinematic testing. RESULTS: No significant kinematic differences were found among the 3 fixation angles. Each fixation angle resulted in significantly less posterior translation than in the sectioned state at all flexion angles (P < .05), with 4.1 mm of average residual laxity during an applied posterior loading. For all graft fixation angles, internal rotation was significantly increased between 60° and 120° of flexion, and external rotation was significantly increased at 90°, 105°, and 120° of flexion compared with the intact state. Graft forces were not significantly different among the 3 fixation angles and remained below reported loads observed during activities of daily living. CONCLUSION: All tested SB PCLR graft fixation angles restored knee laxity to similar levels; however, persistent laxity resulted in significant increases in knee laxity compared with the intact state during posterior tibial loading at all flexion angles, internal rotation at flexion angles ≥60°, and external rotation at ≥75° of flexion. CLINICAL RELEVANCE: The results of this study suggest that SB PCL graft fixation angles of 75°, 90°, and 105° were comparable in restoring knee kinematics and exposed the graft to similar time-zero loads. However, SB PCLRs did not fully reduce knee laxity to the intact state.