Greater Postoperative Biceps Tendon Migration Following Biceps Tenodesis Correlates with Lower Patient Reported Outcomes Scores.

PURPOSE: To assess the relationship between tendon migration, as measured by radiostereometric analysis (RSA), and patient-reported outcome measures (PROMs) following biceps tenodesis (BT); to determine the likelihood of achieving clinically significant outcomes (CSOs) following BT; and to identify factors that impact CSO achievement. METHODS: Patients undergoing arthroscopic suprapectoral or open subpectoral BT at a single, high-volume academic medical center were prospectively enrolled. A tantalum bead sutured to the tenodesis construct was utilized as a radio-opaque marker. Biceps tendon migration was measured on calibrated radiographs at 12 weeks postoperatively. PROMs (Constant-Murley score [Constant], Single Assessment Numeric Evaluation [SANE], and Patient-Reported Outcomes Measurement Information Systemic-Upper Extremity [PROMIS-UE]) were collected preoperatively and at ≥2 years follow-up. RESULTS: Of 115 patients enrolled, 94 (82%) patients were included (median age=52 years and BMI=31.4 kg/m2). At a mean follow-up of 2.9 years, median Constant, SANE, and PROMIS-UE were 33 (interquartile range [IQR]=26-35), 90 (IQR=80-99), and 47 (IQR=42-58), respectively. Median tantalum bead migration was 6.5 mm (IQR 1.8-13.8). There was a significant correlation between migration and Constant (r2 = 0.222, beta= -0.554, 95% CI -1.027- [-0.081], P=0.022), SANE (r2 = 0.238, beta= -0.198, 95% CI -0.337 - [-0.058], P=0.006) and PROMIS-UE (r2 = 0.233, beta= -0.406, 95% CI -0.707 - [-0.104], P=0.009). In univariable analysis, higher BMI was associated with achievement of substantial clinical benefit (SCB, unadj-OR=1.078, 95%CI 1.007-1.161, P=0.038). Greater bead migration was negatively associated with achievement of minimal clinically important difference (MCID, unadj-OR=0.969, 95% CI 0.943-0.993, P=0.014) and patient acceptable symptomatic state (PASS, unadj-OR 0.965, 95% CI 0.937-0.989, P=0.008) on all 3 instruments. CONCLUSION: A 1 cm-increase in tenodesed biceps tendon migration was associated with a decrease in Constant, SANE, and PROMIS-UE of 6, 2, and 4 points, respectively, at a mean of 2.9 years after surgery. Most patients achieved clinically significant outcomes (CSOs) for these PROMs by latest follow-up, and greater biceps tendon construct migration was negatively associated with the likelihood of CSO achievement. LEVEL OF EVIDENCE: IV, retrospective case series.

The Large Focal Isolated Chondral Lesion.

Focal chondral defects (FCDs) of the knee can be a debilitating condition that can clinically translate into pain and dysfunction in young patients with high activity demands. Both the understanding of the etiology of FCDs and the surgical management of these chondral defects has exponentially grown in recent years. This is reflected by the number of surgical procedures performed for FCDs, which is now approximately 200,000 annually. This fact is also apparent in the wide variety of available surgical approaches to FCDs. Although simple arthroscopic debridement or microfracture are usually the first line of treatment for smaller lesions, chondral lesions that involve a larger area or depth require restorative procedures such as osteochondral allograft transplantation or other cell-based techniques. Given the prevalence of FCDs and the increased attention on treating these lesions, a comprehensive understanding of management from diagnosis to rehabilitation is imperative for the treating surgeon. This narrative review aims to describe current concepts in the treatment of large FCDs through providing an algorithmic approach to selecting interventions to address these lesions as well as the reported outcomes in the literature.

Two-Stage Revision Total Knee Arthroplasty for Chronic Histoplasma Capsulatum Prosthetic Joint Infection: A Case Report.

CASE: This report describes a histoplasma capsulatum total knee prosthetic joint infection (PJI) in an immunosuppressed patient treated with a 2-stage revision. The diagnosis of PJI was made based on minor criteria, and the causative organism was identified from cultures obtained at the time of explantation. The patient underwent induction with amphotericin B, followed by oral antifungal therapy and a successful 2-stage revision with a hinged prosthesis with an interval of ∼7 months between stage 1 and stage 2. At the most recent follow-up (18 months), she remained clear from infection with planned lifetime antifungal suppression. CONCLUSION: This case report highlights the importance of consideration of atypical organisms when treating immunocompromised patients. Furthermore, this case report documents one of the few cases of histoplasma PJI and provides a successful treatment algorithm to potentially be applied to future cases.

Posterolateral Corner Reconstruction: Surgical Technique and Postoperative Rehabilitation.

Anatomic posterolateral corner (PLC) reconstruction is utilized for ligamentous knee instability associated with PLC injury in patients who desire a return to active lifestyles1,2. The fibular collateral ligament (FCL) and popliteal tendon (PLT) are reconstructed in anatomic fashion according to techniques described by LaPrade et al.3-7. Description: Various PLC reconstruction techniques have been described; however, the preferred reconstruction technique of the senior author is the method developed by LaPrade et al. that restores the anatomy of the 3 primary stabilizers of the PLC, including the FCL, PLT, and popliteofibular ligament3,5,6. Alternatives: Alternative nonoperative treatments include knee immobilization for 4 weeks and physical therapy. Surgical alternatives include PLC repair, which involves repair of the lateral collateral ligament, PLT, and/or popliteofibular ligament if structures can be anatomically reduced to their attachment site. However, repair of acute grade-III PLC injuries with staged treatment of concurrent cruciate injuries is associated with a substantially higher postoperative PLC failure rate8-10. Rationale: Clinical outcomes have demonstrated that primary repairs have significantly higher rates of reoperation compared with reconstruction; therefore, reconstruction is recommended. Treatment of grade-III PLC injuries with reconstruction of midsubstance tears and any associated cruciate ligament tears results in significantly improved objective stability11. In addition, anatomic PLC reconstruction has demonstrated improved subjective and objective patient outcomes compared with nonsurgical treatment or repair5,11,12. Expected Outcomes: Reconstruction of the PLC offers excellent outcomes after surgery. Studies have shown that the fibular-based technique for treatment of a chronic isolated PLC injury showed good results in terms of clinical outcome, restoring knee varus and rotational stability13. Important Tips: Patients with associated proximal tibiofibular joint instability will benefit from this reconstruction because this technique will add stability to the joint.This surgical approach is technically demanding, requiring proficiency with surgical dissection.Damage to the common peroneal nerve can potentially occur. Careful dissection and placement of retractors should be observed.Risks include surgical failure due to unrecognized malalignment; especially in chronic cases, the patient should have a complete evaluation of the standing alignment and tibial slope12. Acronyms and Abbreviations: FCL = fibular collateral ligamentPFL = popliteofibular ligamentPLC = posterolateral cornerIT = iliotibialIKDC = International Knee Documentation CommitteeACL = anterior cruciate ligamentPCL = posterior cruciate ligamentPEEK = polyetheretherketonePROM = passive range of motion.

Does native glenoid anatomy predispose to shoulder instability? An MRI analysis.

BACKGROUND: It is unclear if native glenohumeral anatomic features predispose young patients to instability and if such anatomic risk factors differ between males and females. The purpose of this study was to compare glenoid and humeral head dimensions between patients with a documented instability event without bone loss to matched controls and to evaluate for sex-based differences across measurements. The authors hypothesized that a smaller glenoid width and glenoid surface area would be significant risk factors for instability, whereas humeral head width would not. METHODS: A prospectively maintained database was queried for patients aged <21 years who underwent magnetic resonance imaging (MRI) for shoulder instability. Patients with prior shoulder surgery, bony Bankart, or glenoid or humeral bone loss were excluded. Patients were matched by sex and age to control patients who had no history of shoulder instability. Two blinded independent raters measured glenoid height, glenoid width, and humeral head width on sagittal MRI. Glenoid surface area, glenoid index (ratio of glenoid height to width), and glenohumeral mismatch ratio (ratio of humeral head width to glenoid width) were calculated. RESULTS: A total of 107 instability patients and 107 controls were included (150 males and 64 females). Among the entire cohort, there were no differences in glenoid height, glenoid width, glenoid surface area, humeral head width, or glenoid index between patients with instability and controls. Overall, those with instability had a greater glenohumeral mismatch ratio (P = .029) compared with controls. When stratified by sex, female controls and instability patients showed no differences in any of the glenoid or humerus dimensions. However, males with instability had a smaller glenoid width by 3.5% (P = .017), smaller glenoid surface area by 5.2% (P = .015), and a greater glenohumeral mismatch ratio (P = .027) compared with controls. CONCLUSION: Compared with controls, males with instability were found to have smaller glenoid width and surface area, and a glenoid width that was proportionally smaller relative to humeral width. In contrast, bony glenohumeral morphology did not appear to be a significant risk factor for instability among females. These sex-based differences suggest that anatomic factors may influence risk of instability for male and female patients differently.

Incidence of Intraoperative and Postoperative Complications After Posterolateral Corner Reconstruction or Repair: A Systematic Review of the Current Literature.

BACKGROUND: Posterolateral corner (PLC) injuries of the knee are being increasingly recognized and treated in current orthopaedic practice. While there are numerous systematic reviews evaluating the management and outcomes after PLC injuries, there are limited data investigating complications after PLC reconstruction or repair. PURPOSE: To systematically review the literature to determine the incidence of postoperative complications after the surgical treatment of PLC injury. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: The Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed (2008-2019), Embase (2008-2019), and MEDLINE (2008-2019) were queried for literature reporting on PLC reconstruction or repair, with or without concomitant ligamentous or meniscal surgery. Data including type of surgery performed, concomitant procedures, and follow-up time were extracted. Complications recorded included intra- and postoperative complications. RESULTS: After the intra- and postoperative complication data of 60 studies (1747 cases) were combined, surgical management of PLC injuries was associated with an intraoperative complication rate of 0.34% (range, 0%-2.8%) and a postoperative complication rate of 20% (range, 0%-51.2%). The most common postoperative complication was arthrofibrosis (range, 0%-20%). The overall infection rate was 1.3% (range, 0%-10%). Four cases of postoperative common peroneal nerve palsy were reported. Failure of reconstruction or repair was reported in 164 (9.4%) of all cases examined (range, 0%-37.1%). CONCLUSION: Although the intraoperative rate of complications during PLC reconstructions is low, postoperative complications rates of 20% can be expected, including arthrofibrosis, infection, and neurovascular injury. PLC structures repaired or reconstructed failed in 9.4% of the cases.

Patient Factors Associated With Clinical Failure Following Arthroscopic Superior Capsular Reconstruction.

PURPOSE: To identify demographic, clinical, and radiographic factors associated with failure after superior capsular reconstruction (SCR). METHODS: Prospectively collected data were analyzed from patients who underwent SCR using a decellularized dermal allograft for an irreparable rotator cuff tear. Demographic characteristics, radiographic findings, concomitant procedures, and patient-reported outcomes (PROs) were recorded. Failure was defined by ≥1 of the following criteria: (1) conversion to reverse total shoulder arthroplasty (RTSA), (2) a decrease in 1-year postoperative shoulder-specific PROs compared with preoperative scores, or (3) patient reports at final follow-up that the shoulder was in a worse condition than before surgery. Preoperative variables were compared between patients meeting the criteria for clinical failure and those who did not. RESULTS: Fifty-four patients (mean age 56.3 ± 5.8 years, range 45 to 70) who underwent SCR, with minimum 1-year follow-up, were included in the analysis. Mean follow-up after surgery was 24 months (range 12 to 53). Eleven patients (20.4%) met criteria for clinical failure. Of the 11, 8 reported decreased American Shoulder and Elbow Surgeons (ASES) or Constant scores or indicated that the operative shoulder was in a worse condition than before surgery. Three patients underwent RTSA in the 6 to 12 months after SCR. Female sex and the presence of a subscapularis tear were associated with failure (P = .023 and P = .029, respectively). A trend toward greater body mass index (BMI), lower preoperative forward flexion, and lower preoperative acromiohumeral distance (AHD) was found in patients with clinical failure (P = .075, P = .088, and P = .081, respectively). No other variable included in the analysis was significantly associated with failure. CONCLUSION: The proportions of female patients and those with subscapularis tear were greater among patients with clinical failure after SCR. Greater BMI, lower preoperative forward flexion, and lower preoperative AHD trended toward association with clinical failure of SCR. LEVEL OF EVIDENCE: 4, case series.

Diagnostic Performance of Artificial Intelligence for Detection of Anterior Cruciate Ligament and Meniscus Tears: A Systematic Review.

PURPOSE: To (1) determine the diagnostic efficacy of artificial intelligence (AI) methods for detecting anterior cruciate ligament (ACL) and meniscus tears and to (2) compare the efficacy to human clinical experts. METHODS: PubMed, OVID/Medline, and Cochrane libraries were queried in November 2019 for research articles pertaining to AI use for detection of ACL and meniscus tears. Information regarding AI model, prediction accuracy/area under the curve (AUC), sample sizes of testing/training sets, and imaging modalities were recorded. RESULTS: A total of 11 AI studies were identified: 5 investigated ACL tears, 5 investigated meniscal tears, and 1 investigated both. The AUC of AI models for detecting ACL tears ranged from 0.895 to 0.980, and the prediction accuracy ranged from 86.7% to 100%. Of these studies, 3 compared AI models to clinical experts. Two found no significant differences in diagnostic capability, whereas one found that radiologists had a significantly greater sensitivity for detecting ACL tears (P = .002) and statistically similar specificity and accuracy. Of the 5 studies investigating the meniscus, the AUC for AI models ranged from 0.847 to 0.910 and prediction accuracy ranged from 75.0% to 90.0%. Of these studies, 2 compared AI models with clinical experts. One found no significant differences in diagnostic accuracy, whereas one found that the AI model had a significantly lower specificity (P = .003) and accuracy (P = .015) than radiologists. Two studies reported that the addition of AI models significantly increased the diagnostic performance of clinicians compared to their efforts without these models. CONCLUSIONS: AI prediction capabilities were excellent and may enhance the diagnosis of ACL and meniscal pathology; however, AI did not outperform clinical experts. CLINICAL RELEVANCE: AI models promise to improve diagnosing certain pathologies as well as or better than human experts, are excellent for detecting ACL and meniscus tears, and may enhance the diagnostic capabilities of human experts; however, when compared with these experts, they may not offer any significant advantage.

Regenerative Potential of Mesenchymal Stem Cells for the Treatment of Knee Osteoarthritis and Chondral Defects: A Systematic Review and Meta-analysis.

PURPOSE: To perform a systematic review and meta-analysis evaluating the effects of mesenchymal stem cells (MSCs) on cartilage regeneration and patient-reported pain and function. METHODS: A systematic review was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using a PRISMA checklist. The Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed (2008-2019), EMBASE (2008-2019), and MEDLINE (2008-2019) were queried in July 2019 for literature reporting use of stem cells to treat knee osteoarthritis or chondral defects. Data describing administered treatment, subject population, injection type, duration of follow-up, pain and functional outcomes, and radiographic and magnetic resonance imaging findings were extracted. Risk of bias was assessed using the Downs and Black scale. Meta-analyses adjusted for random effects were performed, calculating pooled effect sizes in terms of patient-reported pain and function, cartilage quality, and cartilage volume. RESULTS: Twenty-five studies with 439 subjects were identified. There was no significant difference in pain improvement between MSC treatment and controls (pooled standardized mean difference [SMD] = 0.23, P = .30). However, MSC treatment was significantly favored for functional improvement (SMD = 0.66, P < .001). There was improvement in cartilage volume after MSC treatment (SMD = 0.84, P < .001). Regarding cartilage quality, meta-analysis resulted in a small, nonsignificant effect size of 0.37 (95%, -0.03 to 0.77, P = .07). There was risk for potential bias among included studies, with 17 (68%) receiving either a grade of "poor" or "fair." CONCLUSIONS: The pooled SMD from meta-analyses showed statistically significant effects of MSC on self-reported physical function but not self-reported pain. MSCs provided functional benefit only in patients who underwent concomitant surgery. However, this must be interpreted with caution, as there was substantial variability in MSC composition and mode of delivery. MSC treatment provided significant improvement in cartilage volume but not cartilage quality. Preliminary data regarding therapeutic properties of MSC treatment suggest significant heterogeneity in the current literature, and risk of bias is not negligible. LEVEL OF EVIDENCE: II, Systematic Review and Meta-analysis.

First-time Glenohumeral Dislocations: Current Evidence and Considerations in Clinical Decision Making.

The decision to manage first-time shoulder dislocations conservatively or operatively has become increasingly complex because of conflicting literature. Although shoulder dislocations have traditionally been managed with reduction and immobilization, recent evidence has suggested high rates of subsequent recurrence. Surgical intervention is thought to better restore stability and decrease recurrence rates; however, it also has the potential for additional morbidity and financial cost. As such, recent literature has sought to better define patient risk profiles to identify optimal candidates for both conservative and operative management. The purpose of the current review is to provide a comprehensive and evidence-based assessment of the most recent literature to better delineate an appropriate treatment algorithm for this challenging clinical scenario.

Preparation Methods and Clinical Outcomes of Platelet-Rich Plasma for Intra-articular Hip Disorders: A Systematic Review and Meta-analysis of Randomized Clinical Trials.

BACKGROUND: Despite its increasing use in the management of musculoskeletal conditions, questions remain regarding the preparation methods of platelet-rich plasma (PRP) and its clinical applications for intra-articular hip disorders, including femoroacetabular impingement syndrome (FAIS), labral pathology, and osteoarthritis (OA). PURPOSE: To systematically review and assess the preparation methods and clinical outcomes from randomized clinical trials (RCTs) on the use of PRP for intra-articular hip disorders. STUDY DESIGN: Systematic review; Level of evidence, 2. METHODS: A systematic review in accordance with the 2009 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed in September 2019. The Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, PubMed, Ovid Medline, and Embase were queried for studies regarding the use of PRP to treat intra-articular hip disorders. Qualifying articles were English-language RCTs describing the use of PRP for intra-articular hip disorders, either as standalone treatment or surgical augmentation. Two authors independently assessed article eligibility. Data pertaining to patient characteristics, indication for treatment, PRP preparation method, follow-up period, and clinical outcomes were extracted. Study results were qualitatively reported and quantitatively compared using meta-analysis when appropriate. RESULTS: Seven RCTs met inclusion criteria. Four studies described the use of PRP for hip OA and 3 utilized PRP at arthroscopy for FAIS and labral tears. Outcomes after PRP for OA demonstrated improvement in validated patient-reported outcome measures for up to 1 year; however, pooled effect sizes found no statistically significant difference between PRP and hyaluronic acid (HA) regarding pain visual analog scale scores at short-term (≤2 months; P = .27), midterm (4-6 months; P = .85), or long-term (1 year; P = .42) follow-up. When injected at arthroscopy, 1 study reported improved outcomes, 1 reported no difference in outcomes, and 1 reported worse outcomes compared with controls. The meta-analysis demonstrated no statistically significant difference on the modified Harris Hip Score (mHHS) between PRP and control cohorts at a minimum 1-year follow-up. There were considerable deficiencies and heterogeneity in the reporting of PRP preparation methods for both indications. CONCLUSION: Treatment of OA with PRP demonstrated reductions in pain and improved patient-reported outcomes for up to 1 year. However, there was no statistically significant difference between PRP and HA in pain reduction. Likewise, for FAIS and labral surgery there was no statistically significant difference in mHHS outcomes between patients treated with PRP and controls. Given the limited number of studies and variability in PRP preparations, additional high-quality randomized trials are warranted.

Indications and Outcomes for Arthroscopic Hip Labral Reconstruction With Autografts: A Systematic Review.

Background: The acetabular labrum plays a major role in hip function and stability. The gold standard treatment for labral tears is labral repair, but in cases where tissue is not amenable to repair, reconstruction has been demonstrated to provide superior outcomes compared to debridement. Many types of grafts have been used for reconstruction with good to excellent outcomes. Autograft options include iliotibial band (ITB), semitendinosus, and indirect head of the rectus femoris tendon, while allografts have included fascia lata and gracilis tendon allografts. Questions/Purposes: As allografts are not always readily available and have some inherent disadvantages, the aims of this systematic review were to assess (1) indications for labral reconstruction and (2) summarize outcomes, complications, and reoperation rates after arthroscopic labral reconstruction with autografts. Methods: A systematic review of the literature was performed using six databases (PubMed, CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Scopus, and Google Scholar) to identify studies reporting outcomes for arthroscopic labral reconstruction utilizing autografts, with a minimum follow-up of 1 year. Study design, patient demographics, autograft choice, complications, donor site morbidity, reoperation rates, conversion to arthroplasty, and patient reported outcomes were extracted and reported. Results: Seven studies were identified for inclusion with a total of 402 patients (173 females, age range 16-72, follow-up range 12-120 months). The most commonly reported functional outcome score was the modified Harris Hip Score (mHHS), which was reported in six of seven studies. Preoperative mHHS ranged from 56 to 67.3 and improved postoperatively to a range of 81.4-97.8. Conversion to total hip arthroplasty and reoperation rates ranged from 0 to 13.2% and 0 to 11%, respectively. The most common indication for labral reconstruction was an irreparable labrum. Autografts utilized included ITB, hamstring tendons, indirect head of rectus femoris, and capsular tissue. Conclusions: Arthroscopic autograft reconstruction of the acetabular labrum results in significant improvement in the short- and mid-term patient reported outcomes, for properly selected patients presenting with pain and functional limitation in the hip due to an irreparable labral injury.

No Differences in Hip Joint Space Measurements Between Weightbearing or Supine Anteroposterior Pelvic Radiographs.

PURPOSE: To to assess whether there are any significant differences in hip joint space width (JSW) between weight-bearing versus supine pelvic radiographs. METHODS: Standing and supine anteroposterior pelvic radiographs of 86 patients (146 hips) were included. Sample size was sufficiently powered to assess for equivalence between standing and supine films for JSW measurements made at the medial, lateral, and central aspects of the sourcil line. Measurements were made by 2 independent reviewers blinded to patient positioning. Each reviewer repeated a subset of the measurements to assess intra-rater reproducibility. Mean differences in joint space measurements between standing and supine radiographs were reported for each point of the sourcil. Intraclass correlation coefficients (ICCs) for inter and intra-rater reliability were also calculated. RESULTS: There were no significant differences between JSW measurements made on standing and supine pelvic radiographs (P = .468). Furthermore, equivalence testing demonstrated statistical equivalence between standing and supine JSW measurements made based on an equivalence threshold of ±0.5 mm. Inter-rater reliability demonstrated good agreement with an overall ICC of 0.775 (95% confidence interval [CI] 0.734-0.809). Intra-rater reliability also demonstrated good agreement with ICCs of 0.84 (95% CI 0.758-0.889) and 0.798 (95% CI 0.721-0.851) for the 2 reviewers, respectively. CONCLUSIONS: JSW measurements on standing and supine pelvic radiographs were not significantly different, and their inter-rater agreement and intra-rater reproducibility demonstrated good reliability and repeatability. Therefore, either may be used to assess JSW, including measurements that may impact treatment decisions for hip arthroscopy. LEVEL OF EVIDENCE: Level III; retrospective comparative study.

Revision Hip Capsular Repair and Augmentation With a Bioinductive Implant After a Post-arthroscopy Hip Subluxation Event.

In the past decade, the number of hip arthroscopy procedures has exponentially increased, primarily for the treatment of femoroacetabular impingement syndrome and labral lesions. As the techniques have evolved, so has the acknowledgment of the potential complications, including iatrogenic instability that may result from soft-tissue laxity, subtle dysplastic morphologies, or residual defects from capsulotomies in which the capsular closure is insufficient. In most cases, direct capsular repair or plication can be performed at the conclusion of the procedure; however, larger defects, poor-quality tissue, or cases of gross ligamentous laxity may require reconstruction or augmentation. In such instances, several options exist. The purpose of this technical note is to describe a capsular repair augmentation with a bioinductive implant during revision hip arthroscopy.

Editorial Commentary: Shedding Light on the Posterolateral Corner of the Knee: Can We Do it With the Scope? Is There a Real Benefit?

Historically described as the "dark side of the knee," the posterolateral corner of the knee has been a significant focus of anatomic, biomechanical, and clinical outcomes research due to poor treatment outcomes for these injuries before improvements over the past 2 decades. These research efforts have resulted in significant improvements in the understanding, diagnosis, and surgical treatment of these injuries. Perhaps most importantly, improved understanding of the anatomy and biomechanics has led to the development of anatomic-based reconstructions, which have been subsequently validated with both biomechanical and clinical outcomes. Due to the complex anatomy and proximity of neurovascular structures, reconstructions have historically used large "hockey stick" incisions to provide adequate visualization to identify the anatomic insertions of the static stabilizers and ensure adequate protection of neurovascular structures. These anatomic-based techniques have significantly improved the clinical and objective outcomes of the surgical treatment of posterolateral knee injuries. However, as techniques have evolved and the clinical outcomes have improved, clinicians have attempted to develop and employ less-invasive and arthroscopically assisted techniques. Specifically, given the steep learning curve, paucity of clinical outcomes, increased operative time, and the limited view of the anatomy, which may increase the risk of nonanatomic tunnel placement, and injuries to surrounding structures, we cannot support an arthroscopic approach at this time.

Outcomes and Survivorship After Arthroscopic Treatment of Glenohumeral Arthritis: A Systematic Review.

PURPOSE: To perform a systematic review of the literature describing outcomes, surgical procedures, and rates of conversion to arthroplasty after arthroscopic debridement of symptomatic primary glenohumeral osteoarthritis. METHODS: The Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, PubMed, Embase, and Ovid MEDLINE were queried. Articles without sufficiently detailed descriptions of the debridement procedure, those primarily describing cartilage resurfacing procedures, or those that did not report any postoperative outcomes were excluded. Study design, patient demographic characteristics, operative details, imaging findings, patient-reported outcomes, and rates of conversion to arthroplasty were compiled and reported. Assessment of bias was performed using the Methodological Index for Non-randomized Studies (MINORS) criteria. RESULTS: A total of 371 patients (382 shoulders) in 8 studies were included. Patient sample sizes ranged from 8 patients (9 shoulders) to 98 patients (107 shoulders), and the samples were predominantly comprised of male patients (range, 57.1%-100%). The mean age and follow-up period ranged from 38 to 59 years and from 13.7 to 46.8 months, respectively. In studies reporting both preoperative and postoperative outcomes, improvements were found in American Shoulder and Elbow Surgeons scores (range, 8.6-22) and visual analog scale scores for pain (range, 0.4-3.8). There was significant heterogeneity (I2 = 75%) in the rates of conversion to shoulder arthroplasty, which ranged from 4% to 42.4%, with the mean time to conversion ranging from 9 to 56 months. Study heterogeneity improved with subgroup analyses based on minimum duration of follow-up (>2 years) and preoperative radiographic inclusion criteria. CONCLUSIONS: Arthroscopic treatment of glenohumeral osteoarthritis provides improvements in ROM and patient-reported outcomes with minimal complications. Despite variability in procedures and rates of subsequent conversion to arthroplasty, arthroscopic treatment appears to provide symptom relief and functional improvements in carefully selected patients. However, the longevity of improvement remains unclear, with studies including a longer duration of follow-up showing potential regression of symptom relief and increased rates of conversion to arthroplasty. LEVEL OF EVIDENCE: Level IV, systematic review of Level III and IV studies.

Defining the Minimal Clinically Important Difference and Patient Acceptable Symptom State for Microfracture of the Knee: A Psychometric Analysis at Short-term Follow-up.

BACKGROUND: Several studies have investigated failure rates and magnitude of improvement in patient-reported outcome measures after microfracture surgery for focal chondral defects of the knee; however; what constitutes clinically significant improvement in this patient population is poorly understood. PURPOSE: To (1) establish the minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) thresholds for microfracture surgery including the time-dependent nature of these thresholds and (2) identify predictors of achieving the MCID and PASS in patients specifically undergoing microfracture of the knee. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A secure institutional cartilage preservation repository was queried for all patients who underwent microfracture between 2004 and 2017. The distribution method was used to calculate MCID thresholds for the International Knee Documentation Committee (IKDC) score and the Knee injury and Osteoarthritis Outcome Score (KOOS), whereas an anchor-based method was used for the PASS. Multivariate logistic regressions were constructed to determine predictors of achieving the MCID and PASS. RESULTS: A total of 206 patients with a mean ± SD age of 33.7 ± 13.2 years and body mass index of 26.9 ± 5.3 kg/m2 were included. All thresholds for the MCID and PASS increased over time except for the MCID thresholds for the KOOS Sports and Symptoms subscales. The proportion of patients who achieved the MCID (6 months, 78.4%; 12 months, 83.9%; 24 months, 88.6%) and PASS (6 months, 67.7%; 12 months, 79.2%; 24 months, 76.1%) generally increased over time. Older age and larger lesion size were negative independent predictors of MCID achievement. Older age was also a negative predictor of the PASS, whereas male sex and higher preoperative KOOS Symptoms and Pain scores were positive independent predictors of the PASS. CONCLUSION: The MCID and PASS thresholds for the IKDC and KOOS in patients undergoing microfracture of the knee are dynamic, with an increasing number of patients achieving the MCID over time. The percentage achieving the PASS increased between 6 and 12 months and then declined slightly at 24 months. Independent predictors of achieving the MCID were lesion size and age at surgery, whereas predictors of achieving the PASS included lesion size, male sex, and greater preoperative KOOS Symptoms and Pain scores.

What Is the Predictive Ability and Academic Impact of the Altmetrics Score and Social Media Attention?

BACKGROUND: Citation rate and journal impact factor have traditionally been used to assess research impact; however, these may fail to represent impact beyond the sphere of academics. Given that social media is now used to disseminate research, alternative web-based metrics (altmetrics) were recently developed to better understand research impact on social media. However, the relationship between altmetrics and traditional bibliometrics in orthopaedic literature is poorly understood. PURPOSE: To (1) assess the extent that altmetrics correlate with traditional bibliometrics and (2) identify publication characteristics that predict greater altmetrics scores. STUDY DESIGN: Cross-sectional study. METHODS: Articles published in The American Journal of Sports Medicine (AJSM), The Journal of Bone and Joint Surgery, Clinical Orthopaedics and Related Research, Acta Orthopaedica, and Knee Surgery, Sports Traumatology, Arthroscopy between January 2016 and December 2016 were analyzed. Among the extracted publication characteristics were journal, number of authors, geographic region of origin, highest degree of first author, study subject and design, sample size, conflicts of interest, and level of evidence; number of references, institutions, citations, tweets, Facebook mentions, and news mentions; and Altmetric Attention Score (AAS). Multivariate regressions were used to determine (1) publication characteristics predictive of AAS and social media attention (mentions on Twitter, Facebook, and the news) and (2) the relationship between AAS and citation rate. RESULTS: A total of 496 published articles were included, with a mean AAS of 8.6 (SD, 31.7; range, 0-501) and a mean citation rate of 15.0 (SD, 16.1; range, 0-178). Articles in AJSM (ß = 19.9; P < .001), publications from North America (ß = 8.5; P = .033), and studies concerning measure validation/reliability (ß = 25.5; P = .004) were independently associated with higher AAS. Greater AAS score significantly predicted a greater citation rate (ß = 0.16; P < .0001). The citation rate was an independent predictor of greater social media attention on Twitter, Facebook, and the news (odds ratio range, 1.02-1.03; P < .05 all). CONCLUSION: AAS had a significant positive association with citation rates of articles in 5 high-impact orthopaedic journals. Articles in AJSM, studies concerning measure validation and reliability, and publications from North America were positively associated with greater AAS. A greater number of citations was consistently associated with publication attention received on social media platforms.

Do Corticosteroid Injections Before or After Primary Rotator Cuff Repair Influence the Incidence of Adverse Events? A Subjective Synthesis.

PURPOSE: To determine the influence of corticosteroid injections (CSIs) before or after primary rotator cuff repair (RCR) on the risk of (1) revision RCR, (2) retears, and (3) infections. METHODS: The Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, PubMed, Embase, and MEDLINE databases were queried in accordance with the 2009 Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Data pertaining to the use of CSIs before or after primary RCR and adverse events were extracted. A subjective synthesis of these outcomes and bias was performed. RESULTS: A total of 10 studies including 240,976 patients were identified; 20.0% received a perioperative CSI. Of the 48,235 patients who received a CSI, 66.2% did so preoperatively whereas 33.8% did so postoperatively. A total of 78 patients received both preoperative and postoperative CSIs. Three studies examined the influence of preoperative CSIs on revision RCR; the incidence ranged from 3.8% to 10.5% with preoperative CSIs and from 3.2% to 3.4% for controls. Two of these studies analyzed outcomes of patients from the same databases over the same period. Five studies examined the influence of postoperative CSI use on retears; the incidence ranged from 5.7% to 19.0% in patients who received postoperative CSIs and from 10.0% to 18.4% for controls. Three studies examined the influence of CSI use on infection; 2 studies examined the risk of infection after postoperative CSI use, which ranged from 0.0% to 6.7% with CSIs and from 0.0% to 0.5% for controls. CONCLUSIONS: The use of preoperative CSIs could be associated with an increased risk of revision RCR. There were no conclusive data to suggest an increased risk of retear or infection with CSI use based on a subjective synthesis of ranges. There is currently poor-quality literature surrounding this topic. Given that the current literature is limited and heterogeneous, no definitive recommendations can be made on perioperative CSI use for RCR. LEVEL OF EVIDENCE: Level III, systematic review of Level I and III studies.

Posterior Cruciate Ligament.

Improved understanding of the anatomy and biomechanics of the posterior cruciate ligament (PCL) has led to the evolution and improvement of anatomic-based reconstructions. The PCL is composed of the larger anterolateral bundle (ALB) and the smaller posteromedial bundle (PMB). On the femoral side, the ALB spans from the trochlear point to the medial arch point on the roof of the notch, while the PMB occupies the medial wall from the medial arch point to the most posterior aspect of the articular cartilage. Because of these broad and distinct attachments, the bundles have a load-sharing, synergistic and codominant relationship. Both restrict posterior translation; however, the ALB has a proportionally larger role in restricting translation throughout flexion, whereas the PMB has a role comparable to that of the ALB in full extension. In addition, the PMB resists internal rotational at greater flexion angles (> 90°). Consequently, it is difficult to restore native kinematics with a single graft. Biomechanical analysis of single- versus double-bundle PCL reconstructions (SB PCLR vs DB PCLR) demonstrates improved restoration of native kinematics with a DB PCLR, including resistance to posterior translation throughout flexion (15°-120°) and internal rotation in deeper flexion (90°-120°). Similarly, clinical research demonstrates excellent outcomes following DB PCLR, including functional outcomes comparable to those of anterior cruciate ligament reconstructions, with no significant differences between isolated and multiligament PCL injuries. Compared to SB PCLR, systematic review has demonstrated the superiority of DB PCLR based on objective postoperative stress radiography and International Knee Documentation Committee scores in randomized trials. In addition to reconstruction techniques, recent research has identified other factors that impact kinematics and PCL forces, including decreased tibial slope, which leads to increased graft stresses, and incidence of native PCL injuries. As the understanding of these other contributing factors evolves, so will surgical and treatment algorithms that will further improve patients' outcomes.