Minimal Important Clinical Difference Values Are Not Uniformly Valid in the Active Duty Military Population Recovering from Shoulder Surgery.

BACKGROUND: There are multiple methods for calculating the minimal clinically important difference (MCID) threshold, and previous reports highlight heterogeneity and limitations of anchor-based and distribution-based analyses. The Warfighter Readiness Survey assesses the perception of a military population's fitness to deploy and may be used as a functional index in anchor-based MCID calculations. The purpose of the current study in a physically demanding population undergoing shoulder surgery was to compare the yields of two different anchor-based methods of calculating MCID for a battery of PROMs, a standard receiver operator curve (ROC) -based MCIDs and baseline-adjusted ROC MCIDs. METHODS: All service members enrolled prospectively in a multicenter database with prior shoulder surgery that completed pre- and postoperative PROMs at a minimum of 12 months were included. The PROMs battery included Single Assessment Numeric Evaluation (SANE), American Shoulder and Elbow Surgeons score (ASES), Patient Reported Outcome Management Information System (PROMIS) Physical Function (PF), PROMIS Pain Interference (PI), and the Warfighter Readiness survey. Standard anchor-based and baseline-adjusted ROC MCIDs were employed to determine if the calculated MCIDs were both statistically and theoretically valid (95% confidence interval either completely negative or positive). RESULTS: There were 117 patients (136 operations) identified, comprised of 83% males with a mean age of 35.7 ± 10.4 years and 47% arthroscopic labral repair/capsulorrhaphy. Using the standard, anchor-based ROC MCID calculation, the area under the curve (AUC) for SANE, ASES, PROMIS PF, and PROMIS PI were greater than 0.5 (statistically valid). For ASES, PROMIS PF, and PROMIS PI, the calculated MCID 95% CI all crossed 0 (theoretically invalid). Using the baseline-adjusted ROC MCID calculation, the MCID estimates for SANE, ASES, and PROMIS PI were both statistically and theoretically valid if the baseline score was less than 70.5, 69, and 65.7. CONCLUSION: When MCIDs were calculated and anchored to the results of standard, anchor-based MCID, a standard ROC analysis did not yield statistically or theoretically valid results across a battery of PROMs commonly used to assess outcomes after shoulder surgery in the active duty military population. Conversely, a baseline-adjusted ROC method was more effective at discerning changes across a battery of PROMs among the same cohort.

Acute Anterior Cruciate Ligament Reconstruction Performed Within 10 Days of Injury Does Not Increase Risk of Postoperative Arthrofibrosis: A Systematic Review and Meta-analysis.

BACKGROUND: The optimal timing of anterior cruciate ligament (ACL) reconstruction (ACLR) remains a controversial topic. Previous reviews have demonstrated that there are no differences between early and delayed ACLR; however, these studies have been limited by heterogeneous definitions of acute ACL injury. PURPOSE: To evaluate postoperative patient functional outcomes and risk for arthrofibrosis after acute arthroscopic ACLR performed ≤10 days after injury. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: A systematic review was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using multiple medical databases. Inclusion criteria were studies that evaluated postoperative range of motion outcomes for patients undergoing ACLR ≤10 days after initial ACL injury. For included comparative studies comparing patient groups undergoing ACLR ≤10 days and patients undergoing "delayed" ACLR after ≥3 weeks of initial injury, quantitative analysis was performed to assess for differences in postoperative arthrofibrosis, reoperation rates, and patient-reported outcomes between groups. DerSimonian-Laird binary random-effects models were constructed to quantitatively describe the association between the ACLR time period and patient outcomes by generating effect estimates in the form of odds ratios with 95% CIs. Qualitative analysis was performed to describe variably reported patient outcomes and the risk of arthrofibrosis after ACLR for noncomparative studies. RESULTS: Screening yielded 6 full-text articles with 448 patients who underwent ACLR (296 ACLR <10 days, 152 ACLR >3 weeks), with a pooled mean age of 28.1 years. For studies amenable to quantitative analysis, there were no significant differences between ACLR performed ≤10 days and ACLR performed at the 3-week point or after in terms of postoperative stiffness (3 studies; odds ratio, 1.27; P = .508), Tegner scores (2 studies; mean difference, -0.056; P = .155), or reoperation for stiffness (3 studies; odds ratio, 0.869; P = .462). The overall incidence of postoperative arthrofibrosis after 12 months of follow-up was 11 of 296 (3.7%) for ACLRs performed ≤10 days versus 6 of 152 (3.9%) for those performed at the 3-week point or after. CONCLUSION: ACLR performed ≤10 days after the inciting injury does not increase the risk of postoperative arthrofibrosis and demonstrates similar patient-reported outcomes compared with ACLR performed at the 3-week point or after.

Anterior Cruciate Ligament Reconstruction: Fixation Techniques.

Anterior cruciate ligament reconstruction (ACLR) is among the most common procedures performed by orthopaedic sports medicine surgeons and has inherent challenges due to the complex anatomy and biomechanical properties required to reproduce the function and stability of the native ACL. Awareness of the anatomic and biomechanical factors, including graft selection and tunnel placement, along with graft tensioning and fixation techniques, is vital in achieving a successful clinical outcome. Common techniques for ACLR graft fixation include intratunnel fixation with interference screws, suspensory fixation, or hybrid fixation strategies, along with several supplemental fixation techniques. Interference screw fixation may decrease graft-tunnel motion, tunnel widening, and graft creep and may be performed with metallic, PEEK (polyether ether ketone), or bioabsorbable screws. Suspensory fixation techniques primarily include suture-buttons, anchors, staples, and screws/washers. Suspensory fixation allows adequate biomechanical strength, although some techniques have been linked to increased graft-tunnel motion and potential tunnel widening. Supplemental fixation techniques may be performed in the setting of concerns for adequacy of primary fixation and includes the use of suture anchors, staples, and screw/washer devices. Regardless of the implant chosen for fixation, secure fixation is paramount to avoid displacement of the graft and allow for integration into the bone tunnel and facilitates early postoperative rehabilitation. It is important for orthopaedic sports medicine surgeons performing primary and revision ACLR to be familiar with multiple fixation techniques.

No Difference in Recurrent Instability Between Knotted and Knotless Repair Techniques in Arthroscopic Treatment of Isolated Posterior Labral Tears: A Systematic Review.

Purpose: To compare clinical failure, recurrent instability, patient-reported outcome measures (PROMs), and return to sport (RTS) between knotted and knotless fixation methods in arthroscopic posterior labral repair for isolated posterior shoulder instability (PSI). Methods: Multiple databases were queried according to Preferred Reported Items for Systematic Reviews and Meta-Analyses guidelines for clinical studies with Level I to IV evidence, including knotted and knotless suture anchors for arthroscopic posterior labral repair. Combined anterior and posterior instability, multidirectional instability, SLAP injuries, unspecified repair techniques, majority open procedures, and revision surgery were excluded. Results: Screening yielded 17 full-text articles reporting on 852 shoulders undergoing posterior labral repair. Recurrent instability ranged from 0% to 21%, and the rate of revision surgery ranged from 0% to 11% in knotted only, 0% in knotless only, and 2.0% to 8.1% in knotted and knotless studies. Six studies with both pre- and postoperative visual analog scale scores and 7 studies with both pre- and postoperative American Shoulder and Elbow Score scores all showed improvement in scores after intervention regardless of repair technique. Thirteen studies reported RTS or duty rates with a minimum of 79%. Conclusions: Overall recurrent instability after posterior labral repair for isolated PSI was low with improvement in PROMs and favorable RTS rates regardless of fixation method. There was no clear difference in recurrent instability or revision surgery between knotted and knotless fixation methods for isolated posterior labral repair. However, the current literature is predominantly limited by Level III and IV evidence. The quality of literature and lack of standardization on the definition of clinical failure and recurrent instability among surgeons preclude any definitive conclusion regarding one clinically superior fixation method. Level of Evidence: Level IV, systematic review of Level III and IV studies.

Republication of "Osteochondral Lesions of the Talus: Current Concepts in Diagnosis and Treatment".

Osteochondral lesions of the talus (OLTs) are a difficult pathologic entity to treat. They require a strong plan. Lesion size, location, chronicity, and characteristics such as displacement and the presence of subchondral cysts help dictate the appropriate treatment required to achieve a satisfactory result. In general, operative treatment is reserved for patients with displaced OLTs or for patients who have failed nonoperative treatment for 3 to 6 months. Operative treatments can be broken down into cartilage repair, replacement, and regenerative strategies. There are many promising treatment options, and research is needed to elucidate which are superior to minimize the morbidity from OLTs.

Outcomes of Open Versus Arthroscopic Treatment of HAGL Tears.

BACKGROUND: Lesions that involve humeral avulsions of the glenohumeral ligament (HAGLs), although less common, are primary contributors to recurrent events of dislocation and subluxation of the glenohumeral joint. PURPOSE: To describe the clinical presentation, examination, and surgical outcomes of patients presenting with HAGL lesions who underwent repair using an arthroscopic or open technique. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A multicenter retrospective review of prospectively collected data was performed of skeletally mature patients without glenohumeral arthritis who presented with HAGL lesions and subsequently underwent arthroscopic or open repair between 2005 and 2017. Independent variables included patient characteristics, clinical presentation, physical examination findings, and arthroscopic findings. Dependent variables included pre- and postoperative Single Assessment Numeric Evaluation (SANE) score, Western Ontario Shoulder Instability Index (WOSI) score, and range of motion outcomes. RESULTS: Eighteen patients diagnosed with a HAGL lesion who underwent primary arthroscopic repair (n = 7) or open repair (n = 11) were included. There were 17 male patients and 1 female patient with a mean age of 24.9 years (range, 16-38 years). Mean follow-up duration was 50.9 months (range, 24-160 months). Seventeen patients (94.4%) reported pain as the most common symptom, and 7 (38.9%) reported sensation of instability. Scores significantly improved from pre- to postoperative for the arthroscopic and open groups (P < .001): SANE (mean ± SD; arthroscopic, 30.7 ± 15.7 to 92.1 ± 12.2; open, 45.5 ± 8.50 to 90.7 ± 5.24) and WOSI (arthroscopic, 51.4 ± 11.4 to 2.49 ± 3.70; open, 45.5 ± 7.37 to 11.5 ± 5.76). The magnitude of improvement in SANE scores was significantly higher for patients treated arthroscopically (Δ60.0; open, Δ46.5; P = .012). Postoperative WOSI scores were also significantly better in the arthroscopic cohort (2.49 ± 3.70; open, 11.5 ± 5.76; P = .00094). CONCLUSION: Symptomatic HAGL tears present primarily with pain as opposed to instability, necessitating a high index of suspicion for injury. The tears may be treated successfully with an arthroscopic or open technique with significant improvements in patient-reported outcomes and stability.

Survival of anterior cruciate ligament reconstructions in active-duty military populations.

PURPOSE: Anterior cruciate ligament tears and anterior cruciate ligament reconstruction (ACLR) are common in young athletes. The modifiable and non-modifiable factors contributing to ACLR failure and reoperation are incompletely understood. The purpose of this study was to determine ACLR failure rates in a physically high-demand population and identify the patient-specific risk factors, including prolonged time between diagnosis and surgical correction, that portend failure. METHODS: A consecutive series of military service members with ACLR with and without concomitant procedures (meniscus [M] and/or cartilage [C]) done at military facilities between 2008 and 2011 was completed via the Military Health System Data Repository. This was a consecutive series of patients without a history of knee surgery for two years prior to the primary ACLR. Kaplan-Meier survival curves were estimated and evaluated with Wilcoxon test. Cox proportional hazard models calculated hazard ratios (HR) with 95% confidence intervals (95% CI) to identify demographic and surgical factors that influenced ACLR failure. RESULTS: Of the 2735 primary ACLRs included in the study, 484/2,735 (18%) experienced ACLR failure within four years, including (261/2,735) (10%) undergoing revision ACLR and (224/2,735) (8%) due to medical separation. The factors that increased failure include Army Service (HR 2.19, 95% CI 1.67, 2.87), > 180 days from injury to ACLR (HR 1.550, 95% CI 1.157, 2.076), tobacco use (HR 1.429 95% CI 1.174, 1.738), and younger patient age (HR 1.024, 95% CI 1.004, 1.044). CONCLUSION: The overall clinical failure rate of service members with ACLR is 17.7% with minimum four-year follow-up, where more patients are likely to fail due to revision surgery than medical separation. The cumulative probability of survival at 4 years was 78.5%. Smoking cessation and treating ACLR patients promptly are modifiable risk factors impacting either graft failure or medical separation. LEVEL OF EVIDENCE: Level III.

Perioperative Gabapentin May Reduce Opioid Requirement for Early Postoperative Pain in Patients Undergoing Anterior Cruciate Ligament Reconstruction: A Systematic Review of Randomized Controlled Trials.

PURPOSE: To evaluate the efficacy of perioperative gabapentin or pregabalin treatment on postoperative pain and opioid requirement reduction in patients undergoing anterior cruciate ligament reconstruction (ACLR). METHODS: A systematic review of randomized control trials was conducted evaluating the effect of gabapentin or pregabalin on postoperative pain and opioid requirement for patients undergoing ACLR. The primary outcomes assessed were postoperative pain scores and opioid requirements. Secondary outcomes were complications, side effects, dosage, and timing of intervention. RESULTS: The initial search query identified 151 studies and 6 studies were included after full-text articles were reviewed. Three studies investigated the use of gabapentin and three studies investigated pregabalin. All three gabapentin studies reported significantly decreased or equivalent pain scores while also significantly reducing or removing total opioid consumption compared to control groups. Pregabalin demonstrated inconsistent efficacy for pain control and opioid consumption parameters across three studies. One study (pregabalin, n = 1) reported significantly increased incidence of dizziness with pregabalin compared to placebo. CONCLUSIONS: There is moderate evidence demonstrating that preoperative gabapentin may be safe and effective in reducing postoperative pain and opioid consumption after ACLR. Gabapentin may be considered when employed as part of a multimodal analgesia regimen; however, the optimal protocol has yet to be determined. Currently, there is limited evidence demonstrating the efficacy of pregabalin on pain and opioid consumption in the setting of ACLR. LEVEL OF EVIDENCE: Level I, systematic review of Level I Studies.

Characterization of Cartilage Injury and Associated Treatment at the Time of Primary Anterior Cruciate Ligament Reconstruction.

Anterior cruciate ligament (ACL) tears with concomitant cartilage injuries resulting in ACL reconstruction (ACLR) with cartilaginous procedures are common in the young, high-demand population. The purpose of this study was to report and characterize cartilage treatments performed at the time of index ACLR reconstruction and to determine if those treatments are associated with revision surgery (of any kind) in the 4-year follow-up. We performed a consecutive series of active duty service members in the Military Health System Data Repository with ACLR with and without concomitant cartilage procedures done at military facilities between October 2008 and September 2011. Patients were continuously enrolled with no history of knee surgeries for 2 years prior to primary ACLR. ACLR failure was defined as revision ACLR within 4 years following the primary ACLR. Of the 2,735 primary ACLRs included in the study, 5.3% (143/2,735) underwent isolated ACLR with a cartilage procedure. Of these patients, 23.07% (33/143) experienced ACLR failure within 4 years after ACLR with cartilage procedures, including 33.33% (11/33) undergoing revision ACLR. We found concomitant cartilage procedures at time of index ACLR to have the following rates of revision 35.59% (21/59) for microfracture, 14.63% (6/41) for chondroplasty, and 13.95% (6/43) for osteochondral grafts. The overall clinical failure rate of service members with ACLR plus concomitant cartilage procedure is 23.07% with minimum 4-year follow-up. Further research should be done to identify modifiable demographic and surgical factors associated with failure. This is a retrospective case-control study that reflects level of evidence III.

Concomitant Glenolabral Articular Disruption (GLAD) Lesion is Not Associated With Inferior Clinical Outcomes After Arthroscopic Bankart Repair for Shoulder Instability: A Retrospective Comparative Study.

Purpose: The purpose of this study was to compare outcomes between anterior shoulder instability patients with and without glenolabral articular disruption (GLAD) lesions after undergoing arthroscopic Bankart repair and to evaluate potential risk factors for inferior outcomes and recurrent instability. Methods: Prospectively collected data were retrospectively reviewed for patients who underwent arthroscopic Bankart repair with and without GLAD lesions at a minimum of 2 years follow-up. Consecutive patients were matched by age, sex, and number of anchors. Patient-reported outcomes (PROs) were evaluated before and after surgery, including American Shoulder and Elbow Surgeons, Single Assessment Numeric Evaluation, Quick Disabilities of the Arm, Shoulder and Hand, Short Form-12 score, and satisfaction. Recurrent dislocation, subjective instability, and reoperation were analyzed. Additionally, PROs were assessed on the basis of GLAD lesion characteristics. Results: A total of 54 patients (27 GLAD, 27 control) with a mean age of 28.9 ± 11.6 years were analyzed at mean 4.5 ± 1.9 years (range, 2-9 years) follow-up. Thirty-eight (70.3%) of the participants were male. Patients in both groups experienced significant improvements in all PROs (P ≤ .006 for all measures) and reported high median satisfaction (scale 1-10: 10 vs 10, P = .290) at final follow-up. Two patients in the GLAD cohort and 1 in the control cohort underwent reoperation (P = .588). Four (14.8%) patients in each group reported recurrent dislocation (P = 1.0). Additionally, 2 (7.4%) GLAD patients and 1 (3.7%) control patient reported subjective shoulder instability after surgery (P = 1.0). No significant differences in PROs were observed based on anchor/labral advancement or treatment with microfracture, nor were significant correlations observed between GLAD lesion size and PROs (P > .05 for all). Conclusion: Arthroscopic Bankart repair in patients with GLAD lesions resulted in significantly improved outcomes with high satisfaction, which was no different when compared with those without GLAD lesions. Level of Evidence: Level III, retrospective comparative study.

SLAP Repair Versus Subpectoral Biceps Tenodesis for Isolated SLAP Type 2 Lesions in Overhead Athletes Younger Than 35 Years: Comparison of Minimum 2-Year Outcomes.

Background: It remains unclear if young overhead athletes with isolated superior labrum anterior-posterior (SLAP) type 2 lesions benefit more from SLAP repair or subpectoral biceps tenodesis. Purpose: To evaluate clinical outcomes and return to sport in overhead athletes with symptomatic SLAP type 2 lesions who underwent either biceps tenodesis or SLAP repair. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective analysis of prospectively collected data was performed in patients who underwent subpectoral biceps tenodesis (n = 14) or SLAP repair (n = 24) for the treatment of isolated type 2 SLAP lesions. All patients were aged <35 years at time of surgery, participated in overhead sports, and were at least 2 years out from surgery. Clinical outcomes were assessed with the American Shoulder and Elbow Surgeons (ASES) score; Single Assessment Numerical Evaluation (SANE) score; Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score; and the 12-Item Short Form (SF-12) physical component score. Return to sport and patient satisfaction were documented. Clinical failures requiring revision surgery and complications were reported. Results: Preoperative baseline scores in both the tenodesis and SLAP repair groups were similar. There were no significant differences between the groups on any postoperative outcome measure: For biceps tenodesis versus SLAP repair, the ASES score was 92.7 ± 10.4 versus 89.1 ± 16.7, the SANE score was 86.2 ± 13.7 versus 83.0 ± 24.1, the QuickDASH score was 10.0 ± 12.7 versus 9.0 ± 14.3, and SF-12 was 51.2 ± 7.5 versus 52.8 ± 7.7. No group difference in return-to-sports rate (85% vs 79%; P = .640) was noted. More patients in the tenodesis group (80%) reported modifying their sporting/recreational activity postoperatively because of weakness compared with patients in the SLAP repair group (15%; P = .022). One patient in each group progressed to surgery for persistent postoperative stiffness, and 1 patient in the tenodesis group had a postoperative complication related to the index surgery. Conclusion: Both subpectoral biceps tenodesis and SLAP repair provided excellent clinical results for the treatment of isolated SLAP type 2 lesions, with a high rate of return to overhead sports and a low failure rate, in a young and high-demanding patient cohort. More patients reported modifying their sporting/recreational activity because of weakness after subpectoral tenodesis.

Improved Accuracy of Coronal Alignment Can Be Attained Using 3D-Printed Patient-Specific Instrumentation for Knee Osteotomies: A Systematic Review of Level III and IV Studies.

PURPOSE: To evaluate the accuracy and precision of postoperative coronal plane alignment using 3D-printed patient-specific instrumentation (PSI) in the setting of proximal tibial or distal femoral osteotomies. METHODS: A systematic review evaluating the accuracy of 3D-printed PSI for coronal plane alignment correcting knee osteotomies was performed. The primary outcomes were accuracy of coronal plane limb alignment correction and number of correction outliers. Secondary variables were duration of surgery, number of intraoperative fluoroscopic images, complications, cost, and clinical outcomes (as applicable). RESULTS: Ninety-three studies were identified, and 14 were included in the final analysis. Overall, mean postoperative deviation from target correction ranged from 0.3° to 1° for all studies using hip-knee angle measurements and 2.3% to 4.9% for all studies using weight-bearing line measurements. The incidence of correction outliers was assessed in 8 total studies and ranged from 0 to 25% (total n = 10 knees) of patients corrected with 3D-printed PSI. Osteotomies performed with 3D-printed cutting guides or wedges demonstrated significantly shorter operative times (P < .05) and fewer intraoperative fluoroscopic images (P < .05) than control groups in four case control studies. CONCLUSION: Patients undergoing distal femoral osteotomy or proximal tibial osteotomy procedures with 3D-printed patient-specific cutting guides and wedges had highly accurate coronal plane alignment with a low rate of outliers. Patients treated with 3D printed PSI also demonstrated significantly shorter operative times and decreased intraoperative fluoroscopy when compared to conventional techniques. LEVEL OF EVIDENCE: Level IV, systematic review of Level III-IV studies.

Comparative Outcomes Occur After Superficial Medial Collateral Ligament Augmented Repair vs Reconstruction: A Prospective Multicenter Randomized Controlled Equivalence Trial.

BACKGROUND: Although previous studies have reported good short-term results for superficial medial collateral ligament (sMCL) reconstruction, whether an augmented MCL repair is clinically equivalent remains unclear. PURPOSE/HYPOTHESIS: The purpose of this study was to compare clinical outcomes between randomized groups that underwent sMCL augmentation repair and sMCL autograft reconstruction. The hypothesis was that there would be no significant differences in objective or subjective outcomes between groups. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: Patients were prospectively enrolled between 2013 and 2019 from 3 centers. Grade III sMCL injuries were confirmed via stress radiography. Patients were randomized to anatomic sMCL reconstruction versus augmented repair with surgical treatment, determined after examination under anesthesia confirmed sMCL incompetence. Postoperative visits occurred at 6 weeks and 6 months for repeat evaluation, with repeat stress radiography at final follow-up. Patient-reported outcome measures were obtained pre- and postoperatively at 6 months, 1 year, and final follow-up. The primary outcome measure was side-to-side difference on valgus stress radiographs at a minimum follow-up of 1 year. The two 1-sided t test procedure was used to test clinical equivalence for side-to-side difference in valgus gapping, and the Mann-Whitney U test was used to compare postoperative patient-reported outcome measures between groups. RESULTS: A total of 54 patients were prospectively enrolled into this study. Of these, 50 patients had 6-month stress radiograph data, while 40 had 1-year postoperative valgus stress radiograph data. The mean (SD) patient age was 38.0 years (14.2), and body mass index was 25.0 (3.6). Preoperative valgus stress radiographs demonstrated 3.74 mm (1.1 mm) of increased side-to-side gapping overall, while it was 4.10 mm (1.46 mm) in the MCL augmentation group and 3.42 mm (0.55 mm) in the MCL reconstruction group. Postoperative valgus stress radiographs at an average of 6 months were obtained in 50 patients after surgery, which showed 0.21 mm (0.81 mm) for the MCL augmentation group and 0.19 mm (0.67 mm) for the MCL reconstruction group (P = .940). At final follow-up (minimum 1 year), median (interquartile range) Lysholm scores were significantly higher in the reconstruction group (90 [83-99]) as compared with the repair group (80 [67-92]) (P = .031). Final International Knee Documentation Committee (IKDC) scores were also significantly higher for the reconstruction group (85 [68-89]) versus the repair group (72 [60-78] (P = .039). Postoperative Tegner scores were not significantly different between the repair group (5 [3.5-6]) and the reconstruction group (5.5 [4-7]) (P = .123). Patient satisfaction was also not significantly different between repair (7.5 [5.75-9.25]) and reconstruction groups (9.0 [7-10]) (P = .184). CONCLUSION: This study found no difference in objective outcomes between an sMCL augmentation repair and a complete sMCL reconstruction at 1 year postoperatively, indicating equivalence between these procedures. Patient-reported clinical outcomes favored the reconstruction over a repair. In addition, this study demonstrated that anatomic-based treatment of MCL tears with an early knee motion program had a very low risk of graft attenuation and a low risk of arthrofibrosis.

Acute Intervention With Selective Interleukin-1 Inhibitor Therapy May Reduce the Progression of Posttraumatic Osteoarthritis of the Knee: A Systematic Review of Current Evidence.

PURPOSE: To evaluate the efficacy of selective interleukin (IL)-1 inhibitor therapy in the reduction of posttraumatic osteoarthritis (PTOA) progression following knee ligament or meniscal injury. METHODS: A systematic review was conducted evaluating the disease-modifying efficacy of selective IL-1 inhibition in the setting of knee PTOA. RESULTS: The literature search identified 364 articles and 11 studies were included (n = 10 preclinical, n = 1 clinical). Drug delivery in preclinical studies was administered using IL-1Ra-encoded helper-dependent adenovirus particles (n = 3), synovial cells transfected with an IL-1Ra-encoded retroviral vector (n = 3), or varying chemical compositions of nonviral microcapsule gene carriers (n = 4). Intervention with selective IL-1 inhibitor therapy within 2 weeks of injury provided the greatest protective benefits in reducing the progression of PTOA regardless of drug delivery methodology in preclinical models. The majority of studies reported significantly better cartilage integrity and reduction in lesion size in animals treated with gene therapy with the greatest effects seen in those treated within 5 to 7 days of injury. CONCLUSIONS: Early intervention with selective IL-1 inhibitor therapy were effective in reducing proinflammatory IL-1ß levels in the acute and subacute phases following traumatic knee injury in preclinical animal model studies, while significantly reducing cartilage damage, lesion size, and PTOA progression at short-term follow-up. However, it was found that the effect of these therapies diminished over time. CLINICAL RELEVANCE: Acute, intra-articular injection of selective IL-1 inhibitors may reduce PTOA progression, supporting the need for additional basic and clinical investigation.

Autograft Versus Allograft: The Evidence in Hip Labral Reconstruction and Augmentation.

BACKGROUND: Labral augmentation and labral reconstruction have emerged as essential procedures for restoring the anatomic and functional characteristics of the hip joint in patients with a deficient hip labrum or irreparable labral tear. HYPOTHESIS/PURPOSE: The purpose of this study was to compare allograft and autograft hip labral reconstruction and augmentation. We hypothesized that autografts would entail fewer revision arthroscopic procedures. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Patients were identified who underwent labral reconstruction or labral augmentation using iliotibial band (ITB) allograft or ITB autograft performed by a single surgeon between 2011 and 2017. Patient-reported outcome measures collected before surgery and at minimum 2-year follow-up included the following: Hip Outcome Score Activities of Daily Living and Hip Outcome Score Sports-Specific Subscale and, at follow-up, patient satisfaction (range, 1-10, with 10 being very satisfied). Patients followed a standardized rehabilitation protocol after surgery with relative individualization to address each patient's needs. For continuous variables, comparisons between allografts and autografts were made using Student t tests or Mann-Whitney tests. Categorical comparisons were assessed using chi-square or Fisher exact test. Multiple logistic regression was performed to determine the influence of graft choice on risk of revision or THA. RESULTS: A total of 205 hips met 2-year inclusion criteria. ITB allografts were used for 55 patients (37 augmentations, 18 reconstructions) and ITB autografts for 150 patients (34 augmentations, 116 reconstructions). Females represented a greater proportion of allograft versus autograft patients (71% vs 46%, respectively; P = .001). Overall, autograft patients had larger alpha angles (66.6° vs 59.1°; P = .001) and longer grafts (46 vs 41 mm; P = .03) compared with allograft patients. A total of 13 (23.6%) patients required revision surgery in the allograft group compared with 11 (7.3%) in the autograft group (P < .001). After controlling for sex, procedure (reconstruction vs augmentation), and previous surgery, the odds of revision were higher for allograft patients (OR, 4.1; 95% CI, 1.5-11.6). No significant differences in conversion to THA were observed between groups (allograft = 9%; autograft = 6%; P = .50), even after adjustment for the above covariates (OR, 2.3; 95% CI, 0.6-7.9). No differences in postoperative patient-reported outcome measures or patient satisfaction were observed between groups. CONCLUSION: Labral augmentation or reconstruction with autograft has a significantly lower revision rate than labral augmentation or reconstruction with allograft.

A High-Sensitivity International Knee Documentation Committee Survey Index From the PROMIS System: The Next-Generation Patient-Reported Outcome for a Knee Injury Population.

BACKGROUND: Patient-reported outcomes (PROs) measure progression and quality of care. While legacy PROs such as the International Knee Documentation Committee (IKDC) survey are well-validated, a lengthy PRO creates a time burden on patients, decreasing adherence. In recent years, PROs such as the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function and Pain Interference surveys were developed as computer adaptive tests, reducing time to completion. Previous studies have examined correlation between legacy PROs and PROMIS; however, no studies have developed effective prediction models utilizing PROMIS to create an IKDC index. While the IKDC is the standard knee PRO, computer adaptive PROs offer numerous practical advantages. PURPOSE: To develop a nonlinear predictive model utilizing PROMIS Physical Function and Pain Interference to estimate IKDC survey scores and examine algorithm sensitivity and validity. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: The MOTION (Military Orthopaedics Tracking Injuries and Outcomes Network) database is a prospectively collected repository of PROs and intraoperative variables. Patients undergoing knee surgery completed the IKDC and PROMIS surveys at varying time points. Nonlinear multivariable predictive models using Gaussian and beta distributions were created to establish an IKDC index score, which was then validated using leave-one-out techniques and minimal clinically important difference analysis. RESULTS: A total of 1011 patients completed the IKDC and PROMIS Physical Function and Pain Interference, providing 1618 complete observations. The algorithms for the Gaussian and beta distribution were validated to predict the IKDC (Pearson = 0.84-0.86; R2 = 0.71-0.74; root mean square error = 9.3-10.0). CONCLUSION: The publicly available predictive models can approximate the IKDC score. The results can be used to compare PROMIS Physical Function and Pain Interference against historical IKDC scores by creating an IKDC index score. Serial use of the IKDC index allows for a lower minimal clinically important difference than the conventional IKDC. PROMIS can be substituted to reduce patient burden, increase completion rates, and produce orthopaedic-specific survey analogs.

Superior Capsule Reconstruction With a 3 mm-Thick Dermal Allograft Partially Restores Glenohumeral Stability in Massive Posterosuperior Rotator Cuff Deficiency: A Dynamic Robotic Shoulder Model.

BACKGROUND: Superior capsule reconstruction (SCR) has been shown to improve shoulder function and reduce pain in patients with isolated irreparable supraspinatus tendon tears. However, the effects of SCR on biomechanics in a shoulder with an extensive posterosuperior rotator cuff tear pattern remain unknown. PURPOSE/HYPOTHESIS: The purpose was to (1) establish a dynamic robotic shoulder model, (2) assess the influence of rotator cuff tear patterns, and (3) assess the effects of SCR on superior humeral head translation after a posterosuperior rotator cuff tear. It was hypothesized that a posterosuperior rotator cuff tear would increase superior humeral head translation when compared with the intact and supraspinatus tendon-deficient state and that SCR would reduce superior humeral head translation in shoulders with massive rotator cuff tears involving the supraspinatus and infraspinatus tendons. STUDY DESIGN: Controlled laboratory study. METHODS: Twelve fresh-frozen cadaveric shoulders were tested using a robotic arm. Kinematic testing was performed in 4 conditions: (1) intact, (2) simulated irreparable supraspinatus tendon tear, (3) simulated irreparable supra- and infraspinatus tendon tear, and (4) SCR using a 3 mm-thick dermal allograft (DA). Kinematic testing consisted of static 40-N superior force tests at 0°, 30°, 60°, and 90° of abduction and dynamic flexion, abduction, and scaption motions. In each test, the superior translation of the humeral head was reported. RESULTS: In static testing, SCR significantly reduced humeral superior translation compared with rotator cuff tear at all abduction angles. SCR restored the superior stability back to native at 60° and 90° of abduction, but the humeral head remained significantly and superiorly translated at neutral position and at 30° of abduction. The results of dynamic testing showed a significantly increased superior translation in the injured state at lower elevation angles, which diminished at higher elevation, becoming nonsignificant at elevation >75°. SCR reduced the magnitude of superior translation across all elevation angles, but translation remained significantly different from the intact state up to 60° of elevation. CONCLUSION: Massive posterosuperior rotator cuff tears increased superior glenohumeral translation when compared with the intact and supraspinatus tendon-insufficient rotator cuff states. SCR using a 3-mm DA partially restored the superior stability of the glenohumeral joint even in the presence of a simulated massive posterosuperior rotator cuff tear in a static and dynamic robotic shoulder model. CLINICAL RELEVANCE: The biomechanical performance concerning glenohumeral stability after SCR in shoulders with large posterosuperior rotator cuff tears is unclear and may affect clinical outcomes in daily practice.

Mobilized Peripheral Blood Stem Cells are Pluripotent and Can Be Safely Harvested and Stored for Cartilage Repair.

PURPOSE: The primary objective of this study was to reproduce and validate the harvest, processing and storage of peripheral blood stem cells for a subsequent cartilage repair trial, evaluating safety, reliability, and potential to produce viable, sterile stem cells. METHODS: Ten healthy subjects (aged 19-44 years) received 3 consecutive daily doses of filgrastim followed by an apheresis harvest of mononuclear cells on a fourth day. In a clean room, the apheresis product was prepared for cryopreservation and processed into 4 mL aliquots. Sterility and qualification testing were performed pre-processing and post-processing at multiple time points out to 2 years. Eight samples were shipped internationally to validate cell transport potential. One sample from all participants was cultured to test proliferative potential with colony forming unit (CFU) assay. Five samples, from 5 participants were tested for differentiation potential, including chondrogenic, adipogenic, osteogenic, endoderm, and ectoderm assays. RESULTS: Fresh aliquots contained an average of 532.9 ± 166. × 106 total viable cells/4 mL vial and 2.1 ± 1.0 × 106 CD34+ cells/4 mL vial. After processing for cryopreservation, the average cell count decreased to 331.3 ± 79. × 106 total viable cells /4 mL vial and 1.5 ± 0.7 × 106 CD34+ cells/4 mL vial CD34+ cells. Preprocessing viability averaged 99% and postprocessing 88%. Viability remained constant after cryopreservation at all subsequent time points. All sterility testing was negative. All samples showed proliferative potential, with average CFU count 301.4 ± 63.9. All samples were pluripotent. CONCLUSIONS: Peripheral blood stem cells are pluripotent and can be safely harvested/stored with filgrastim, apheresis, clean-room processing, and cryopreservation. These cells can be stored for 2 years and shipped without loss of viability. CLINICAL RELEVANCE: This method represents an accessible stem cell therapy in development to augment cartilage repair.

Preventative and Disease-Modifying Investigations for Osteoarthritis Management Are Significantly Under-represented in the Clinical Trial Pipeline: A 2020 Review.

PURPOSE: To conduct a review of active United States-based clinical trials investigating preventative, symptom resolution, and disease-modifying therapies for osteoarthritis (OA). METHODS: We conducted a review of currently active clinical trials for OA using data obtained from the ClinicalTrials.gov database as of August 2020. The inclusion criteria were active studies registered in the United States that involved the prevention, symptom resolution, or disease modification of OA. Descriptive statistics were recorded and summarized. RESULTS: A total of 3,859 clinical trials were identified, and 310 were included in the final analysis. Of the currently active trials, 89% (n = 275) targeted symptom resolution in patients with existing OA, 6% (n = 19) targeted OA disease-modifying therapeutics, and 5% (n = 16) targeted the prevention of OA in high-risk patients (P < .001). Primary interventions included medical devices (44%, n = 137), pharmaceutical drugs (14%, n = 42), surgical procedures (14%, n = 42), cellular biologics (13%, n = 41), and behavioral therapies (13%, n = 41). There was a significantly higher number of disease-modifying therapeutics for cellular biologics than pharmaceutical drugs (30% vs 14%) (P = .015). Most trials targeted the knee joint (63%, P = .042), with 38% of all trials evaluating joint arthroplasty. There were no significant differences between private sector and government funding sources (43% and 49%, respectively) (P = .288), yet there was a significantly lower rate of funding from industry (8%) (P = .026). CONCLUSIONS: There was a significantly higher number of clinical trials investigating symptomatic resolution therapy (89%) for existing OA in comparison to preventative (5%) and disease-modifying (6%) therapies. The most common interventions involved medical devices and joint replacement surgery, with the knee joint accounting for more than 60% of the current clinical trials for OA. There was a significantly higher number of disease-modifying therapeutics for cellular biologics than pharmaceutical drugs. Funding of clinical trials was split between the private sector and government, with a low rate of reported funding from industry partners. CLINICAL RELEVANCE: Identifying existing needs in the current market may help increase rates of research funding or optimize current funding pathways, in this study, specifically for targeting unaddressed focus areas in OA research. Our systematic review highlights the potential need for additional research and development regarding OA preventative and disease-modifying therapies.

Meniscal Repair Techniques for Middle- and Posterior-Third Tears.

Technical advancements in meniscal repairs have greatly contributed to the ability to repair a variety of meniscal tears that were once thought untreatable. The gold-standard treatment for arthroscopic meniscal body repair remains an inside-out technique. The advantages of this technique are innate to the low-profile nature of the suture-passing construct, which allows for perpendicular access to tears with the benefit of multiple fixation points, in contrast to often bulkier all-inside repair devices. This technique requires a posteromedial or posterolateral incision for safe suture passing and needle retrieval and necessitates a surgical team experienced in this method of repair. However, the newest generation of all-inside devices has allowed for more facile placement of a variety of suture types. The all-inside repair technique includes both capsular-based and meniscal-based fixation, is not limited by a need for additional experienced surgical personnel to pass and retrieve needles, and does not require additional incisions. Regardless of fixation type, meniscal repair has been shown to improve long-term functional scores when compared with meniscectomy. Additionally, biological adjuncts have been introduced into the repair algorithm to improve healing rates when performing isolated meniscal repairs. Preparing the healing site with abrasion or trephination creates vascular channels that can facilitate repair. Intercondylar-notch marrow venting attempts to replicate the environment created by anterior cruciate ligament drilling for which healing rates are notably higher than those with isolated meniscal repairs. The use of fibrin clots in inside-out meniscal repairs with suturing of the clot to the area of the tear has also shown promising early healing rates on both magnetic resonance imaging and second-look arthroscopy. Finally, biological adjuncts such as platelet-rich plasma and concentrated bone marrow aspirate have shown both early clinical and radiographic improvements in Level IV case series, but further research is needed to more definitively measure their utility in the setting of meniscal repair.