Editorial Commentary: Early Clinical Results Are Promising for Meniscus Centralization as an Augment to Medial Meniscus Root Repair.

Meniscal root tears remain a common problem, with devastating biomechanical and clinical consequences. Thankfully, numerous techniques have been developed to repair the symptomatic meniscal root tear. However, rates of conversion to arthroplasty are reported to be 21% to 33% at 10 years, and persistent extrusion of the meniscus at follow-up is a known limitation of current root repair techniques. There is also growing evidence that some medial meniscal root tears may be an effect of meniscal extrusion, rather than the cause of it. In that vein, failure to correct extrusion may be a key mechanism of clinical and radiographic failure despite successful meniscus root repair. Techniques that "centralize" the meniscus (such as centralization with anchors at the tibial rim, meniscotibial ligament repair, deep medial collateral ligament repair, or circumferential suture augmentation of the meniscus) may improve patient outcomes by better correcting meniscal extrusion. Indications could be extrusion greater than 3 mm and documented extrusion before the root tear.

Editorial Commentary: Osteochodral Autograft and Allograft Show Favorable Outcomes for High-Grade Hip Femoral Cartilage Lesions, but Caution Is Required for Impaction Injuries and Osteonecrosis.

Articular cartilage defects of the hip pose therapeutic challenges. Among patients undergoing hip arthroscopy for femoroacetabular impingement syndrome, more than 20% may have partial- or full-thickness chondral damage, and patients with high-grade (International Cartilage Repair Society grade 3 or 4) damage who undergo arthroscopic treatment of femoroacetabular impingement syndrome have higher rates of reoperation at 10-year follow-up. Arthroscopic and open techniques have been developed to translate cartilage restoration options initially developed in the knee for use in the hip. Arthroscopic options include chondroplasty, microfracture, biologic cartilage scaffolds, autologous chondrocyte implantation, and minced cartilage autograft (albeit more commonly in the acetabulum than the femoral head). Open techniques include autologous chondrocyte grafting, osteochondral autograft transfer (including mosaicplasty), osteochondral allograft transplantation, and arthroplasty. Open osteochondral allograft and autograft transplantation show improved patient-reported outcomes and forestall arthroplasty in young patients with high-grade cartilage defects of the femoral head. A recent review shows survivorship of 70% to 87.5% for allograft and 61.5% to 96% for autograft. At the same time, outcomes are not universally positive, particularly for patients with posttraumatic impaction injuries and high-grade osteonecrosis. Until further data better clarify the indications and contraindications, widespread adoption of open cartilage transplantation to the femoral head should be approached with caution, especially for older patients, in whom the gold standard of total hip arthroplasty has excellent survivorship at long-term follow-up.

Editorial Commentary: Meniscal Allograft Transplantation Is Effective for Adolescents With Meniscal Insufficiency, Although Outcomes May Decline Over Time.

Over the last several years, there has been a shift from arthroscopic partial meniscectomy to meniscal repair, especially in the younger patient. In case of a necessary partial meniscectomy, some patients have unremittent symptoms of pain and effusion corresponding to the postmeniscectomy syndrome. In these patients without large coronal malalignment, meniscal allograft transplantation is a valuable option to restore contact pressures, promote a chondroprotective microenvironment, and potentially delay secondary surgical interventions symptoms. In the adolescent population, meniscal allograft transplantation has been shown to effectively improve patient-reported outcomes with a low conversion to arthroplasty. However, these treatments are far from ideal, and prevention is certainly better than the cure: timely diagnosis of meniscus injuries, appropriate treatment with meniscus repair rather than partial meniscectomy, even in the complex tear patterns, and consideration of corrective osteotomy for milder cases of malalignment.

Early Anterior Cruciate Ligament Treatment Might Be Crucial for Acute Combined Anterior Cruciate Ligament and Medial Collateral Ligament Injuries: A Systematic Review of the Various Treatment Strategies.

PURPOSE: To assess the outcomes of acute, combined, complete anterior cruciate ligament (ACL) and medial collateral ligament (MCL) injuries in the literature. METHODS: A literature search using PubMed, Embase, Scopus, and Cochrane Reviews was performed following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. The inclusion criteria were studies reporting outcomes of complete ACL-MCL injuries at a minimum of 12 months' follow-up. Data were presented as ranges. RESULTS: Twenty-seven studies with 821 patients were included (mean age, 29 years; 61% male patients; mean follow-up period, 27 months). There were 4 randomized trials, 10 Level III studies, and 13 Level IV studies. Nine different strategies were noted, of which nonoperative MCL treatment with acute ACL reconstruction and acute MCL repair with acute ACL reconstruction were most commonly performed. Nonoperative MCL-ACL treatment and acute MCL repair with nonoperative ACL treatment led to low rates of valgus stability at 30° of flexion (27%-68% and 36%-77%, respectively) compared with acute ACL reconstruction with either nonoperative MCL treatment (80%-100%), acute MCL repair (65%-100%), or acute MCL reconstruction (81%-100%). Lysholm scores were not different between the strategies. CONCLUSIONS: Outcomes in this systematic review suggest that ACL stabilization in the acute setting might result in the lowest rates of residual valgus laxity, whereas there is no clear difference between the different MCL treatments along with acute ACL reconstruction. Nonoperative MCL treatment with either nonoperative or delayed ACL reconstruction, as well as acute MCL repair with either nonoperative or delayed ACL reconstruction, leads to higher rates of valgus laxity. LEVEL OF EVIDENCE: Level IV, systematic review of Level I to IV studies.

Bioactive and Bioinductive Implants Are Increasingly Used in Orthopaedic Sports Medicine but Adequately Controlled Studies Are Needed: A Scoping Review.

PURPOSE: To describe the currently available literature reporting clinical outcomes for bioactive and bioinductive implants in sports medicine. METHODS: In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic search of 4 databases was completed to identify eligible studies. Inclusion criteria were studies using bioactive or bioinductive implants in human clinical studies for sports medicine procedures. Data were extracted and reported in narrative form, along with study characteristics. RESULTS: In total, 145 studies were included involving 6,043 patients. The majority of included studies were level IV evidence (65.5%), and only 36 included a control group (24.8%). Bioactive materials are defined as any materials that stimulate an advantageous response from the body upon implantation, whereas bioinductive materials provide a favorable environment for a biological response initiated by the host. Bioactivity can speed healing and improve clinical outcome by improving vascularization, osteointegration, osteoinduction, tendon healing, and soft-tissue regeneration or inducing immunosuppression or preventing infection. The most common implants reported were for knee (67.6%, primarily cartilage [most commonly osteochondral defects], anterior cruciate ligament, and meniscus), shoulder (16.6%, primarily rotator cuff), or ankle (11.7%, primarily Achilles repair). The most common type of implant was synthetic (44.1%), followed by autograft (30.3%), xenograft (16.6%), and allograft (9.0%). In total, 69% of implants were standalone treatments and 31% were augmentation. CONCLUSIONS: The existing bioactive and bioinductive implant literature in sports medicine is largely composed of small, low-level-of-evidence studies lacking a control group. CLINICAL RELEVANCE: Before bioactive implants can be adapted as a new standard of care, larger, comparative clinical outcome studies with long-term follow-up are essential.

Knotless Re-tensionable Direct Fixation of Medial Meniscus Posterior Root Tears.

Over the past decade, there has been an increased awareness of the recognition and treatment of medial meniscus posterior root tears. Recent systematic reviews and meta-analyses have shown that surgical repair of medial meniscus posterior root tears is effective in improving patient-reported outcome measures and decreasing the progression of osteoarthritis when compared with nonoperative treatment or meniscectomy. The available techniques currently consist of transosseous suture fixation and direct suture anchor fixation, with transosseous repairs being the most frequently performed. Transosseous fixation relies on indirect fixation on the anterior tibial cortex, which may predispose to gap formation at the repair site. On the other hand, suture anchor fixation is technically demanding with arthroscopic placement of the anchor perpendicular to the tibial plateau at the posterior medial root insertion. Furthermore, re-tensioning of the construct is not possible with the current techniques. In this technical note, we present a knotless re-tensionable direct fixation technique using an anterior tibial tunnel, which has the advantages of direct fixation, a rip-stop suture configuration, a reproducible surgical technique, and the possibility of re-tensioning of the repaired meniscal root.

Arthroscopic suture bridge fixation for acute bony Bankart with anterior glenohumeral instability: a case report and narrative review.

Background and Objective: Anterior shoulder dislocations can result in acute glenoid rim fractures that compromise the bony stability of the glenohumeral joint. Adequate fixation of these fractures is required to restore stability, decrease shoulder pain, and facilitate return to activity. The double-row suture bridge is a relatively novel fixation technique, first described in 2009, that accomplishes internal fixation with sufficient stability using an all-arthroscopic technique to restore the glenoid footprint. A 40-year-old female with recurrent anterior shoulder instability in the setting of seizure disorder was found to have a bony Bankart lesion of 25% to 30% with a concomitant superior labral tear. The patient was treated with a double-row bony Bankart bridge and labral repair. At six months follow-up, she has progressed to a full recovery with no recurrence. Methods: A search was conducted in May 2023 in PubMed, EMBASE, and CINAHL with the search terms bony Bankart, bone Bankart, osseous Bankart, acute, bridge, suture bridge, double row. Key Content and Findings: Double-row suture bridge repairs result in improvement in shoulder function as determined by ASES (93.5), QuickDASH (4.5), SANE (95.9), and SF-12 (55.6). The overall recurrence rate of anterior instability after a bony Bankart bridge repair is 8%. When examining the return to prior level of function, 81.4% of patients were able to do so with only 7.9% of patients reporting significant modifications to their activity level. In mid-term results, double row suture bridge demonstrates similar outcomes to other all-arthroscopic fixation methods of bony Bankart injuries. Importantly, bony Bankart bridge remains a viable option for critical glenoid lesions over the 20% cutoff used in other all arthroscopic techniques. Biomechanically, the double-row suture bridge offers distinct benefits over its single-row counterpart including increased compression, reduced displacement, and reduced step-off. Conclusions: Although there is limited data, the studies discussed and the demonstrative case show the potential benefit of all-arthroscopic double-row suture bridge fixation including increased compression, decreased displacement, and a lower complication rate in patients with large bony Bankart lesions traditionally requiring bony augmentation. However, more robust studies are necessary to determine the long-term success of the double-row suture bridge.

Batter's Shoulder: All-Knotless Posterior Labral Repair With Retensionable Anchors for Treatment of Batter's Shoulder.

Batter's Shoulder is a unique injury that may be associated with recurrent microtrauma followed by acute subluxation of the humeral head on the posterior glenoid edge, leading to posterior labral tears. Early identification of this injury is critical, as it may be treated with conservative nonsurgical treatments prior to labral tear onset. If conservative treatment fails and pain persists, surgical options include arthroscopic fixation to reapproximate the posterior labrum to the glenoid and restore capsular tension. Previous studies have shown the benefit of using knotless suture anchors in arthroscopic shoulder fixation. This technical note demonstrates that Batter's Shoulder is a unique injury associated with posterior labral tears of the shoulder and provides a contemporary method of arthroscopic fixation of a posterior labral tear using retensionable knotless all-suture anchors.

An Expedited Sling Immobilization Protocol After Isolated Biceps Tenodesis Results in Clinical and Patient-Reported Postoperative Outcomes Equivalent to a Standard Rehabilitation Protocol.

Purpose: To characterize clinical and patient-reported outcomes for patients after isolated biceps tenodesis (BT) who underwent either standard or expedited sling immobilization protocols following surgery. Methods: This retrospective cohort study compared patients who were assigned to use a sling for either 4 to 6 weeks (standard) or 0 to 2 weeks (expedited) following an isolated BT. Primary endpoint included rate of re-rupture, surgical revision, loss of fixation, and Popeye deformity. Secondary endpoints included shoulder range of motion (ROM) as well as pre- and postoperative patient-reported outcomes (PROs) of pain and function. Missing data were managed via multiple imputation with chained equations. Complication prevalence 95% confidence intervals were calculated using the Clopper Pearson method and a series of hierarchical mixed effects linear regressions were performed to assess differences between sling interventions in PROs and ROM. Results: The average age of the standard cohort (n = 66) was 49 years (±14 years), and the average age of the expedited cohort (n = 69) was 47 years (±14 years). The expedited and standardized cohorts demonstrated 0.4 and 0.3 complications per 10,000 exposure days, respectively, with no significant difference between groups (1.4 [95% confidence interval 0.2-10.0], P = .727). There was no demonstrated difference in forward flexion, abduction, or external ROM. The expedited group had less improvement in visual analog scale for pain scores that was not clinically significant and there were no differences in PROs of function. Conclusions: No statistically significant difference in the rate of re-rupture, surgical revision, loss of fixation, or Popeye deformity was noted between protocols after isolated BT. Furthermore, there were no clinically significant differences in ROM or PROs identified between protocols after isolated BT. This study suggests that patients who have undergone isolated BT may safely discontinue sling use within 2 weeks after surgery. Level of Evidence: Level III, retrospective comparative study.

Rates and predictors of reimplantation of matrix-induced autologous chondrocyte implantation following first stage cartilage harvest: A cohort study.

PURPOSE: To assess the reimplantation rate and predictors of patients requiring second-staged matrix-induced autologous chondrocyte implantation (MACI) reimplantation after initial first stage cartilage biopsy. METHODS: A retrospective review was performed from 2018 to 2022 among patients who underwent only phase I MACI biopsy procedure (biopsy group) or both phase I with transition to phase II implantation of chondrocytes (implantation group) at a single tertiary center. Demographic, qualitative, and quantitative measurements were recorded, and univariate and multivariate regression analysis was performed to assess predictors of ultimately requiring second stage MACI implantation. RESULTS: A total of 71 patients (51% female, age 27.7 ± 10.6 years (range 12-50)) were included in this study. Eventually, 25 of 71 patients (35.2%) experienced persistence of symptoms after initial MACI biopsy and other concomitant procedures, requiring second-stage implantation. Univariate analysis showed the implantation group compared to the biopsy group had a greater lesion size (5.2 cm2 ± 3.3 vs. 3.3 cm2 ± 1.4, p = 0.024), a higher proportion patients ≥ 26 years of age (76% vs. 43%, p = 0.009), a medial femoral condyle lesion more commonly (33% vs 11%, p = 0.005), were more often female (72% vs. 39%, p = 0.008), and had less often soft tissue repair at time of biopsy (32% vs. 61%, p = 0.020). Backward multivariate logistic regression analysis revealed that size of the lesion (OR 1.43, p = 0.031) and age ≥ 26 years old at time of biopsy (OR 3.55, p = 0.042) were independent predictors of not responding to initial surgery and requiring implantation surgery. CONCLUSION: This study found that 35% of patients undergoing MACI phase I biopsy harvest eventually required autologous implantation. Independent risk factors for progressing to implantation after failed initial surgery were larger defect size and older age. LEVEL OF EVIDENCE: III, Cohort Study.

Previous Knee Surgery, Anteromedial Portal Drilling, Quadriceps Tendon Autograft, and Meniscal Involvement Associated With Delayed Return to Sport After Anterior Cruciate Ligament Reconstruction in Amateur Athletes.

Purpose: To identify prognostic factors associated with a delayed return-to-sport (RTS) time in amateur athletes who return to full participation after a primary isolated anterior cruciate ligament (ACL) reconstruction. Methods: A retrospective review was performed among athletes who underwent ACL reconstruction between October 2014 and October 2021. Inclusion criteria were any amateur athletes with an ACL reconstruction who had a documented RTS and greater than 1-year follow-up. Nonathletes, those with multiligamentous knee injury, and those missing documented RTS timelines were excluded. RTS was defined as participation in athletics at a level equivalent to or greater than the preinjury level participation. Demographic and prognostic factors, including previous knee surgery, meniscal involvement, level of participation, surgical approach, and graft type, were recorded along with RTS time and analyzed via Poisson regression. Results: In total, 91 athletes, average age 18.8 (± 6.7) years, who underwent ACL reconstruction at a single institution from 2014 to 2021 were identified with an average follow-up time of 4.6 (± 2.5) years (range 1.1, 9.0). Meniscal involvement (1.11; 95% confidence interval [CI] 1.08-1.15, P < .001) and previous knee surgery (1.43; 95% CI 1.29-1.58; P < .001) were related to a delayed RTS. Quadriceps tendon and bone-patellar tendon-bone autografts, as well as allograft, showed a significant association with a longer RTS time when compared with hamstring autograft (1.16, 95% CI 1.13-1.20, P < .001; 1.04, 95% CI 1.01-1.07, P = .020; 1.11, 95% CI 1.03-1.19, P = .004, respectively), as did anteromedial portal drilling, when compared with the outside in approach for femoral drilling (1.19, 95% CI 1.16-1.23, P < .001). Conclusions: Previous knee surgery, anteromedial femoral drilling, quadriceps tendon autograft, and meniscus tear were most associated with a delayed timeline for RTS among young athletes who were able to return. Level of Evidence: Level IV, prognostic case series.