All-Inside Anterior Cruciate Ligament Reconstruction Using Quadrupled Semitendinosus: Comparable 2-Year Outcomes in Male and Female Patients.

PURPOSE: To determine 2-year functional outcomes using an all-inside quadrupled semitendinosus anterior cruciate ligament (ACL) reconstruction technique in male and female patients. METHODS: A total of 100 patients who underwent quadrupled semitendinosus all-inside hamstring ACL reconstruction by a single surgeon were enrolled. Patient-reported outcome scores collected preoperatively and postoperatively included visual analog scale, Veterans Rand 12-Item Health Survey (VR-12; Physical and Mental), Marx Activity Scale, Knee Injury and Osteoarthritis Outcome Scores (KOOS), and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). RESULTS: A total of 100 ACL reconstructions comprising 62 female, and 38 male patients were included in this study. Mean graft diameter was 9.4 mm in female and 9.8 mm in male patients (range, 9-11). Outcome scores demonstrated improvement from preoperative to 2-year postoperative respectively: visual analog scale pain 3.18, 1.07, VR-12 physical 36.35, 52.64, VR-12 mental 53.96, 54.65, KOOS pain 59.17, 89.03, KOOS symptoms 52.64, 80.79, KOOS Activities of Daily Living 69.38, 95.4, KOOS Sport 28.97, 81.25, KOOS Quality of Life 27.54, 71.56, WOMAC Pain 71.56, 92.65, WOMAC Stiffness 60.55, 84.13, and WOMAC Function 69.38, 95.4. Marx activity score decreased from baseline (10.98) to 2 years' postoperatively (8.75). At 2 years, patient expectations were met or exceeded with regards to pain (94%), motion and strength (91%), normal function of daily living (95%), and return to sport (79%). CONCLUSIONS: Anatomic all-inside quadrupled semitendinosus ACL reconstruction improves functional outcomes similarly to previous studies between baseline and clinical follow-up at 1-year and 2-years postoperatively and is comparable in both male and female patients. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Predicting Quadrupled Graft Length and Diameter Using Single-Strand Tendon Dimensions in All-Inside Anterior Cruciate Ligament Reconstruction.

PURPOSE: To determine whether single-strand semitendinosus autograft or allograft dimensions can reliably predict quadrupled graft diameter and length. METHODS: Intraoperative semitendinosus graft measurements were recorded for consecutive all-inside anterior cruciate ligament (ACL) reconstructions from 2013 to 2016 and retrospectively reviewed. Intraoperative single-strand tendon length and width and the corresponding quadrupled graft length and diameter were recorded. Pearson correlation coefficients were used to assess the linear association between single-strand width and quadrupled diameter, as well as between single-strand length and quadrupled length. Linear regression models were used to predict quadrupled values. To test the accuracy of the predicted quadrupled values, dimensions from an additional series of 30 all-inside ACL reconstructions were reviewed. RESULTS: Seventy-three ACL reconstruction procedures were reviewed. We excluded 12 grafts because gracilis and semitendinosus constructs were used. Thus 61 semitendinosus quadrupled grafts (30 autografts and 31 allografts) were included. Single-strand width was associated with quadrupled diameter (P = .012), and single-strand length was associated with quadrupled graft length (P < .001). CONCLUSIONS: Quadrupled hamstring graft length and diameter may be accurately predicted based on length and width of the semitendinosus tendon used for all-inside, single-bundle ACL reconstruction. The ability to predict quadrupled graft dimensions can guide the surgeon in intraoperative decision making and ensure the desired ACL graft dimensions are achieved, thereby minimizing the risk of ACL reconstruction failure. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Symptomatic Focal Knee Chondral Injuries in National Football League Combine Players Are Associated With Poorer Performance and Less Volume of Play.

PURPOSE: To (1) describe the magnetic resonance imaging (MRI) characteristics of knee chondral injuries identified at the National Football League (NFL) Combine and (2) assess in-game performance of prospective NFL players with previously untreated knee chondral injuries and compare it with matched controls. METHODS: All players with knee chondral injuries identified at the NFL Combine (2009-2015) were retrospectively reviewed. Players with prior knee surgery were excluded. A knee MRI for each player was reviewed; location, modified International Cartilage Repair Society (ICRS) grade (I-IV), and associated compartment subchondral edema were documented. Position, respective NFL Draft pick selection number, games started, played, snap percentage, and position-specific performance metrics during the first 2 NFL seasons were recorded for the injury and injury-free control group composed of players with (1) no prior knee injury, (2) no significant missed time prior to the NFL (≤2 total missed games in college), (3) no history of knee surgery, and (4) drafted in the respective NFL Draft following the NFL Combine. RESULTS: Of the 2,285 players reviewed, 101 (4.4%) had an injury without prior knee surgery. The patella (63.4%) and trochlea (34%) were most commonly affected. Defensive linemen were at highest risk for unrecognized injuries (odds ratio 1.8, P = .015). Players with previously untreated injuries, compared with controls, were picked later (mean pick: 125.8) and played (mean: 23) and started (mean: 10.4) fewer games during the initial 2 NFL seasons (P < .001 for all). Particularly, subchondral bone edema and full-thickness cartilage injuries were associated with fewer games played (P = .003). CONCLUSIONS: The patellofemoral joint was most commonly affected in NFL Combine participants. Previously untreated knee articular injuries in players at the NFL Combine are associated with poorer early NFL performance in comparison to uninjured players. Subchondral bone edema and full-thickness cartilage injury on MRI were associated with fewer games played during the initial NFL career. LEVEL OF EVIDENCE: Level III, case-control study.

Management and subsequent outcomes of patellar sleeve injuries: A retrospective case series of 90 pediatric and adolescent patients.

Purpose: This study aims to report the epidemiology of patellar sleeve injuries, describe diagnostic findings and treatment, and assess functional outcomes following different treatments. Methods: A medical database was queried from 1990 to 2016 to identify patients ≤18 years presenting to a single pediatric institution with a patellar sleeve injury. Patients with significant comorbidities or previously operatively treated for ipsilateral knee injuries were excluded. Standard demographic data, mechanism of injury, skeletal maturity, injury-related radiographic parameters, along with treatment paradigms, post-treatment clinical and radiographic findings, and patient-reported outcomes were collected. Results: A total of 90 patients, mean age of 10.7 years (range: 7-17) was included, of which 69 (77%) were male. Seventy-three percent of all injuries occurred while playing sports (particularly football/basketball/soccer), with "direct blow" or "landing" being the most prevalent mechanisms of injury. Twenty-six (29%) underwent operative treatment, with transosseous suture fixation being the most popular surgical technique (73%). Of the 64 (71%) non-operatively treated patients, 18 (39%) were placed in a hinged knee brace locked in extension with the remainder split between casting and standard knee immobilizer. Compared to the non-operative cohort, a higher percentage of the operative group had a pre-treatment extensor lag (p < 0.001) and greater fragment displacement (p < 0.001) with patella alta (p < 0.001) on imaging. There was no difference in outcome scores (Pedi-IKDC/Lysholm) or patella alta on radiographs between groups. Post-treatment surveys indicated no difference in residual pain or ability to return to sport. Conclusion: This large case series provides valuable epidemiologic, clinical, and radiographic data describing patellar sleeve fractures, along with outcomes following non-operative and operative treatments. Level of evidence: IV.

Complete Resolution of Refractory Axial Low Back Pain After Myomectomy.

ABSTRACT: We present a case of a 39-yr-old woman with a 3-mo history of axial low back pain who was found to have a 3.8-cm uterine fibroid, which was initially thought to be an incidental finding. Her low back pain failed to respond to conservative management, and she was eventually referred to gynecology. Her pain subsequently resolved after myomectomy. To the best of our knowledge, complete resolution of low back pain after myomectomy has not been previously described in the literature. Although uterine fibroids are commonly noted on imaging, they are often ignored. We encourage clinicians to consider fibroids as pain generators, especially when treating patients with refractory axial low back pain.

Technical Pearls for Arthroscopic Labral Augmentation of the Hip.

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

Survivorship and Patient-Reported Outcomes After Comprehensive Arthroscopic Management of Glenohumeral Osteoarthritis: Minimum 10-Year Follow-up.

BACKGROUND: Few long-term outcome studies exist evaluating glenohumeral osteoarthritis (GHOA) treatment with arthroscopic management. PURPOSE: To determine outcomes, risk factors for failure, and survivorship for the comprehensive arthroscopic management (CAM) procedure for the treatment of GHOA at minimum 10-year follow-up. STUDY DESIGN: Case series; Level of evidence, 3. METHODS: The CAM procedure was performed on a consecutive series of patients with advanced GHOA who opted for joint preservation surgery and otherwise met criteria for total shoulder arthroplasty. At minimum 10-year follow-up, postoperative outcome measures included change in the American Shoulder and Elbow Surgeons, Single Assessment Numeric Evaluation, 12-Item Short Form Health Survey (SF-12) Physical Component Summary, and visual analog scale for pain, along with the QuickDASH (shortened version of Disabilities of the Arm, Shoulder and Hand) and satisfaction score. Kaplan-Meier survivorship analysis was performed, with failure defined as progression to arthroplasty. RESULTS: In total, 38 CAM procedures were performed with 10-year minimum follow-up (range, 10-14 years) with a mean patient age of 53 years (range, 27-68 years) at the time of surgery. Survivorship was 75.3% at 5 years and 63.2% at minimum 10 years. Those who progressed to arthroplasty did so at a mean 4.7 years (range, 0.8-9.6 years). For those who did not undergo arthroplasty, American Shoulder and Elbow Surgeons scores significantly improved postoperatively at 5 years (63.3 to 89.6; P < .001) and 10 years (63.3 to 80.6; P = .007). CAM failure was associated with severe preoperative humeral head incongruity in 93.8% of failures as compared with 50.0% of patients who did not go on to arthroplasty (P = .008). Median satisfaction was 7.5 out of 10. CONCLUSION: Significant improvements in patient-reported outcomes were sustained at minimum 10-year follow-up in young patients with GHOA who underwent a CAM procedure. The survivorship rate at minimum 10-year follow-up was 63.2%. Humeral head flattening and severe joint incongruity were risk factors for CAM failure. The CAM procedure is an effective joint-preserving treatment for GHOA in appropriately selected patients, with sustained positive outcomes at 10 years.

Tibial tubercle fractures in children and adolescents: a large retrospective case series.

To report patient characteristics, fracture types, treatment methods, early clinical outcomes and complications of children and adolescents treated for tibial tubercle fractures. Retrospective case series of patients 18 years old and younger treated for tibial tubercle fractures at a single institution from 1995 to 2015. Clinical and radiographic outcomes were reported at minimum six-month follow-up. In 228 patients, 236 tibial tubercle fractures were identified, of whom, 198 (87%) were males. Mean age and BMI was 14.3 years and 25.0, respectively. Pre-existing Osgood-Schlatter disease was identified in 31% cases and was most commonly associated with type I fractures (P < 0.001). Most fractures occurred while participating in athletics (86%). Initial treatment was surgical for 67% fractures. Type III fractures were most common (41%), followed by type I (29%). Type I fractures were most commonly treated nonoperatively (91%) and types II-V fractures were most commonly treated surgically (89%, P < 0.001). Compartment syndrome was identified in 4 (2%) patients, 3 of which had type IV fractures. Most patients returned to sports (88%). Tibial tubercle fractures are sports-related injuries and occur most commonly in adolescent males. They can be associated with pre-existing Osgood-Schlatter disease, a higher than average BMI, and a small but relevant risk of compartment syndrome. Following treatment, most patients return to sports participation.

Segmental Meniscus Allograft Transplantation.

Meniscal tears treated with partial meniscectomies have been shown to significantly increase contract pressures within the tibiofemoral joint, and a complete focal meniscal deficiency may render the entirety of the meniscus functionally incompetent. Although various techniques of meniscal transplantation have been described, these techniques may require the excision of a considerable amount of healthy meniscal tissue. Furthermore, failures continue to frequently occur. Therefore, attempts to restoring normal knee kinematics and biomechanical forces are essential. Segmental meniscus allograft transplantations may offer the advantage of a robust repair by both maintaining knee biomechanics and biology while maximizing preservation of native meniscal tissue. Also, most meniscal deficiency involves only a portion of the meniscus, and thus we developed this technique to segmentally transplant only the deficient portion. The purpose of this Technical Note is to describe a technique of segmental medial meniscus allograft transplantation in a patient with focal medial meniscus deficiency.

Biomechanical Analysis of Segmental Medial Meniscal Transplantation in a Human Cadaveric Model.

BACKGROUND: Meniscal deficiency has been reported to increase contact pressures in the affected tibiofemoral joint, possibly leading to degenerative changes. Current surgical options include meniscal allograft transplantation and insertion of segmental meniscal scaffolds. Little is known about segmental meniscal allograft transplantation. PURPOSE: To evaluate the effectiveness of segmental medial meniscal allograft transplantation in the setting of partial medial meniscectomy in restoring native knee loading characteristics. STUDY DESIGN: Controlled laboratory study. METHODS: Ten fresh-frozen human cadaveric knees underwent central midbody medial meniscectomy and subsequent segmental medial meniscal allograft transplantation. Knees were loaded in a dynamic tensile testing machine to 1000 N for 20 seconds at 0°, 30°, 60°, and 90° of flexion. Four conditions were tested: (1) intact medial meniscus, (2) deficient medial meniscus, (3) segmental medial meniscal transplant fixed with 7 meniscocapsular sutures, and (4) segmental medial meniscal transplant fixed with 7 meniscocapsular sutures and 1 suture fixed through 2 bone tunnels. Submeniscal medial and lateral pressure-mapping sensors assessed mean contact pressure, peak contact pressure, mean contact area, and pressure mapping. Two-factor random-intercepts linear mixed effects models compared pressure and contact area measurements among experimental conditions. RESULTS: The meniscal-deficient state demonstrated a significantly higher mean contact pressure than all other testing conditions (mean difference, ≥0.35 MPa; P < .001 for all comparisons) and a significantly smaller total contact area as compared with all other testing conditions (mean difference, ≤140 mm2; P < .001 for all comparisons). There were no significant differences in mean contact pressure or total contact area among the intact, transplant, or transplant-with-tunnel groups or in any outcome measure across all comparisons in the lateral compartment. No significant differences existed in center of pressure and relative pressure distribution across testing conditions. CONCLUSION: Segmental medial meniscal allograft transplantation restored the medial compartment mean contact pressure and mean contact area to values measured in the intact medial compartment. CLINICAL RELEVANCE: Segmental medial meniscal transplantation may provide an alternative to full meniscal transplantation by addressing only the deficient portion of the meniscus with transplanted tissue. Additional work is required to validate long-term fixation strength and biologic integration.