Insufficient Evidence for Anterior Cruciate Ligament Reconstruction Utilizing Suture Tape Augmentation: A Systematic Review of Clinical Outcomes at Minimum 1-Year Follow-up.

PURPOSE: To perform a systematic review of clinical studies to directly compare clinical outcomes of patients undergoing anterior cruciate ligament reconstruction (ACLR) with versus without suture tape (ST) augmentation. METHODS: A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify comparative studies directly comparing outcomes of ACLR with versus without ST augmentation with a minimum follow-up of 12 months. The search terms used were anterior cruciate ligament suture tape. Patients were evaluated based on graft failure rates, return to sport (RTS), anteroposterior (AP) laxity, and patient-reported outcomes (PROs). RESULTS: Five studies (all Level III) met inclusion criteria, including a total of 246 patients undergoing ACLR with ST augmentation (SA group) and 282 patients undergoing ACLR without augmentation (control group). Patient age ranged from 14.9 to 29.7 years. The mean follow-up time ranged from 24.0 to 48.6 months. The mean body mass index ranged from 25.3 to 26.3 kg/m2 and the overall percentage of males ranged from 43.4% to 69.0%. Overall, the graft failure rate ranged from 1.0% to 25.0% in the SA group and 8.0% to 20.0% in the control group. Among the studies that reported RTS rates, the rate ranged from 69.2% to 88.9% in the SA group and 51.5% to 87.5% in the control group. Among all PROs, 2 studies found a significant difference in the Tegner score favoring the SA group. Otherwise, no significant differences were found between groups in terms of PROs. No significant differences in AP laxity were found between groups within any particular study. There was heterogeneity between studies regarding surgical techniques, postoperative rehabilitation protocols, and reported PROs. CONCLUSIONS: There is insufficient evidence to suggest that patients undergoing ACLR with ST augmentation may experience favorable clinical outcomes compared with ACLR alone. LEVEL OF EVIDENCE: Level III, systematic review of Level III studies.

Concomitant Tibial Tubercle Osteotomy Reduces the Risk of Revision Surgery After Medial Patellofemoral Ligament Reconstruction for the Treatment of Patellar Instability.

PURPOSE: To compare postoperative complication rates between patients who underwent medial patellofemoral ligament reconstruction (MPFLR) and those who underwent MPFLR with tibial tubercle osteotomy (TTO) in a large-scale study. A secondary goal was to investigate demographic associations with outcomes. METHODS: Patients who underwent MPFLR (n = 3,480) or MPFLR-TTO (n = 615) for patellar instability were identified in the PearlDiver database. Rates of surgery for infection, procedures for knee stiffness, patellar fracture, and revision MPFLR within 2 years postoperatively were compared using multivariable logistic regression. Demographic associations with outcomes were also investigated. RESULTS: The MPFLR-TTO cohort exhibited a significantly lower rate of revision surgery at 2 years (0.8% vs 1.9%; odds ratio [OR], 0.33; 95% confidence interval [CI], 0.10-0.80; P = .036) when compared with the MPFLR group. Independent of index procedure, patients younger than 21 years had significantly lower rates of requiring procedures for knee stiffness (OR, 0.35; 95% CI, 0.22-0.54; P < .001) and any complication at 2 years (OR, 0.59; 95% CI, 0.45-0.78; P < .001) when compared with older patients. Male patients displayed a significantly lower rate of requiring procedures for knee stiffness at 2 years than female patients (OR, 0.46; 95% CI, 0.25-0.78; P = .007). Tobacco use was associated with a significantly higher rate of postoperative infection at 2 years (OR, 2.35; 95% CI, 1.00-5.38; P = .046). CONCLUSIONS: The MPFLR cohort exhibited higher rates of revision surgery at 2 years compared with the MPFLR-TTO cohort. Patient age under 21 years was associated with lower rates of any complication and requiring procedures for knee stiffness, male sex was associated with a lower rate of requiring procedures for knee stiffness, and tobacco use was associated with a higher rate of surgery for postoperative infection. This information can assist surgeons when counseling patients before these procedures are performed. LEVEL OF EVIDENCE: Level III, retrospective, comparative prognostic trial.

Addition of the Sartorius Tendon Improves Biomechanics of a Four-Strand Hamstring Anterior Cruciate Ligament Autograft.

PURPOSE: The purpose of this study was to quantify and compare the biomechanical properties and change in graft size when adding the sartorius tendon as a fifth strand to a four-strand ST-G hamstring autograft. Additionally, the sartorius tendon was tested individually to quantify its independent biomechanical properties. METHODS: Four-strand and five-strand hamstring tendon grafts were harvested from matched cadaveric knees (mean age: 81.6 ± 9.8). These matched grafts were biomechanically tested using a MTS servohydraulic test system at a rate of testing representative of physiologic tears. The mean diameter, cross-sectional area, and ultimate load to failure were quantified and compared with a one-sided, paired Student's t-test. A P < .05 was considered statistically significant. RESULTS: The mean diameter of the five-strand graft was significantly larger than the four-strand graft (9.30 ± .84 mm vs 8.10 ± .42 mm; P = .002). The average ultimate load to failure of the five-strand graft was 65.3% higher than the four-strand graft (2984.05 ± 1085.11 N vs. 1805.03 ± 557.69 N; P = .009) and added 14.8% to the diameter of the four strand ST-G autograft. CONCLUSIONS: The addition of the sartorius tendon to a four-strand hamstring autograft significantly increased ultimate load to failure by 65%, graft cross-sectional area by 32%, and graft diameter by 15% compared to a traditional four-strand ST-G autograft. This information can be helpful to surgeons who wish to improve the strength of a four-strand ST-G autograft and for undersized grafts as an alternative to allograft supplementation. CLINICAL RELEVANCE: The addition of the sartorius to the four-strand ST-G hamstring autograft significantly increases the ultimate load to failure and overall graft diameter, which can be particularly helpful in undersized autografts as an alternative to allograft supplementation.

Mechanical properties of revision ACL reconstruction.

The aim of this study is to evaluate the mechanical properties of a revision anterior cruciate ligament (ACL) reconstruction after redrilling the original tibial bone tunnel through a retained composite screw compared with initial soft tissue graft fixation. A total of 24 porcine tendons were fixed to porcine tibial tunnels with a 10 × 35 mm composite interference screw. Following the pullout test, a revision tunnel was drilled through the first interference screw and a second graft was fixed in the bone tunnel using a larger composite screw (11 × 35 mm). Following insertion of the revision screw, the graft was reloaded as described for the primary reconstruction. Load versus displacement data were recorded for each test. There were no significant differences between the primary and revision reconstruction constructs for yield load (p = 0.62), linear stiffness (p = 0.18), maximum failure load (p = 0.57), and yield displacement (p = 0.46). These results indicate that the mechanical properties of tibial fixation for ACL reconstruction with a composite screw following a revision provide similar fixation compared with initial reconstruction in this model. Revising a failed composite ACL construct by means of overdrilling and reinstrumenting may provide fixation equivalent to the initial reconstruction.

The Addition of a Pericapsular Nerve Group Block for Postoperative Pain Control Does Not Result in Less Narcotic Use After Hip Arthroscopy: A Systematic Review.

Purpose: To perform a systematic review of clinical studies evaluating the pericapsular nerve group (PENG) block in patients undergoing hip arthroscopy. Methods: A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify comparative studies of patients undergoing the PENG block before hip arthroscopy. The search phrase used was hip arthroscopy pericapsular nerve block. Patients were evaluated based on analgesic consumption, time to discharge from the postanesthesia care unit (PACU), and pain scores (Numeric Rating Scale and visual analog scale). The Modified Coleman Methodology Score was used to evaluate study methodology quality. Results: Five studies (2 Level I, 3 Level III) met inclusion criteria. The 5 studies included the following comparison groups: 0.9% normal saline injection, general anesthesia alone, and general anesthesia with intraoperative pericapsular bupivacaine injection. The 2 randomized controlled trials included in this review reported no significant difference between groups regarding opioid consumption. One of these did not find any statistically significant differences in their secondary outcomes either, including patient satisfaction with analgesia, opioid-related adverse events, or persistent opioid use at 1 week. However, the other 3 studies found significantly lower opioid consumption in patients receiving the PENG block versus the control group intraoperatively, in the PACU, and/or postoperatively. Four studies reported significantly lower pain levels in the PENG block group compared with the control groups, measured differently in each study: 24 hours postoperatively, initial pain score in the PACU, mean score in the PACU, and highest score in the PACU. None of the studies found significantly worse outcomes in the PENG block group compared to the comparison group. Conclusions: Systematic review of randomized controlled trials shows that patients undergoing hip arthroscopy who receive a PENG block do not consume fewer opioids for postoperative pain control than patients who do not receive the block. Level of Evidence: Level III, systematic review of Level I-III studies.

Outcomes of arthroscopic and open surgical repair of isolated subscapularis tendon tears.

PURPOSE: Reports of the results of subscapularis repairs make up a very small minority of the published literature on rotator cuff repairs, yet subscapularis tears cause significant pain and dysfunction for patients. The goals of this study were to systematically review the published results after subscapularis repair and to compare arthroscopic versus open techniques when appropriate. METHODS: The Cochrane, PubMed, and Embase databases were reviewed for studies evaluating isolated subscapularis repairs. If a study reported outcomes for both subscapularis and supraspinatus tears, a subgroup analysis of isolated subscapularis tears was necessary for inclusion in this review. Other inclusion criteria included a minimum of 1-year follow-up. RESULTS: We found 3 arthroscopic repair studies and 6 open repair studies that met all inclusion criteria. The mean patient age was 49.2 years, and the mean time from injury to surgical repair was 11.1 months. Constant scores were consistent between groups, with a mean postoperative score of 88.1. Pain scores improved significantly after repair, with a mean of 13.4 (on a scale ranging from 0 to 15, with 15 being no pain) in the arthroscopic repair group and 11.5 in the open repair group. Concomitant procedures were common, with biceps tenodesis being the most common, having been performed in 54.8% of shoulders, followed by biceps tenotomy and biceps recentering. Healing was reported in 90% to 95% of shoulders. CONCLUSIONS: Subscapularis tears can cause significant morbidity and often occur as traumatic injury in a younger population. Pain and function can be restored with repair, with excellent healing rates. The characteristic injury pattern suggested by a review of the literature is 1 where such tears are full thickness yet involve a portion of the tendon in the craniocaudal dimension. Concomitant procedures are common and can affect the results, because biceps tenotomy and tenodesis have been shown to significantly improve pain as well. All studies were Level IV, which introduced selection bias. LEVEL OF EVIDENCE: Level IV, systematic review of Level IV studies.

Local and Systemic Complications of Knee and Hip Arthroscopy: A Matched-Cohort Study.

Background: Surgeons are familiar with the complication rates and risks of knee arthroscopy, but comparative data between hip arthroscopy and knee arthroscopy are lacking. Purpose: To compare complications in knee arthroscopy, the most common arthroscopic procedure, with those in hip arthroscopy. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective matched-cohort study analyzing patients who received a primary hip or knee arthroscopy was performed using the PearlDiver database. A total of 19,735 patients were identified for each cohort. Systemic complications and readmissions were assessed at 3 months postoperatively. Local complications and reoperations were assessed at 6 months, 12 months, and 24 months postoperatively. All categorical variables were compared using chi-square analysis. Results: Hip arthroscopy had significantly higher rates of nerve injury, stiffness, heterotopic ossification, and avascular necrosis (all P < .001) than knee arthroscopy at all observed time periods postoperatively. Hip arthroscopy also had a greater rate of all local joint complications than knee arthroscopy (16.79% vs 11.80%; P < .001). Knee arthroscopy was found to have higher incidences of deep vein thrombosis (0.98% vs 0.66%; P < .001) and myocardial infarction (0.06% vs 0.00%; P < .001) as well as a higher overall systemic complication rate (3.93% vs 3.44%; P = .013). Hip arthroscopy was found to have higher rates of subsequent arthroscopy, arthroplasty, and overall reoperation when compared with knee arthroscopy (11.99% vs 14.99%; P < .001) at all time periods up to 24 months postoperatively. Conclusion: Although the systemic complication rate was higher in knee arthroscopy, local joint complications, reoperation, and total complication rates were higher for hip arthroscopy. Surgeons should be aware of these potential differences to best discuss and mitigate risks with this expanding patient population.

Midterm Safety of Carbon Dioxide Insufflation of the Knee During Arthroscopic Cartilage-Based Procedures.

BACKGROUND: When compared with fluid arthroscopy, carbon dioxide (CO2) insufflation offers an increased scope of view and a more natural-appearing joint cavity, and it eliminates floating debris that may obscure the surgeon's view. Despite the advantages of CO2 insufflation during knee arthroscopy and no reported cases of air emboli, the technique is not widely used because of concerns of hematogenous gas leakage and a lack of case series demonstrating safety. PURPOSE/HYPOTHESIS: To investigate the safety profile of CO2 insufflation during arthroscopic osteochondral allograft transplantation of the knee and report the midterm clinical outcomes using this technique. We hypothesized that patients undergoing CO2 insufflation of the knee joint would have minimal systemic complications, allowing arthroscopic cartilage work in a dry field. STUDY DESIGN: Case series; level of evidence, 4. METHODS: A retrospective chart review was performed of electronic medical records for patients who underwent arthroscopic osteochondral allograft transplantation of the knee with the use of CO2 insufflation. Included were patients aged 18 to 65 years who underwent knee arthroscopy with CO2 insufflation from January 1, 2015, to January 1, 2021, and who had a minimum follow-up of 24 months. All procedures were performed by a single, fellowship-trained and board-certified sports medicine surgeon. The patients' electronic medical records were reviewed in their entirety for relevant demographic and clinical outcomes. RESULTS: We evaluated 27 patients (14 women and 13 men) with a mean age of 38 and a mean follow-up of 39.2 months. CO2 insufflation was used in 100% of cases during the placement of the osteochondral allograft. None of the patients sustained any systemic complications, including signs or symptoms of gas embolism or persistent subcutaneous emphysema. CONCLUSION: The results of this case series suggest CO2 insufflation during knee arthroscopy can be performed safely with minimal systemic complications and provide an alternative environment for treating osteochondral defects requiring a dry field in the knee.

Magnetic resonance angiography for the evaluation of vascular injury in knee dislocations.

Knee dislocations can cause extensive soft tissue disruption including vascular insufficiency to the leg secondary to popliteal artery injury. Physical exam may miss vascular injury and possible late occlusion, but there is controversy regarding use of angiography to evaluate patients after dislocation. Magnetic resonance angiography (MRA) has been shown to be equally effective as angiography in evaluating vascular injury and to have fewer complications than angiography. Patients with knee dislocations routinely receive magnetic resonance imaging (MRI) to assess ligament integrity. The purpose of our study was to determine whether it may be prudent and convenient to obtain an MR angiogram at the same time as an MRI scan, with less morbidity and discomfort than with conventional angiography. Sixteen patients with frank and occult knee dislocations were prospectively evaluated over 2 years. After reduction, a physical exam was performed including ankle brachial index (ABI). With ABI < 0.90, emergent vascular surgery consult and angiogram was performed. Patients with ABI > 0.90 were observed for 3 days with serial physical exams, and MRI/MRA was performed as soon as possible. Sixteen dislocations were identified. Two of 16 (12.5%) had abnormal ABIs and received an angiogram and subsequent revascularization. Two had normal exams, but refused MRA. Twelve had normal exams and received MRI/MRA showing a normal popliteal artery with no adverse events. ABI had 100% sensitivity for vascular injury; however, there remains concern among treating surgeons about missing an occult injury such as an intimal tear. Because MRA has been shown to be as accurate and useful as angiography, we may be able to evaluate ligamentous and vascular injury simultaneously with less morbidity than that with conventional angiography.

Epidemiology, Diagnosis, and Management of Tibial Tubercle Avulsion Fractures in Adolescents.

Although rare, tibial tubercle avulsion fracture must be considered in the differential diagnosis for the pediatric patient presenting with acute knee pain. In the adolescent population, tibial tubercle avulsion fracture is a rare injury that is typically seen in boys who engage in sporting activities that involve jumping or sprinting. The proximal tibial physis closes distally in the posteromedial to anterolateral direction, creating an environment that predisposes the tubercle to a potential avulsion injury. Historically, the Ogden classification has guided nonoperative and operative management of this condition. Multiple fracture fixation methods have been described with the overall goal of restoring the extensor mechanism and the joint surface.

Current Concepts in the Evaluation and Management of Type II Superior Labral Lesions of the Shoulder.

BACKGROUND: Superior labrum tears extending from anterior to posterior (SLAP lesion) are a cause of significant shoulder pain and disability. Management for these lesions is not standardized. There are no clear guidelines for surgical versus non-surgical treatment, and if surgery is pursued there are controversies regarding SLAP repair versus biceps tenotomy/tenodesis. OBJECTIVE: This paper aims to briefly review the anatomy, classification, mechanisms of injury, and diagnosis of SLAP lesions. Additionally, we will describe our treatment protocol for Type II SLAP lesions based on three groups of patients: throwing athletes, non-throwing athletes, and all other Type II SLAP lesions. CONCLUSION: The management of SLAP lesions can be divided into 4 broad categories: (1) nonoperative management that includes scapular exercise, restoration of balanced musculature, and that would be expected to provide symptom relief in 2/3 of all patients; (2) patients with a clear traumatic episode and symptoms of instability that should undergo SLAP repair without (age < 40) or with (age > 40) biceps tenotomy or tenodesis; (3) patients with etiology of overuse without instability symptoms should be managed by biceps tenotomy or tenodesis; and (4) throwing athletes that should be in their own category and preferentially managed with rigorous physical therapy centered on hip, core, and scapular exercise in addition to restoration of shoulder motion and rotator cuff balance. Peel-back SLAP repair, Posterior Inferior Glenohumeral Ligament (PIGHL) release, and treatment of the partial infraspinatus tear with debridement, PRP, or (rarely) repair should be reserved for those who fail this rehabilitation program.

Anterior cruciate ligament tears for the primary care sports physician: what to know on the field and in the office.

Anterior cruciate ligament (ACL) injuries are relatively common and can lead to knee dysfunction. The classic presentation is a non-contact twisting injury with an audible pop and the rapid onset of swelling. Prompt evaluation and diagnosis of ACL injuries are important. Acute treatment consists of cessation of the sporting activity, ice, compression, and elevation with evaluation by a physician familiar with ACL injuries and their management. The diagnosis is made with the use of patient history and physical examination as well as imaging studies. Radiographs may show evidence of a bony injury. MRI confirms the diagnosis and evaluates the knee for concomitant injuries to the cartilage, menisci and other knee ligaments. For active patients, operative treatment is often recommended while less-active patients may not require surgery. The goal of this review is to discuss the diagnosis of an ACL injury and provide clear management strategies for the primary-care sports medicine physician.

Comparison of the cheese-wiring effects among three sutures used in rotator cuff repair.

PURPOSE: The goal of this study was to compare the cheese-wiring effects of three sutures with different coefficients of friction. MATERIALS AND METHODS: Sixteen human cadaveric shoulders were dissected to expose the distal supraspinatus and infraspinatus muscle tendons. Three sutures were stitched through the tendons: #2 Orthocord(™) suture (reference #223114, DePuy Mitek, Inc., Raynham, MA), #2 ETHIBOND* EXCEL Suture, and #2 FiberWire(®) suture (FiberWire(®), Arthrex, Naples, FL). The sutures were pulled by cyclic axial forces from 10 to 70 N at 1 Hz for 1000 cycles through a MTS machine. The cut-through distance on the tendon was measured with a digital caliper. RESULTS: The cut-through distance in the supraspinatus tendons (mean ± standard deviation, n = 12) were 2.9 ± 0.6 mm for #2 Orthocord(™) suture, 3.2 ± 1.2 mm for #2 ETHIBOND* suture, and 4.2 ± 1.7 mm for #2 FiberWire(®) suture. The differences were statistically significant analyzing with analysis of variance (P = 0.047) and two-tailed Student's t-test, which showed significance between Orthocord(™) and FiberWire(®) sutures (P = 0.026), but not significant between Orthocord(™) and ETHIBOND* sutures (P = 0.607) or between ETHIBOND* and FiberWire(®) sutures (P = 0.103). CONCLUSION: The cheese-wiring effect is less in the Orthocord(™) suture than in the FiberWire(®) suture in human cadaveric supraspinatus tendons. CLINICAL RELEVANCE: Identification of sutures that cause high levels of tendon cheese-wiring after rotator cuff repair can lead to better suture selection.

Recognizing and managing complications in ACL reconstruction.

The number of anterior cruciate ligament reconstruction is increasing. Avoiding complications in anterior cruciate ligament reconstruction requires attention to surgical details. Errors during graft harvest, tunnel drilling, graft placement, graft fixation, or the presence of unrecognized pathology can lead to poor outcome. Postoperatively attention must be paid to range of motion, progress with physical therapy, and functional return to activity. Prompt recognition of complications is essential to minimize adverse patient outcomes.

Paget-schroetter syndrome: a review of effort thrombosis of the upper extremity from a sports medicine perspective.

Paget-Schroetter is a rare diagnosis in the general population; however, it is more common in younger, physically active individuals. Clinicians must be familiar with the symptoms, physical examination, and initial imaging and treatment to expedite care and prevent possible life-threatening complications. Urgent referral to a regional specialist may improve the opportunity for thrombolysis to restore blood flow through the subclavian vein and to decrease the chance of pulmonary embolus, recurrent thrombosis, or need for vein grafting, as well as to improve the time to return to full activity (athletics and/or manual labor).

The mechanical axes of the wrist are oriented obliquely to the anatomical axes.

BACKGROUND: the complex motions of the wrist are described in terms of four anatomical directions that are accomplished through the multiple articulations of the carpus. With minimal tendinous insertions, the carpus is primarily a passive structure. This emphasizes the importance of its mechanical properties, which few studies have examined to date. The purpose of the present study was to determine the mechanical properties of the wrist in twenty-four different directions of wrist motion. METHODS: the moment-rotation mechanical behavior of six fresh-frozen cadaver wrists was determined in four directions: flexion, extension, ulnar deviation, and radial deviation. Twenty other directions that were a combination of these anatomical directions were also studied. A custom-designed jig was interfaced with a standard materials testing system to apply unconstrained moments. Moments of ± 2 Nm were applied, and the moment-rotation data were recorded and analyzed to determine the neutral zone, range of motion, and stiffness values as well as the orientation of the envelope of these values. RESULTS: the envelope of wrist range-of-motion values was ellipsoidal in shape and was oriented obliquely (p < 0.001) to the direction of pure flexion-extension by a mean (and standard deviation) of 26.6° ± 4.4°. The largest wrist range of motion was a mean of 111.5° ± 10.2°, in the direction of ulnar flexion, 30° from pure flexion. The largest stiffness (mean, 0.4 Nm/deg) was in the direction of radial flexion, while the smallest stiffness (mean, 0.15 Nm/deg) was in the direction of ulnar flexion. CONCLUSIONS: the mechanical axes of the wrist are oriented obliquely to the anatomical axes. The primary mechanical direction is one of radial extension and ulnar flexion, a direction along a path of the dart thrower's wrist motion. CLINICAL RELEVANCE: understanding the mechanical function of the wrist can aid clinical treatment decisions, arthroplasty, and implant designs. The findings of this study provide new evidence that the mechanical axes of the wrist are not collinear with the anatomical axes.