The impact of Canadian-produced research on the global orthopedic literature: a bibliometric analysis.

BACKGROUND: Little is known about the quality and impact of Canadian-produced research relative to that of other developed nations. The purpose of this study was to determine the contribution of Canadian authors to the orthopedic literature globally and nationally as well as Canada's research productivity in orthopedics. We hypothesized that Canada ranks among the most impactful countries in terms of orthopedic research productivity. METHODS: We performed a bibliometric analysis to identify articles published between 2001 and 2020 in the category of orthopedics. We identified Canada's global rank in terms of overall productivity and assessed the contributions of individual Canadian authors. We also examined the quality of publications as determined by category normalized citation impact (CNCI) and publication in the top quartile of journals (%Q1) in terms of impact factor. In addition, we calculated the percentage of Canadian publications that were in orthopedics. RESULTS: We identified 10 821 orthopedic publications from 2001 to 2020. Canada placed sixth globally in terms of productivity in orthopedic research. The annual productivity of Canadian orthopedic researchers increased over the study period by a factor of 3.2. In terms of research quality, with a %Q1 of 36.5% and a CNCI of 1.22, Canada outperformed Asian countries and the United States; the latter country had a %Q1 of 35.3% and a CNCI of 1.14 over the study period. CONCLUSION: The body of Canadian orthopedic literature has grown consistently over the past 20 years. Despite the overall leadership of the United States and other developed nations such as China and Japan, Canada ranks among the most influential countries in terms of the quality and quantity of orthopedic research.

Transosseous-Equivalent/Suture Bridge Arthroscopic Rotator Cuff Repair in Combination With Late Postoperative Mobilization Yield Optimal Outcomes and Retear Rate: A Network Meta-analysis of Randomized Controlled Trials.

PURPOSE: The purpose of this study was to perform a network meta-analysis of the randomized controlled trials (RCTs) in the literature in order to assess the evidence defining the optimal combination of surgical technique single-row repair (SRR), double-row repair (DRR), or transosseous-equivalent/suture bridge (TOE/SB) arthroscopic rotator cuff repair (ARCR) and postoperative rehabilitation (early or late) protocol for ARCR. METHODS: The literature search was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Randomized SSR-early trials (RCTs) comparing SRR vs DRR vs TOE/SB ARCR techniques were included, as well as early vs late postoperative range of motion. Clinical outcomes were compared using a frequentist approach to network meta-analysis, with statistical analysis performed using R. The treatment options were ranked using the P-score. RESULTS: Twenty-eight studies comprising 2,181 total shoulders met the inclusion criteria. TOE/SB-late (odds ratio [OR], 0.19; 95% confidence interval [CI], 0.08-0.46) and DRR-late (OR, 0.25; 95% CI, 0.12-0.52) were found to significantly reduce the rate of retear, with TOE/SB-late resulting in the highest P-score for the American Shoulder and Elbow Surgeons (P-score: 0.7911) score and retear rate (P-score: 0.8725). DRR-early did not result in any significant improvements over the SRR-early group, except in internal rotation. There was no significant difference in forward flexion between groups, with almost equivalent P-scores. Furthermore, TOE/SB-early and TOE/SB-late trended toward worsening external rotation compared with the control. CONCLUSIONS: The current study suggests that rotator cuff repair using the TOE/SB technique and late postoperative mobilization yields the highest functional outcomes and lowest retear rate in the arthroscopic management of symptomatic rotator cuff tears. LEVEL OF EVIDENCE: Level I, meta-analysis of Level I studies.

Open Subpectoral Biceps Tenodesis May Be an Alternative to Arthroscopic Repair for SLAP Tears in Patients Under 30.

PURPOSE: The purpose of the current study is to compare the outcomes of open subpectoral biceps tenodesis (BT) to arthroscopic repair (AR) for SLAP tears in patients under the age of 30 years. METHODS: A retrospective review of patients under the age of 30 years who underwent either isolated BT or AR for a diagnosis of a SLAP tear between 2011 and 2019 was performed. Patients were included if they were >16 years old at the time of surgery, had an isolated SLAP tear involving instability of the biceps-labral anchor (types II-IV), were skeletally mature, and had a minimum follow-up of 12 months. The American Shoulder & Elbow Surgeons score, visual analog scale, Subjective Shoulder Value, patient satisfaction, willingness to undergo surgery again, revisions, and return to play (RTP) were evaluated. A P value of <.05 was considered statistically significant. RESULTS: Our study included 103 patients in total; 29 patients were treated with BT, and 74 were treated with AR. The mean age was 24.8 years, and the mean follow-up duration was 60 months. At final follow-up, there was no difference between treatment groups in any of the functional outcome measures assessed (P > .05). Overall, there was no significant difference in the total rate of RTP (BT: 76.3%, AR: 85%; P = .53), timing of RTP (BT: 8.8 months, AR: 9.4 months; P = .61), and total rate of RTP among overhead athletes (BT: 84.2%, AR: 83.3%; P > .99). Among those undergoing AR, 9 required a revision procedure (11.5%) compared to none treated with BT (P = .11). CONCLUSIONS: In patients under the age of 30 years with a symptomatic isolated SLAP tear, BT may be a reliable alternative to AR. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Anterior Shoulder Instability Part III-Revision Surgery, Rehabilitation and Return to Play, and Clinical Follow-Up-An International Consensus Statement.

PURPOSE: The purpose of this study was to establish consensus statements via a modified Delphi process on revision surgery, rehabilitation and return to play, and clinical follow-up for anterior shoulder instability. METHODS: A consensus process on the treatment using a modified Delphi technique was conducted, with 65 shoulder surgeons from 14 countries across 5 continents participating. Experts were assigned to one of 9 working groups defined by specific subtopics of interest within anterior shoulder instability. RESULTS: The primary relative indications for revision surgery include symptomatic apprehension or recurrent instability, additional intra-articular pathologies, and symptomatic hardware failure. In revision cases, the differentiating factors that dictate treatment are the degree of glenohumeral bone loss and rotator cuff function/integrity. The minimum amount of time before allowing athletes to return to play is unknown, but other factors should be considered, including restoration of strength, range of motion and proprioception, and resolved pain and apprehension, as these are prognostic factors of reinjury. Additionally, psychological factors should be considered in the rehabilitation process. Patients should be clinically followed up for a minimum of 12 months or until a return to full, premorbid function/activities. Finally, the following factors should be included in anterior shoulder instability-specific, patient-reported outcome measures: function/limitations impact on activities of daily living, return to sport/activity, instability symptoms, confidence in shoulder, and satisfaction. CONCLUSION: Overall, 92% of statements reached unanimous or strong consensus. The statements that reached unanimous consensus were indications and factors affecting decisions for revision surgery, as well as how prior surgeries impact procedure choice. Furthermore, there was unanimous consensus on the role of psychological factors in the return to play, considerations for allowing return to play, as well as prognostic factors. Finally, there was a lack of unanimous consensus on recommended timing and methods for clinical follow-up. LEVEL OF EVIDENCE: Level V, expert opinion.

Anterior Shoulder Instability Part II-Latarjet, Remplissage, and Glenoid Bone-Grafting-An International Consensus Statement.

PURPOSE: The purpose of this study was to establish consensus statements via a modified Delphi process on the Latarjet procedure, remplissage, and glenoid-bone grafting for anterior shoulder instability. METHODS: A consensus process on the treatment utilizing a modified Delphi technique was conducted, with 65 shoulder surgeons from 14 countries across 5 continents participating. Experts were assigned to one of 9 working groups defined by specific subtopics of interest within anterior shoulder instability. RESULTS: The technical approaches identified in the statements on the Latarjet procedure and glenoid bone-graft were that a subscapularis split approach should be utilized, and that it is unclear whether a capsular repair is routinely required. Furthermore, despite similar indications, glenoid bone-grafting may be preferred over the Latarjet in patients with bone-loss greater than can be treated with a coracoid graft, and in cases of surgeon preference, failed prior Latarjet or glenoid bone-grafting procedure, and epilepsy. In contrast, the primary indications for a remplissage procedure was either an off-track or engaging Hill-Sachs lesion without severe glenoid bone loss. Additionally, in contrast to the bone-block procedure, complications following remplissage are rare, and loss of shoulder external rotation can be minimized by performing the tenodesis via the safe-zone and not over medializing the fixation. CONCLUSION: Overall, 89% of statements reached unanimous or strong consensus. The statements that reached unanimous consensus were the prognostic factors that are important to consider in those undergoing a glenoid bone-grafting procedure including age, activity level, Hill-Sachs Lesion, extent of glenoid bone-loss, hyperlaxity, prior surgeries, and arthritic changes. Furthermore, there was unanimous agreement that it is unclear whether a capsular repair is routinely required with a glenoid bone graft, but it may be beneficial in some cases. There was no unanimous agreement on any aspect related to the Latarjet procedure or Remplissage. LEVEL OF EVIDENCE: Level V, expert opinion.

Anterior Shoulder Instability Part I-Diagnosis, Nonoperative Management, and Bankart Repair-An International Consensus Statement.

PURPOSE: The purpose of this study was to establish consensus statements via a modified Delphi process on the diagnosis, nonoperative management, and Bankart repair for anterior shoulder instability. METHODS: A consensus process on the treatment using a modified Delphi technique was conducted, with 65 shoulder surgeons from 14 countries across 5 continents participating. Experts were assigned to one of 9 working groups defined by specific subtopics of interest within anterior shoulder instability. RESULTS: The independent factors identified in the 2 statements that reached unanimous agreement in diagnosis and nonoperative management were age, gender, mechanism of injury, number of instability events, whether reduction was required, occupation, sport/position/level played, collision sport, glenoid or humeral bone-loss, and hyperlaxity. Of the 3 total statements reaching unanimous agreement in Bankart repair, additional factors included overhead sport participation, prior shoulder surgery, patient expectations, and ability to comply with postoperative rehabilitation. Additionally, there was unanimous agreement that complications are rare following Bankart repair and that recurrence rates can be diminished by a well-defined rehabilitation protocol, inferior anchor placement (5-8 mm apart), multiple small-anchor fixation points, treatment of concomitant pathologies, careful capsulolabral debridement/reattachment, and appropriate indications/assessment of risk factors. CONCLUSION: Overall, 77% of statements reached unanimous or strong consensus. The statements that reached unanimous consensus were the aspects of patient history that should be evaluated in those with acute instability, the prognostic factors for nonoperative management, and Bankart repair. Furthermore, there was unanimous consensus on the steps to minimize complications for Bankart repair, and the placement of anchors 5-8 mm apart. Finally, there was no consensus on the optimal position for shoulder immobilization. LEVEL OF EVIDENCE: Level V, expert opinion.

Improved Functional Outcome Scores Associated with Greater Reduction in Cam Height Using the Femoroacetabular Impingement Resection Arc During Hip Arthroscopy.

PURPOSE: We sought to evaluate the association between postoperative cam lesion measured by the femoroacetabular impingement resection (FAIR) arc and show 2-year patient outcomes following hip arthroscopy. METHODS: A retrospective review of prospectively gathered data from 2013-2017 was performed. All patients who underwent hip arthroscopy for femoroacetabular impingement resection (FAI) with ≥2-year follow-up were included. Cam FAIR arc measurements were made preoperatively and postoperatively on a 45° Dunn view radiograph. The clinical effect of postoperative cam maximal radial distance (MRD) was assessed using the modified Harris Hip Score (mHHS) and Non-Arthritic Hip Score (NAHS). Patients were divided into subgroups based on relationship to the mean and standard deviations for cam MRD. One half standard deviation above the mean was found to be 3.15 mm. RESULTS: Sixty-one hips in 59 consecutive patients (age 38.1 ± 13.1; body mass index [BMI]: 25.5 ± 4.3; 36 females) were included. Mean preoperative and postoperative cam maximal radial distances (MRD) were 4.5 ± 1.7 mm and 2.3 ± 1.7 mm (P < .001), respectively. The interclass correlation coefficient was excellent (>.9) for all measurements. There were no differences in age, sex, BMI or preoperative mHHS/NAHS between <3.15 mm and >3.15 mm cam MRD groups (P > .05). Using linear regression, cam MRD was found to be significantly associated with 2-year outcomes for both mHHS (R2 = .21, P < .001) and NAHS (R2 = .004). Subgroup analysis demonstrated that patients in the cam MRD < 3.15 mm group had significantly higher mHHS (89.7 vs 70.0, P < .001) and NAHS scores (90.5 vs 72.9, P < .001) than those in the >3.15 mm group. Additionally, more patients in the <3.15 mm group reached the minimal clinically important difference (95.2% vs 78.9%, P = .048) and were above patient acceptable symptomatic state (95.2% vs 52.6%, P < .001) compared to the >3.15 mm group. CONCLUSION: Patients with a lower postoperative cam MRD relative to the FAIR arc demonstrated significantly improved outcomes as compared to those with higher postoperative MRD at two-year follow-up. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Knotted Versus Knotless Anchors for Labral Repair in the Shoulder: A Systematic Review.

PURPOSE: To compare biomechanical and clinical outcomes between knotless and knotted anchors in arthroscopic labral repair, specifically in (1) Bankart repair, (2) SLAP repair, (3) posterior labral repair, and (4) remplissage augmentation of Bankart repair. METHODS: MEDLINE, EMBASE, and the Cochrane Library were searched according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to find biomechanical and clinical studies comparing knotted and knotless anchors using the search term "knotless anchor." RESULTS: Overall, 17 studies met inclusion criteria. There were 7 studies evaluating the biomechanical outcomes, of which 5 found mixed results between knotted and knotless anchors for arthroscopic Bankart repair, 1 demonstrated a difference for SLAP repair favoring knotless anchors, and 2 showed no significant difference for Remplissage in terms of ultimate load-to-failure. Four studies evaluated knotless labral anchors compared with knotted anchors in patients undergoing arthroscopic Bankart repair with no significant differences in outcomes reported between the 2 anchor types, except in one study that found an improved visual analog scale score and a lower recurrence and revision rate with knotted anchors. Five studies evaluated knotless anchors compared with knotted anchors in patients undergoing SLAP repair, and none of the included studies found any significant differences in the patient reported outcome measures or revision rates. Of the 5 studies comparing operative time, 4 found a reduced time with knotless anchors. CONCLUSIONS: The clinical results show no significant differences in outcomes between knotless and knotted anchors for labral repair in the shoulder, including Bankart repair, SLAP repair, and posterior labral repair. However, there was conflicting evidence supporting knotless or knotted anchors in the biomechanical studies. However, operative times may be reduced with the use of knotless anchors. LEVEL OF EVIDENCE: III, A Systematic Review of Level II and III studies.

No difference in 90-day complication rate following open versus arthroscopic Latarjet procedure.

The purpose of this study was to compare the 90-day complication rate between the open and arthroscopic Latarjet procedure. A retrospective review of patients who underwent an open or arthroscopic Latarjet procedure at NYU Langone Health between 2012 and 2019 was performed. The complications, readmissions, and reoperations within 90 days were assessed. Outcomes were compared between the two approaches, and a p value of < 0.05 was considered to be statistically significant. The study included 150 patients (open: 110; arthroscopic: 40), with no patients lost to follow-up within the first 90 days. Both cohorts were similar in terms of patient demographics. No intra-operative complications were observed in either group. Overall, there were 4 post-operative complications with the open approach and 2 with the arthroscopic approach (3.6% and 5.0%, respectively; n.s.) during the study period. Three patients required a readmission within the 90-day period; one patient in both groups required a revision Latarjet for graft fracture, and one patient in the open Latarjet required irrigation and debridement for deep infection (n.s.). With the open approach, there were 2 (2.3%) wound complications, 1 graft complication, and 1 (1.1%) nerve injury. With the arthroscopic approach, there was 1 (2.8%) wound complication and 1 (2.8%) hardware complication. The safety, and 90-day complication and readmission profile of arthroscopic Latarjet is similar to open Latarjet procedure. LEVEL OF EVIDENCE: Level III.

Short-term complications of the Latarjet procedure: a systematic review.

PURPOSE: The purpose of this study is to evaluate the short-term complication rate following the open and arthroscopic Latarjet procedures and to meta-analyze the studies comparing the 2 approaches. METHODS: PubMed was searched according to Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines to find clinical and biomechanical studies comparing complication rates in open and arthroscopic Latarjet procedures. A literature search of MEDLINE, Embase, and the Cochrane Library was performed based on the PRISMA guidelines. Clinical studies reporting on the complications following the open or arthroscopic Latarjet were included. Meta-analysis was performed for comparative studies using Review Manager, version 5.3. A P value of <.05 was considered statistically significant. RESULTS: Overall, 89 studies (Level of Evidence [LOE] I: 2, LOE II: 2, LOE III: 24, LOE IV: 61) met inclusion criteria, with 7175 shoulders. Following the open Latarjet procedure, the overall complication rate was 6.1%, with a 1.9% occurrence of graft-related complications, 1.1% hardware, 1.1% wound, 0.9% nerve, and 1.2% other complications. Following the arthroscopic Latarjet procedure, the overall complication rate was 6.8%, with a 3.2% occurrence of graft-related complications, 1.9% hardware, 0.5% wound, 0.7% nerve, and 0.5% other complications. Complications were reported in 7 studies comparing 379 patients treated with the open Latarjet and 531 treated with the arthroscopic Latarjet, with no statistically significant difference between the two (P = .81). CONCLUSION: Our study established that the overall complication rate following the Latarjet procedure was 6%-7%, with the most common complication being graft-related. Furthermore, based on the current evidence, there is no significant difference in the complication rate between the open and arthroscopic Latarjet procedures.

Effectiveness of radiographs and computed tomography in evaluating primary elbow osteoarthritis.

BACKGROUND: Preoperative radiographic assessment of osteophyte and loose body locations is critical in planning an arthroscopic débridement for primary elbow osteoarthritis. The purpose of this study was to evaluate the effectiveness of radiographs and computed tomography (CT) in localizing osteophytes and loose bodies. METHODS: A consecutive series of 36 patients with primary elbow osteoarthritis was investigated with radiographs and multiaxial 2-dimensional CT prior to elbow arthroscopy. The location of osteophytes and loose bodies was assessed in 9 anatomic locations by 2 fellowship-trained upper extremity surgeons. The diagnostic effectiveness of both imaging modalities was evaluated by calculating the sensitivity and specificity and compared to the gold standard of elbow arthroscopy. Inter- and intrarater percentage agreement between the observations was calculated using Kappa score. RESULTS: The mean sensitivity for detecting osteophytes in the 9 different anatomic locations was 46% with radiographs and 98% with CT, whereas the mean specificity was 66% and 21% for radiographs and CT, respectively. The mean sensitivity and specificity for loose body detection with radiography were 49% and 89%, respectively, whereas CT had a mean sensitivity of 98% and specificity of 47%. The overall inter-rater percentage agreement between the surgeons in detecting osteophytes and loose bodies on radiographs was 80% and 85%, respectively, whereas on CT it was 95% for detecting osteophytes and 91% for loose bodies. CONCLUSION: CT has greater sensitivity than radiographs for the detection of osteophytes and loose bodies in primary elbow osteoarthritis. The lower specificity of CT may be due to this imaging modality's ability to detect small osteophytes and loose bodies that may not be readily identified during elbow arthroscopy. Radiographs have an inferior inter-rater percentage agreement compared with CT. CT is a valuable preoperative investigation to assist surgeons in identifying the location of osteophytes and loose bodies in patients undergoing surgery for primary elbow osteoarthritis.

Return to play criteria among shoulder surgeons following shoulder stabilization.

PURPOSE: The purpose of this study was to survey the members of North American and European shoulder surgery and sports medicine societies to evaluate their criteria for deciding when an athlete can safely return to play (RTP) following shoulder stabilization surgery. METHODS: A survey was sent to the members of the American Shoulder and Elbow Surgeons (ASES), American Orthopaedic Society for Sports Medicine (AOSSM), European Society for Sports Traumatology, Knee Surgery and Arthroscopy (ESSKA), and European Society for Surgery of the Shoulder and the Elbow (SECEC). Surgeons were asked which criteria they used to determine when an athlete can return to play following the arthroscopic Bankart repair and Latarjet procedures, with additional questions on how time from surgery and participation in collision sports affect return. RESULTS: Overall, 317 surgeons responded to the survey. Following arthroscopic Bankart repair, the most common criteria used were time (98.7%), strength (74.8%), and range of motion (70%). The most commonly reported time point was 4 months (43.8%), and the majority used an additional time period, most commonly 2 months (38.2%), before allowing a collision athlete to return to play (75.4%). Interestingly, the addition of a remplissage procedure did not affect decision making regarding RTP in most cases (92.1%). Following the Latarjet procedure, the most common criteria used were time (98.4%), strength (67.5%), and range of motion (65.9%). Less than half reported using imaging to assess for radiographic union before allowing patients to return to play (47%), and the most common modality was plain radiography (80%). The most common time point was 4 months (33.1%), and the majority reported waiting an additional period of time, most commonly by 2 months (25.9%), before allowing a collision athlete to return to play (59.6%). CONCLUSION: Despite the absence of evidence-based guidelines on when athletes can safely return to play following shoulder stabilization surgery, there exists minimal variability in recommendations between North American and European shoulder surgeons. Further research is required to better define criteria for RTP after the arthroscopic Bankart repair and Latarjet procedures.

A randomized, double-blind sham-controlled trial on the efficacy of arthroscopic tennis elbow release for the management of chronic lateral epicondylitis.

BACKGROUND: Tennis elbow is a common elbow pathology typically affecting middle-aged individuals that can lead to significant disability. Most cases resolve within 2 years of symptom onset, but a subset of patients will develop persistent symptoms despite appropriate conservative management. There are several surgical approaches used to treat chronic tennis elbow, with arthroscopic surgery becoming an increasingly popular approach to address this pathology in North America. This procedure involves the arthroscopic release of the extensor carpi radialis brevis tendon (ECRB) origin at the elbow. The potential benefit of arthroscopic treatment of this condition is improved patient outcomes and shorter recovery time following surgery. The results of this technique have been reported only in the context of case series, which have shown positive results. However, in order to justify its widespread use and growing popularity, a high level of evidence study is required. The purpose of this prospective, randomized sham-controlled trial is to determine whether arthroscopic tennis elbow release is effective at treating chronic lateral epicondylitis. METHODS: We will conduct a prospective single center, double-blind, randomized sham-controlled parallel arm trial evaluating the efficacy of arthroscopic tennis elbow release in adult patients with symptoms for at least 6 months. Patients will undergo intraoperative randomization after diagnostic arthroscopy of the elbow to receive either ECRB release (through the creation of a lateral portal) or a sham lateral portal and no ECRB release. The primary outcome will be the Mayo Elbow Performance Score (MEPS) at 1 year follow-up. Secondary outcomes will be the abbreviated Disability of the Shoulder and Hand (DASH) score, American Shoulder and Elbow Surgeons elbow (ASES-e) score and grip strength at 3, 6, 12 and 24 months as well as return-to-work time, ability to return to full duty and adverse outcomes. DISCUSSION: Results of this study will provide empirical high quality evidence to guide clinical decision-making in patients with chronic tennis elbow. TRIAL REGISTRATION: NCT02236689 (September 8, 2014).

Lateral knee laxity increases the risk of excessive joint line obliquity after medial opening-wedge high tibial osteotomy.

BACKGROUND: Medial opening-wedge high tibial osteotomy (HTO) is a well-recognized treatment for patient with varus knee osteoarthritis. Joint line obliquity has recently been suggested to negatively impact clinical outcomes following HTO, but little is known about what factors lead to increased joint line obliquity. The purpose of the current study was (1) to evaluate whether increased preoperative lateral knee laxity, represented by the joint line convergence angle, results in increased joint line obliquity in a consecutive series of patients treated with HTO and (2) to determine the effect of advanced arthritic changes on joint line obliquity. HYPOTHESIS: Increased joint line convergence angle would be associated with increased joint line obliquity. PATIENTS AND METHODS: All HTOs performed at our center between 2010-2017 were retrospectively reviewed. Patients were excluded if pre- and postoperative standing alignment radiographs were not available. Varus-producing osteotomies were excluded. Patients were subdivided according to their preoperative joint line convergence angle (≤3° or >3°) and the degree of radiographic arthritic change. The primary outcome measure was the postoperative joint line obliquity. Categorical variables were compared using the paired samples t-test. Survival analysis was performed for failure and overall rate of reoperation. RESULTS: During the study period, 90 HTO were performed, and 38 patients (42 knees; M/F: 32/6; mean age: 41.6; mean follow-up: 4.72 years) met the inclusion criteria. The most common surgical indications were varus knee osteoarthritis (n=27, 64.3%) and osteochondritis dissecans (n=7, 8.2%). Patients with a preoperative joint line convergence angle >3° demonstrated significantly greater joint line obliquity postoperatively as compared to those with a joint line convergence angle ≤3° (6.4°±4.6° vs. 2.5°±5.7°, respectively; p=0.02). Patients with advanced arthritic changes had significantly lower preoperative (-3°±3.4° vs. -5.6°±4.1°; p=0.03) and greater postoperative (5.8°±4° vs. 2.2°±6.4°; p=0.04) joint line obliquity as compared to those with minimal arthritic changes. There were 12 complications among the 42 procedures: one conversion to total knee replacement (TKR), one hardware failure (fixation revised), one infection, and 9 hardware removals. Overall survival using conversion to TKR was 96.23% (95% CI 0.92-1.0) at 10 years. DISCUSSION: Lateral knee laxity, as defined by a preoperative joint line convergence angle >3°, and advanced arthritic changes are associated with increased postoperative joint line obliquity following medial opening-wedge high tibial osteotomy. Soft-tissue adaptation should be accounted for in order to avoid excessive joint line obliquity following high tibial osteotomy, and the planned correction should be reduced by 25% in patients with a preoperative joint line convergence angle >3° when templating using standing alignment radiographs. LEVEL OF EVIDENCE: IV.

Return to Play After Non-Operative Management of Primary Anterior Shoulder Instability A Systematic Review.

PURPOSE: The purpose of the current study was to system-atically review the evidence in the literature to ascertain the rate of return to play and subsequent recurrence rates after first-time anterior shoulder instability in athletes. METHODS: A literature search of MEDLINE, EMBASE, and The Cochrane Library was performed based on the PRISMA guidelines. Studies evaluating the outcomes of athletes with primary anterior shoulder dislocation were included. Return to play and subsequent recurrent instability were evaluated. RESULTS: Twenty-two studies with 1,310 patients were included. The mean age of included patients was 30.1 years, 83.1% were male, and the mean follow-up was 68.9 months. Overall, 76.5% were able to return to play, with 51.5% able to return to play at their pre-injury level. The pooled recurrence rate was 54.7%, with best-case and worst-case analysis revealing the recurrence rate to be between 50.7% to 67.7% in those able to return to play. Among collision athletes, 88.1% were able to return to play, with 78.7% experiencing a recurrent instability event. CONCLUSION: The current study demonstrates that non-operative management of athletes with primary anterior shoulder dislocation results in a low rate of success. While the majority of athletes are able to return to play, there is a low rate of return to their pre-injury level of play, and there is a high rate of recurrent instability.

Outcomes Following Medial Patellofemoral Ligament Reconstruction with Allograft A Systematic Review.

PURPOSE: The purpose of this study was to systematically review the evidence in the literature in order to evaluate the outcomes following medial patellofemoral ligament (MPFL) reconstruction with allograft compared to autograft reconstruction. METHODS: A systematic literature search was performed based on PRISMA guidelines using the EMBASE, MEDLINE, and The Cochrane Library databases. Inclusion criteria for the study was clinical studies reporting on MPFL reconstruction with allograft. Recurrence rate, complications, rate of return-to-play, and functional outcomes including the Kujala, Tegner, and visual analog scale (VAS) scores were evaluated. Statistical analysis was performed using GraphPad Prism 8.3. RESULTS: Our review identified 12 studies with a total of 336 patient knees meeting the inclusion criteria. The majority of patients were female (61.6%), with a mean age of 22.3 years and a mean follow-up of 43.4 months. The overall rate of recurrence of lateral patellar instability was 2.7% in the allograft cohort as compared to 7.8% in the autograft cohort (p = 0.01). The mean Kujala score was 91.8%, and the mean VAS score was 1.3 at final follow-up. Additionally, 81.5% of patients were able to return to play in the studies reporting this outcome measure. The overall complication rate was 1.4%. CONCLUSION: The overall rate of recurrence was lower following MPFL reconstruction with allograft as compared to autograft in the treatment of lateral patellar instability. Additionally, there were excellent patient reported outcomes and a low complication rate following the use of allograft for MPFL reconstructionPurpose: The purpose of this study was to systematically review the evidence in the literature in order to evaluate the outcomes following medial patellofemoral ligament (MPFL) reconstruction with allograft compared to autograft reconstruction. METHODS: A systematic literature search was performed based on PRISMA guidelines using the EMBASE, MEDLINE, and The Cochrane Library databases. Inclusion criteria for the study was clinical studies reporting on MPFL reconstruction with allograft. Recurrence rate, complications, rate of return-to-play, and functional outcomes including the Kujala, Tegner, and visual analog scale (VAS) scores were evaluated. Statistical analysis was performed using GraphPad Prism 8.3. RESULTS: Our review identified 12 studies with a total of 336 patient knees meeting the inclusion criteria. The majority of patients were female (61.6%), with a mean age of 22.3 years and a mean follow-up of 43.4 months. The overall rate of recurrence of lateral patellar instability was 2.7% in the allograft cohort as compared to 7.8% in the autograft cohort (p = 0.01). The mean Kujala score was 91.8%, and the mean VAS score was 1.3 at final follow-up. Additionally, 81.5% of patients were able to return to play in the studies reporting this outcome measure. The overall complication rate was 1.4%. CONCLUSION: The overall rate of recurrence was lower following MPFL reconstruction with allograft as compared to autograft in the treatment of lateral patellar instability. Additionally, there were excellent patient reported outcomes and a low complication rate following the use of allograft for MPFL reconstruction.

A modified Delphi consensus statement on patellar instability: part II.

Aims: The aim of this study was to establish consensus statements on medial patellofemoral ligament (MPFL) reconstruction, anteromedialization tibial tubercle osteotomy, trochleoplasty, and rehabilitation and return to sporting activity in patients with patellar instability, using the modified Delphi process. Methods: This was the second part of a study dealing with these aspects of management in these patients. As in part I, a total of 60 surgeons from 11 countries contributed to the development of consensus statements based on their expertise in this area. They were assigned to one of seven working groups defined by subtopics of interest. Consensus was defined as achieving between 80% and 89% agreement, strong consensus was defined as between 90% and 99% agreement, and 100% agreement was considered unanimous. Results: Of 41 questions and statements on patellar instability, none achieved unanimous consensus, 19 achieved strong consensus, 15 achieved consensus, and seven did not achieve consensus. Conclusion: Most statements reached some degree of consensus, without any achieving unanimous consensus. There was no consensus on the use of anchors in MPFL reconstruction, and the order of fixation of the graft (patella first versus femur first). There was also no consensus on the indications for trochleoplasty or its effect on the viability of the cartilage after elevation of the osteochondral flap. There was also no consensus on postoperative immobilization or weightbearing, or whether paediatric patients should avoid an early return to sport.

A modified Delphi consensus statement on patellar instability: part I.

Aims: The aim of this study was to establish consensus statements on the diagnosis, nonoperative management, and indications, if any, for medial patellofemoral complex (MPFC) repair in patients with patellar instability, using the modified Delphi approach. Methods: A total of 60 surgeons from 11 countries were invited to develop consensus statements based on their expertise in this area. They were assigned to one of seven working groups defined by subtopics of interest within patellar instability. Consensus was defined as achieving between 80% and 89% agreement, strong consensus was defined as between 90% and 99% agreement, and 100% agreement was considered to be unanimous. Results: Of 27 questions and statements on patellar instability, three achieved unanimous consensus, 14 achieved strong consensus, five achieved consensus, and five did not achieve consensus. Conclusion: The statements that reached unanimous consensus were that an assessment of physeal status is critical for paediatric patients with patellar instability. There was also unanimous consensus on early mobilization and resistance training following nonoperative management once there is no apprehension. The statements that did not achieve consensus were on the importance of immobilization of the knee, the use of orthobiologics in nonoperative management, the indications for MPFC repair, and whether a vastus medialis oblique advancement should be performed.

Arthroscopic Repair of the "Tibial Avulsion Triad"-ACL Posterolateral Bundle, PCL, and Lateral Meniscus Posterior Root: The Triple Tunnel Technique.

Tibial avulsion fractures of the posterior cruciate ligament (PCL) are rare injuries that can be fixed either via and open or arthroscopic approach to restore native knee biomechanics. The advantage of arthroscopic fixation is the ability to treat concomitant intra-articular pathologies that are otherwise difficult to identify and manage via an open approach, such as medial meniscal root tears and avulsions. This technical note describes an all-arthroscopic technique of treating a rare and previously undescribed injury pattern consisting of PCL tibial and lateral meniscus posterior root bony avulsions and ACL posterolateral bundle tibial peel-off, termed the "tibial avulsion triad".

Development of an In Vitro Swan Neck Deformity Biomechanical Model.

BACKGROUND: Injury to the finger's extensor mechanism is a common cause of swan neck deformity (SND). Progression of extensor and flexor tendon imbalance negatively affects laxity of the volar plate, resulting in the inhibition of proper finger motion. The complexity of finger anatomy, however, makes understanding the pathomechanics of these deformities challenging. Therefore, development of an SND model is imperative to understand its influence on finger biomechanics and to provide an in vitro model to evaluate the various treatment options. METHODS: The index, middle, and ring fingers from 8 cadaveric specimens were used in an in vitro active motion simulator to replicate finger flexion/extension. An SND model was developed through sectioning of the terminal extensor tendon at the distal insertion (creating a mallet finger) and transverse retinacular ligament (TRL). A strain gauge inserted under the volar plate measured laxity of the plate, and electromagnetic trackers recorded proximal interphalangeal joint (PIPJ) angles. RESULTS: Strain in the volar plate increased progressively with creation of the mallet and SND conditions (P = .015). Although not statistically significant, the mallet finger condition accounted for 26% of the increase, whereas sectioning of the TRL accounted for 74% (P = .031). As predicted, PIPJ hyperextension was not detectable by joint angle measurement; however, the PIPJ angle had a strong positive correlation with volar plate strain (R2 = 1.0, P < .001). CONCLUSION: Volar plate strain measurement, in an in vitro model, can detect an induced SND. Moreover, as a surrogate for PIPJ hyperextension, volar plate strain may be useful to evaluate the time-zero effectiveness of various surgical interventions.