Men and women demonstrate comparable rates of failures and reoperations following primary osteochondral allograft transplantation of the knee, but women undergo reoperation sooner.

PURPOSE: To compare the differences between men and women who receive primary osteochondral allograft transplantation of the knee with regard to preoperative disease presentation, failures and reoperations. METHODS: A retrospective review of patients ≥18 years old who underwent primary osteochondral allograft transplantation between 2002 and 2020 by a single surgeon with a minimum of 2-year follow-up was performed. Demographic, preoperative, intraoperative and postoperative data were collected for all included patients. Patients were then assigned to two groups, either male or female, based on their reported sex. Statistical analysis was performed to assess sex-related differences in baseline characteristics, comparative survival analysis for determining survival probabilities, and regression analysis for determining variables associated with subsequent reoperation or failure. RESULTS: Among the 437 patients that were identified, 337 patients (77.1% follow-up, 161 men, 176 women) with a minimum of 2-year follow-up were included in our study. The mean age of included patients was 31.3 ± 9.9 years (range, 18.0-55.9), with a BMI of 26.7 ± 4.4 (range, 19.0-39.0) and a mean follow-up of 5.6 ± 2.6 years (range, 2.0-16.3). Male patients had significantly higher body mass index (BMI) (p ≤ 0.01), were more likely to have lesions on the medial femoral condyle (p = 0.041), and had larger lesions at the medial femoral condyle (p ≤ 0.01) and lateral femoral condyle (p ≤ 0.01). 36.8% of patients experienced subsequent reoperation (59 male, 65 female). Mean time to reoperation was 3.5 ± 2.8 years (range, 0.4-16.3 years) in males and 2.1 ± 1.9 years (range, 0.1-13.5 years) in females. No significant difference was found between the two groups with regard to reoperation rates (n.s.) or survivability free from reoperation (n.s.), but females were found to undergo reoperation sooner (p = 0.028). Sixty-three (18.7%) patients experienced subsequent graft failure (36 male, 27 female). No significant difference was found between the two groups in terms of failure rates, time to failure, survivability free from failure, or mode of failure (n.s. for all). CONCLUSIONS: Despite several differences in baseline demographics and intraoperative variables, no significant differences were found between men and women receiving primary osteochondral allograft transplantation of the knee with regard to failure or reoperation, with the exception that women underwent reoperation sooner. STUDY DESIGN: Retrospective Comparative Cohort Study. LEVEL OF EVIDENCE: Level III.

Borderline Hip Dysplasia - Best Treated with Hip Arthroscopy or Periacetabular Osteotomy?

PURPOSE OF REVIEW: As the field of hip preservation evolves, the diagnosis of borderline dysplasia (defined as a lateral center edge angle between 18°-25°) has shown itself to be one of the more challenging diagnoses to treat. As the nuances of acetabular coverage have come to light, the question of whether borderline hip dysplasia is best treated with isolated hip arthroscopy, periacetabular osteotomy, or whether a combined procedure is best, is now top of mind. The goal of these procedures is to not only improve patient symptoms, but to correct underlying pathology and ideally slow the development of hip osteoarthritis. The purpose of this review is to summarize the recent literature and clinical findings regarding both isolated hip arthroscopy and periacetabular osteotomy in the surgical management of borderline hip dysplasia. RECENT FINDINGS: Current research demonstrates improved postoperative clinical outcome scores for both patients who had isolated hip arthroscopy in the setting of borderline hip dysplasia and for those patients who underwent periacetabular osteotomy. Mid-term outcomes for patients in both groups have showed low rates of conversion to total hip arthroplasty. No gold standard in the surgical management of borderline hip arthroscopy exists. Improved clinical outcomes have been seen postoperatively in patients who undergo hip arthroscopy and in patients who undergo periacetabular osteotomy. Successful clinical outcomes seem to rely on treatment of the underlying clinical pathology and are largely based on the appropriate surgical indications and appropriate surgical techniques. Surgical decision making in this patient population should be individualized based on a comprehensive evaluation of the patient.

A Prospective, Randomized, Double-Blind Clinical Trial to Investigate the Efficacy of Autologous Bone Marrow Aspirate Concentrate During Arthroscopic Meniscectomy in Patients With Early Knee Osteoarthritis.

BACKGROUND: Despite being recognized as a safe procedure with minimal reported complications, injecting autologous bone marrow aspirate concentrate (BMAC) as an adjuvant to arthroscopic partial meniscectomy (APM) for symptomatic patients with meniscal tears and concomitant knee osteoarthritis (OA) has not been studied in randomized controlled trials. PURPOSE: To compare patient-reported outcome measure (PROM) scores and radiographic outcomes in symptomatic patients with meniscal tears and concomitant mild knee OA who underwent APM with and without an autologous BMAC injection administered at the time of surgery. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: Enrolled patients aged ≥18 years determined to have a symptomatic meniscal tear with concomitant mild knee OA suitable for APM and meeting inclusion and exclusion criteria were randomized into 2 groups: BMAC and control (no BMAC). The primary endpoint of the study was the International Knee Documentation Committee (IKDC) score at 1 year postoperatively. Secondary endpoints included radiographic outcomes (Kellgren-Lawrence grade) at 1 year postoperatively and various PROM scores, including those for the IKDC, Knee injury and Osteoarthritis Outcome Score (KOOS), visual analog scale, and Veterans RAND 12-Item Health Survey, at 3 months, 6 months, 1 year, and 2 years after meniscectomy. RESULTS: Of the 95 enrolled patients, 83 (87.4%) were included for final analysis. No significant differences were found between the groups with regard to patient characteristics, intraoperative variables, concomitant procedures, preoperative PROM scores, or preoperative radiographic findings. At 1 year postoperatively, the BMAC group failed to demonstrate significantly better IKDC scores (P = .687) or radiographic outcomes (P > .05 for all radiographic measures) compared with the control group. Secondary PROM scores also did not significantly differ between the groups (P > .05 for all PROMs). However, there were higher achievement rates of the minimal clinically important difference for the KOOS Sport (100.0% vs 80.0%, respectively; P = .023) and KOOS Symptoms (92.3% vs 68.0%, respectively; P = .038) at 1 year postoperatively in the BMAC group than in the control group. All PROMs, excluding the VR-12 mental score, showed significant improvements compared with baseline at all postoperative time points for both the BMAC and control groups. CONCLUSION: The addition of an autologous BMAC injection during APM did not result in significant changes in IKDC scores or radiographic outcomes at the 1-year postoperative mark. Secondary PROM scores were generally comparable between the 2 groups, but there was higher minimal clinically important difference achievement for the KOOS Sport and KOOS Symptoms at 1 year postoperatively in the BMAC group. In patients with symptoms consistent with a meniscal tear who had concomitant mild OA, the addition of BMAC to arthroscopic debridement did not affect the outcome. REGISTRATION: NCT02582489 (ClinicalTrials.gov).

Bioabsorbable Screw Fixation Provides Good Results With Low Failure Rates at Mid-term Follow-up of Stable Osteochondritis Dissecans Lesions That Do Not Improve With Initial Conservative Treatment.

Purpose: To evaluate the clinical and radiographic outcomes of patients who have undergone bioabsorbable screw fixation for intact, stable grade I and II osteochondritis dissecans (OCD) lesions for which at least 6 months of conservative management has failed. Methods: A retrospective review of prospectively collected data from a single institution was performed to identify patients who underwent internal fixation of stable grade I and II OCD lesions (according to the Guhl classification) between January 2010 and January 2020. Patients were included regardless of the presence of concomitant procedures. The inclusion criteria consisted of (1) primary surgery, (2) failure of at least 6 months of conservative management, (3) the use of a bioabsorbable screw (or screws), and (4) minimum 2-year clinical follow-up. Radiographs were obtained at a minimum of 1 year postoperatively. Patient demographic characteristics, clinical patient-reported outcomes, complications, and failure rates were noted. Results: Twenty-four knees among 23 patients (96% follow-up) were analyzed and followed up for 6.36 ± 3.42 years (range, 2.0-12.7 years). Patients showed statistically significant postoperative improvements in all patient-reported outcomes including the Lysholm score, International Knee Documentation Committee score, and Knee Injury and Osteoarthritis Outcome Score subscales (P < .05). In 3 knees (12%), a reoperation was required due to failure at an average of 3.64 years after the index procedure. No specific complications were attributed to the use of bioabsorbable screws. Patients in whom primary surgical treatment failed did not differ in demographic characteristics, arthroscopic findings, or surgical treatment from those who had successful treatment. Conclusions: Internal fixation of stable grade I and II OCD lesions with bioabsorbable screws produces reliable results with a 12% rate of failure in appropriately indicated patients in whom at least 6 months of conservative management has failed. Clinical outcomes improved significantly during the mid-term follow-up period. Level of Evidence: Level IV, therapeutic case series.

Revision and Primary Meniscal Allograft Transplantations Provide Clinical Benefit at Mid-Term Follow-Up: A Matched-Cohort Analysis of Patient-Reported Outcomes, Reoperations, and Failures.

PURPOSE: To report the mid-term outcomes of patients who underwent revision meniscal allograft transplantation (RMAT) and compare survivorship free from reoperation and failure with a matched cohort of patients who underwent primary meniscal allograft transplantation (PMAT). METHODS: A retrospective review of prospectively collected data identified patients who underwent RMAT and PMAT between 1999 and 2017. A cohort of PMAT patients matched at a ratio of 2:1 with respect to age, body mass index, sex, and concomitant procedures served as the control group. Patient-reported outcome measures (PROMs) at baseline and at a minimum of 5 years postoperatively were collected. PROMs and the achievement of clinically significant outcomes were analyzed within groups. Graft survivorship free from meniscal reoperation and failure (arthroplasty or subsequent RMAT) was compared between cohorts using log-rank testing. RESULTS: During the study period, 22 RMATs were performed in 22 patients. Of these RMAT patients, 16 met the inclusion criteria (73% follow-up rate). The mean age of RMAT patients was 29.7 ± 9.3 years, and the mean follow-up period was 9.9 ± 4.2 years (range, 5.4-16.8 years). There were no differences between the RMAT cohort and the 32 matched PMAT patients with respect to age (P = .292), body mass index (P = .623), sex (P = .537), concomitant procedures (P ≥ .286), or baseline PROMs (P ≥ .066). The patient acceptable symptomatic state was achieved by the RMAT cohort for the subjective International Knee Documentation Committee score (70%), Lysholm score (38%), and Knee Injury and Osteoarthritis Outcome Score subscales (Pain [73%], Symptoms [64%], Sport [45%], Activities of Daily Living [55%], and Quality of Life [36%]). In the RMAT cohort, 5 patients (31%) underwent subsequent reoperation at a mean of 4.7 ± 2.1 years (range, 1.7-6.7 years) and 5 patients met the criteria for failure at a mean of 4.9 ± 2.9 years (range, 1.2-8.4 years). There were no significant differences in survivorship free from reoperation (P = .735) or failure (P = .170) between the RMAT and PMAT cohorts. CONCLUSIONS: At mid-term follow-up, most patients who underwent RMAT achieved the patient acceptable symptomatic state for the subjective International Knee Documentation Committee score and the Knee Injury and Osteoarthritis Outcome Score subscales of Pain, Symptoms, and Activities of Daily Living. Additionally, there were no differences in survival free from meniscal reoperation or failure between the PMAT and RMAT cohorts. LEVEL OF EVIDENCE: Level III, retrospective comparative cohort.

Revision and Conversion to Arthroplasty Are Low Among Adolescents Undergoing Meniscal Allograft Transplantation Using the Bridge-In-Slot Technique at Midterm Follow-Up.

PURPOSE: To report midterm outcomes after primary medial and lateral meniscal allograft transplantation (MAT) with fresh-frozen allografts implanted with the bridge-in-slot technique in the adolescent patient population. METHODS: Adolescent patients less than 18 years old at the time of primary MAT from 1999 to 2016 were retrospectively identified. International Knee Documentation Committee (IKDC) subjective form, Lysholm, and Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales scores were collected before surgery and at 1-year, 2-year, and a minimum 5-year follow-up. Thresholds for achieving clinically significant outcomes were calculated, and the proportion of patients achieving minimal clinically important difference (MCID), patient-acceptable symptomatic state (PASS), and substantial clinical benefit (SCB) was determined. Meniscus reoperation (partial, subtotal, or total meniscectomy, repair, or failure) and failure (revision MAT or conversion to arthroplasty) rates were determined. RESULTS: Forty-four (female n = 33; male n = 11) of 62 identified patients met inclusion criteria and were followed for a mean of 9.5 ± 3.8 years (range, 5.0-17.7). Lateral MAT was performed in most patients (n = 35/44 [80%]). Isolated MAT was performed in 27 (61%) patients. Common concomitant procedures included osteochondral allograft transplantation (32%), autologous chondrocyte implantation (18%), and anterior cruciate ligament reconstruction (14%). MCID, PASS, and SCB were achieved by patients at a minimum 5-year follow-up for IKDC (62%; 76%; 31%), Lysholm (62%; 79%; 23%), and KOOS questionnaires (Pain [65%; 81%; 41%], Symptoms [58%; 81%; 47%], Activities of Daily Living [53%; 77%; 35%], Sport [86%; 75%; 50%], and Quality of Life [59%; 81%; 59%]), respectively. Fourteen patients (32%) underwent reoperation at an average of 5.0 ± 4.3 years (range, 0.8-14.0) after MAT. Three (7%) patients met criteria for failure, requiring revision MAT an average of 3.8 ± 1.1 years (range, 2.8-4.9) after transplantation. No patients underwent arthroplasty. Overall survival free from failure at 1, 2, 5, and 10 years was 100%, 100%, 93%, and 93%, respectively. At the time of final follow-up, 80% of patients reported satisfaction with their current physical status. CONCLUSIONS: Primary MAT in adolescent patients resulted in significant and durable functional improvements at mid- to long-term follow-up. At an average of 9.5 years after surgery, meniscal reoperation rate was 32% whereas graft survival free of revision MAT was 93%. Adolescents undergoing MAT demonstrated similar functional outcomes and graft survivability when compared to available adult MAT literature. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Minimum 10-Year Clinical Outcomes and Survivorship of Meniscal Allograft Transplantation With Fresh-Frozen Allografts Using the Bridge-in-Slot Technique.

BACKGROUND: Meniscal allograft transplantation (MAT) has been shown to provide clinical benefits in patients with symptomatic meniscal deficiency in the short term and midterm. There is, however, a paucity of data regarding long-term outcomes after MAT using fresh-frozen allografts and the bridge-in-slot technique. PURPOSE: To report clinical outcomes and revision rates after primary MAT with fresh-frozen allografts and the bridge-in-slot technique in a large case series of patients at a 10-year minimum follow-up. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective review of prospectively collected data was performed on patients undergoing primary MAT between 2001 and 2012. Lysholm, International Knee Documentation Committee subjective form, and Knee injury and Osteoarthritis Outcome Score subscales were collected preoperatively and at 1-, 2-, 5-, and minimum 10-year follow-ups. Cox proportional hazards modeling was used to identify variables associated with reoperation and failure, defined as revision MAT or conversion to arthroplasty. Reoperation was defined as a subsequent surgical intervention on the transplanted meniscus, including partial or total meniscectomy, meniscal repair, or failure as defined in the previous sentence. RESULTS: A total of 174 patients undergoing MAT met the inclusion criteria and were followed for a mean of 12.7 ± 2.7 years (range, 10.0-21.0 years). The mean age at surgery was 28.3 ± 10.1 years. The patients were predominantly female (n = 92; 53%), and medial MAT was the most commonly performed procedure (n = 91; 52%). Concomitant procedures were performed in 115 patients (66%), with the most common procedure being osteochondral allograft transplantation (n = 59; 34%). Patients demonstrated statistically significant postoperative improvements at all time points for all patient-reported outcome measures (P≤ .0001). A total of 65 patients (37%) underwent a meniscal reoperation at a mean time of 6.6 ± 5.5 years (range, 0.3-16.7 years) postoperatively. A total of 40 patients (23%) met the criteria for failure at a mean time of 7.3 ± 5.0 years (range, 1.0-17.4 years) after MAT, with 22 of these patients having undergone a previous meniscal reoperation. At the final follow-up, 13 patients (7%) had undergone revision MAT and 27 (15%) had converted to arthroplasty. The MAT survival rates free of meniscal reoperation and failure were 73% and 85% at 10 years and 60% and 72% at 15 years, respectively. At the time of the final follow-up, 86% of patients reported that they were satisfied with their overall postoperative condition. CONCLUSION: Primary MAT demonstrates efficacy and durability with high rates of patient satisfaction at a minimum 10-year follow-up. Patients should be counseled that although reoperation rates may approach 40% at 15 years, rates of overall revision MAT and conversion to arthroplasty remain low at long-term follow-up.

Long-term outcomes after osteochondral allograft transplantation to the humeral head.

BACKGROUND: Long-term outcomes of osteochondral allograft (OCA) transplantation to the humeral head have been sparsely reported in the literature. PURPOSE: To evaluate outcomes and survivorship of OCA transplantation to the humeral head in patients with osteochondral defects at a minimum of 10 years of follow-up. METHODS: A registry of patients who underwent humeral head OCA transplantation between 2004 and 2012 was reviewed. Patients completed pre and postoperative surveys including the American Shoulder and Elbow Surgeons score, Simple Shoulder Test, Short Form 12 (SF-12), and the visual analog scale. Failure was defined by conversion to shoulder arthroplasty. RESULTS: Fifteen of 21 (71%) patients with a minimum of ten year of follow-up (mean: 14.2 ± 2.40) were identified. Mean patient age was 26.1 ± 8.8 years at the time of transplantation and eight (53%) patients were male. Surgery was performed on the dominant shoulder in 11 of the 15 (73%) cases. The use of local anesthetic delivered via an intra-articular pain pump was the most often reported underlying etiology of chondral injury (n = 9; 60%). Eight (53%) patients were treated with an allograft plug, while seven (47%) patients were treated with a mushroom cap allograft. At final follow-up, mean American Shoulder and Elbow Surgeons (49.9 to 81.1; P = .048) and Simple Shoulder Test (43.1 to 83.3; P = .010) significantly improved compared to baseline. Changes in mean SF-12 physical (41.4 to 48.1; P = .354), SF-12 mental (57.5 to 51.8; P = .354), and visual analog scale (4.0 to 2.8; P = .618) did not reach statistical significance. Eight (53%) patients required conversion to shoulder arthroplasty at an average of 4.8 ± 4.7 years (range: 0.6-13.2). Kaplan-Meier graft survival probabilities were 60% at 10 years and 41% at 15 years. CONCLUSION: OCA transplantation to the humeral head can result in acceptable long-term function for patients with osteochondral defects. While patient-reported outcomes metrics were generally improved compared to baseline, OCA graft survival probabilities diminished with time. The findings from this study can be used to counsel future patients with significant glenohumeral cartilage injuries and set expectations about the potential for further surgery.

Patient-Specific Variables Associated with Failure to Achieve Clinically Significant Outcomes After Meniscal Allograft Transplantation at Minimum 5 Year Follow-Up.

PURPOSE: To determine the improvements in patient-reported outcome measures (PROMs) necessary to achieve minimal clinically important difference (MCID), patient-acceptable symptomatic state (PASS), and substantial clinical benefit (SCB) after primary meniscal allograft transplantation (MAT) at a minimum of 5-year follow-up, while identifying variables predictive of achieving clinically significant outcomes (CSOs). METHODS: A retrospective review was performed to identify patients undergoing primary MAT at a single institution from 1999 to 2016. Lysholm, International Knee Documentation Committee (IKDC), and Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales were collected before surgery and at a minimum of 5-year follow-up. A distribution-based approach was used to calculate MCID, whereas an anchor-based approach was used to calculate SCB and PASS. Multivariate logistic regression was performed to determine factors associated with CSO achievement. RESULTS: A total of 202 patients undergoing MAT (56% medial, 44% lateral) were included with a mean follow-up of 9.8 ± 4.1 years, age of 29.7 ± 8.5 years, and body mass index (BMI) of 26.5 ± 4.7. Thresholds for achieving MCID, PASS, and SCB, respectively, at a minimum 5-year follow-up for Lysholm (10.3, 74.5, 32.5), IKDC (12.1, 55.6, 29.1), and KOOS subscales questionnaires (Pain [11.0, 70.7, 25.1], Symptoms [11.0, 60.8, 19.6], Activities of Daily Living [10.5, 90.3, 17.9], Sport [16.2, 47.4, 37.5], and Quality of Life [13.6, 40.5, 37.3]) were calculated. Reduced odds of achieving MCID were associated with higher preoperative PROM scores, BMI, patient age, concomitant osteotomy, male sex, and worker's compensation (WC) status. Reduced odds of achieving PASS were associated with lower preoperative PROM scores, higher BMI (particularly ≥30), patient age, and WC status. Reduced odds of achieving SCB were associated with higher preoperative PROM scores and WC status. CONCLUSIONS: This study established the MCID, PASS, and SCB at 5-year minimum follow-up for the Lysholm score, IKDC, and KOOS subscales in patients who underwent MAT. Increased BMI and patient age, male sex, performance of concomitant osteotomy, WC status, and preoperative PROM scores were associated with failure to achieve CSOs after primary MAT at a minimum of 5-year follow-up. LEVEL OF EVIDENCE: Level IV, therapeutic study, retrospective case series.

Prospective Randomized Trial of Biologic Augmentation With Bone Marrow Aspirate Concentrate in Patients Undergoing Arthroscopic Rotator Cuff Repair.

BACKGROUND: Although initial studies have demonstrated that concentrated bone marrow aspirate (cBMA) injections promote rotator cuff repair (RCR) healing, there are no randomized prospective studies investigating clinical efficacy. HYPOTHESIS/PURPOSE: To compare outcomes after arthroscopic RCR (aRCR) with and without cBMA augmentation. It was hypothesized that cBMA augmentation would result in statistically significant improvements in clinical outcomes and rotator cuff structural integrity. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: Patients indicated for aRCR of isolated 1- to 3-cm supraspinatus tendon tears were randomized to receive adjunctive cBMA injection or sham incision. Bone marrow was aspirated from the iliac crest, concentrated using a commercially available system, and injected at the aRCR site after repair. Patients were assessed preoperatively and serially until 2 years postoperatively via the following functional indices: American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), Simple Shoulder Test, 12-Item Short Form Health Survey, and Veterans RAND 12-Item Health Survey. Magnetic resonance imaging (MRI) was performed at 1 year to assess rotator cuff structural integrity according to Sugaya classification. Treatment failure was defined as decreased 1- or 2-year ASES or SANE scores as compared with preoperative baseline, the need for revision RCR, or conversion to total shoulder arthroplasty. RESULTS: An overall 91 patients were enrolled (control, n = 45; cBMA, n = 46): 82 (90%) completed 2-year clinical follow-up and 75 (82%) completed 1-year MRI. Functional indices significantly improved in both groups by 6 months and were sustained at 1 and 2 years (all P < .05). The control group showed significantly greater evidence of rotator cuff retear according to Sugaya classification on 1-year MRI (57% vs 18%; P < .001). Treatment failed for 7 patients in each group (control, 16%; cBMA, 15%). CONCLUSION: cBMA-augmented aRCR of isolated supraspinatus tendon tears may result in a structurally superior repair but largely fails to significantly improve treatment failure rates and patient-reported clinical outcomes when compared with aRCR alone. Additional study is warranted to investigate the long-term benefits of improved repair quality on clinical outcomes and repair failure rates. REGISTRATION: NCT02484950 (ClinicalTrials.gov identifier).

Rotator Cuff Repair in the Pediatric Population Displays Favorable Outcomes: A Systematic Review.

Purpose: To systematically review the literature to determine the injury mechanisms, presentation, and timing of diagnosis for pediatric patients with intratendinous rotator cuff tears and to determine the efficacy of surgical intervention for affected patients. Methods: PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Scopus were searched. Studies were included if they involved only pediatric patients, soft-tissue rotator cuff injuries managed surgically, and reported outcomes. Patient characteristics, injury mechanisms, physical examination and imaging findings, time to diagnosis, surgical technique, and treatment outcomes were extracted. Findings were descriptively analyzed with weighted means and proportions. Results: Twenty-one studies comprising 78 patients were included. The age range was 8 to 17 years and 57 were male. The supraspinatus (n = 56) was the most injured tendon. American football was the most reported sport played at the time of injury. Most patients were diagnosed within 6 months of injury via magnetic resonance imaging. Arthroscopic management was undertaken in 68 patients. Forty-six of 51 patients for whom data were available returned to sports at a range of 2.5 to 12 months postoperatively. Repair failure occurred in three patients. Conclusions: The extant literature regarding rotator cuff tears in pediatric patients is limited to reports of low methodological quality. Qualitative synthesis of this low-level literature reveals that rotator cuff tears are mostly reported in male collision sport athletes but may also occur in female athletes and/or throwing athletes. These injuries are often successfully managed via arthroscopic repair, and patients and their families can be reassured that the majority of patients return to sports following surgery. Level of Evidence: Level IV, systematic review of level IV studies.

Meniscal ramp lesions - Skillful neglect or routine repair?

Background: Meniscal ramp lesions are injuries of the posterior horn of the medial meniscus at the meniscocapsular junction or the meniscotibial ligament and are frequently associated with concomitant anterior cruciate ligament (ACL) injury. Objective: To review the current literature on meniscal ramp lesion management to better define the indications for and outcomes of repair. Methods: A narrative literature review was performed using PubMed, Embase, and Scopus databases. Studies of all evidence levels (I-V) pertaining to meniscal ramp lesions were reviewed and included. Results: The incidence of ramp lesions has been reported between 16% and 42%. Arthroscopy remains the diagnostic gold standard as magnetic resonance imaging has limited sensitivity. Biomechanically, ramp lesions are known to increase anterior tibial translation and rotational laxity. Clinical investigations regarding optimal management are largely limited to studies of low evidence levels. While case series have demonstrated that repair is safe and efficacious, comparative studies have failed to suggest that repair of stable lesions results in superior outcomes when compared to conservative treatment approaches. However, repair may be warranted in unstable ramp lesion injuries despite the increased risk for revision surgery. Conclusion: While there is evidence to suggest that ramp lesion repair can restore joint kinematics, the current body of clinical literature fails to suggest that outcomes following repair are superior to injuries managed conservatively. The current body of clinical literature is limited, and further robust, long-term study is warranted to better guide injury diagnosis and management protocol.

Defining Clinically Significant Outcomes Following Superior Capsular Reconstruction With Acellular Dermal Allograft.

PURPOSE: To define clinically significant outcomes (CSO) thresholds for minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient-acceptable symptomatic state (PASS) in patients undergoing superior capsular reconstruction (SCR) with an acellular dermal allograft. We also evaluated patient-specific variables predictive of achieving CSO thresholds. METHODS: The American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Single Assessment Numeric Evaluation (SANE), and subjective Constant-Murley (Constant) scores were collected preoperatively and at the most recent follow up for patients undergoing SCR from 2010 to 2019. A distribution-based approach was used to calculate MCID, and an anchor-based approach was used to calculate SCB and PASS. Logistic regression was used to determine factors associated with CSO achievement. RESULTS: Fifty-eight patients were identified (n = 39 males; n = 19 females) with a mean age of 53.4 ± 14.1 years at surgery and an average follow-up of 23 months. The MCID, SCB, and PASS were 11.2, 18.02, and 68.82 for ASES, 14.5, 23.13, and 69.9 for SANE, and 3.6, 10, and 18 for Constant, respectively. Subscapularis tear, female sex, and workers compensation (WC) status reduced odds of achieving MCID. Reduced odds of achieving Constant SCB were associated with older age, female sex, and WC status, while concomitant distal clavicle excision during SCR and lower preoperative ASES increased odds of achieving ASES SCB. Reduced odds for achieving ASES PASS were associated with female sex and WC status, while reduced odds for achieving SANE PASS were associated with subscapularis tearing preoperatively. CONCLUSION: On the basis of calculated values for MCID, SCB, and PASS, subscapularis tearing, WC status, age, and sex are associated with failure to achieve clinically significant outcomes following SCR. Concomitant distal clavicle excision during SCR and lower preoperative ASES was predictive for achievement of MCID and SCB. By defining the thresholds and variables predictive of achieving CSOs following SCR, surgeons may better counsel patients prior to SCR. LEVEL OF EVIDENCE: Level IV, case series.

Caffeine reverses the unconsciousness produced by light anesthesia in the continued presence of isoflurane in rats.

Currently no drugs are employed clinically to reverse the unconsciousness induced by general anesthetics. Our previous studies showed that caffeine, when given near the end of an anesthesia session, accelerated emergence from isoflurane anesthesia, likely caused by caffeine's ability to elevate intracellular cAMP levels and to block adenosine receptors. These earlier studies showed that caffeine did not rouse either rats or humans from deep anesthesia (≥ 1 minimum alveolar concentration, MAC). In this current crossover study, we examined whether caffeine reversed the unconsciousness produced by light anesthesia (< 1 MAC) in the continued presence of isoflurane. The primary endpoint of this study was to measure isoflurane levels at the time of recovery of righting reflex, which was a proxy for consciousness. Rats were deeply anesthetized with 2% isoflurane (~1.5 MAC) for 20 minutes. Subsequently, isoflurane was reduced to 1.2% for 10 minutes, then by 0.2% every 10 min; animals were monitored until the recovery of righting reflex occurred, in the continued presence of isoflurane. Respiration rate, heart rate and electroencephalogram (EEG) were monitored. Our results show that caffeine-treated rats recovered their righting reflex at a significantly higher inspired isoflurane concentration, corresponding to light anesthesia, than the same rats treated with saline (control). Respiration rate and heart rate increased initially after caffeine injection but were then unchanged for the rest of the anesthesia session. Deep anesthesia is correlated with burst suppression in EEG recordings. Our data showed that caffeine transiently reduced the burst suppression time produced by deep anesthesia, suggesting that caffeine altered neuronal circuit function but not to a point where it caused arousal. In contrast, under light anesthesia, caffeine shifted the EEG power to high frequency beta and gamma bands. These data suggest that caffeine may represent a clinically viable drug to reverse the unconsciousness produced by light anesthesia.