Editorial Commentary: Subacromial Balloon Spacer Is an Alternative to Rotator Cuff Repair in Older, Lower-Demand Patients Who Prioritize Pain Relief and Faster Recovery Over Strength Restoration.

The subacromial balloon spacer was originally designed to treat massive irreparable rotator cuff tears in patients with pain but preserved function, and favorable results have been reported. However, surgeons have expanded its application to include use as an adjunct for salvage procedures such as superior capsular reconstruction and tendon transfer, as a delivery device for steroids or biologics, and as an augmentation in the setting of primary or revision rotator cuff tear. When adapting technology to new techniques, one must ask, What is the basis by which we can expect success? In rotator cuff repair, the technology of anchor, suture, and repair configurations is such that mechanical failure is rare. Failure occurs because of lack of biological healing. It is hard to imagine how the balloon may improve biology. In addition, an intact tendon is not required for acceptable patient function or pain relief. The balloon spacer is an alternative to repair in properly selected older, lower-demand patients who prioritize pain relief over strength restoration in exchange for faster recovery.

Editorial Commentary: Arthroscopic Subacromial Balloon Spacer for Massive Rotator Cuff Tears Results in Fast Recovery and Lasting Pain Relief.

Repair of rotator cuff tear is challenging because poor biologic factors can negatively impact tendon healing and risk complications. Sometimes, instead of attempting complex procedures with a guarded prognosis to reconstruct or replace rotator cuff like tissue, less is more. Minimally invasive, arthroscopic subacromial balloon spacer (SBS) for massive rotator cuff tears, demonstrates excellent long-term outcomes. Radiographically, SBS outcomes may be concerning, but clinically, patients do well. If pain is the primary complaint and function is maintained, the balloon spacer is an excellent option with a fast recovery. However, if function is deficient, or if the patient prioritizes strength recovery as their primary desired outcome, then more invasive procedures are often indicated.

Editorial Commentary: Subacromial Balloon Spacer for Management of Massive Irreparable Posterosuperior Rotator Cuff Tears Improves Shoulder Range of Motion and Patient-Reported Outcome Measures.

Considerable controversy exists regarding the management of massive posterosuperior rotator cuff tears. This conversation has been invigorated further by the emergence of the subacromial balloon spacer for management of patients with tear patterns deemed irreparable. Most data lend support to the balloon spacer improving shoulder range of motion and patient-reported outcome measures, with a simplified technique and accelerated patient recovery. Biomechanical data support both decreased contact pressure in the subacromial space and humeral re-centering. Patient indications are increasingly being defined and include lower-demand patients who prioritize pain relief over strength recovery and have maintained active elevation, absence of glenohumeral arthritis, and an intact subscapularis. The subacromial balloon spacer has shown largely positive results at mid-term follow-up. Further data are still needed to determine long-term outcomes and the impact on future revision surgery or conversion to reverse arthroplasty, as well as expanded indications such as large tears that are mechanically repairable but carry a substantial risk of failure of healing. For now, so far, so good.

Balloon Spacer Implant Is an "Intermediate Value" Innovation Relative to Partial Repair for Full-Thickness Massive Rotator Cuff Repairs: A Cost-Utility Analysis.

PURPOSE: To evaluate the cost-utility of a balloon spacer implant relative to partial repair (PR) for the surgical treatment of full-thickness massive rotator cuff tears (MRCTs). METHODS: A decision-analytic model comparing balloon spacer with PR was developed using data from a prospective, randomized, single-blinded, multicenter-controlled trial of 184 randomized patients. Our model was constructed on the basis of the various event pathways a patient could have after the procedure. The probability that each patient progressed to a given outcome and the quality-adjusted life years (QALY) associated with each outcome were derived from the clinical trial data. Incremental cost utility ratio (ICUR) and incremental net monetary benefit were calculated on the basis of a probabilistic sensitivity analysis using Monte Carlo simulations of 1,000 hypothetical patients progressing through the decision-analytic model. One-way sensitivity and threshold analyses were performed by varying cost, event probability, and QALY estimates. RESULTS: The balloon spacer had an ICUR of $106,851 (95% confidence interval $96,317-$119,143) relative to PR for surgical treatment of MRCT. Across all patients, the balloon spacer was associated with greater 2-year QALY gain compared with PR (0.20 ± 0.02 for balloon spacer vs 0.18 ± 0.02 for PR), but with substantially greater total 2-year cost ($9,701 ± $939 for balloon spacer vs $6,315 ± $627 for PR). PR was associated with a positive incremental net monetary benefit of $1,802 (95% confidence interval $1,653-$1,951) over balloon spacer at the $50,000/QALY willingness-to-pay threshold. CONCLUSIONS: Compared with PR, the balloon spacer is an "intermediate-value" innovation for treatment of MRCT over a 2-year postoperative period with an ICUR value that falls within the $50,000 to $150,000 willingness-to-pay threshold. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Blood Flow Restriction Enhances Recovery After Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

PURPOSE: To conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) evaluating neuromuscular and clinical outcomes of blood flow restriction (BFR) training after anterior cruciate ligament reconstruction (ACLR) compared with non-BFR rehabilitation protocols. METHODS: A systematic review was performed in accordance with the 2020 Preferred Reporting Items for Systematic reviews and Meta Analyses guidelines by querying PubMed, MEDLINE, Scopus, the Cochrane Database for Systematic Review, and the Cochrane Central Register for Controlled Trials databases from inception through December 2023 to identify Level I and II RCTs evaluating outcomes of BFR training after ACLR compared with non-BFR rehabilitation. A meta-analysis was performed using random-effects models with standardized mean difference (SMD) for pain, muscle strength, and muscle volume, whereas mean difference was calculated for patient-reported outcome measures. RESULTS: Eight RCTs, consisting of 245 patients, met inclusion criteria, with 115 patients undergoing non-BFR rehabilitation compared with 130 patients undergoing BFR after ACLR. Mean patient age was 27.2 ± 6.7 years, with most patients being male (63.3%, n = 138/218). The length of the BFR rehabilitation protocol was most commonly between 8 and 12 weeks (range, 14 days to 16 weeks). Most studies set the limb/arterial occlusion pressure in the BFR group at 80%. When compared with non-BFR rehabilitation, BFR resulted in significant improvement in isokinetic muscle strength (SMD: 0.77, P = .02, I2: 58%), International Knee Documentation Committee score (mean difference: 10.97, P ≤ .00001, I2: 77%), and pain (SMD: 1.52, P = .04, I2: 87%), but not quadriceps muscle volume (SMD: 0.28, P = .43, I2: 76%). CONCLUSIONS: The use of BFR after ACLR led to improvements in pain, International Knee Documentation Committee score, and isokinetic muscle strength, with variable outcomes on the basis of quadriceps strength, volume, and thickness when compared with non-BFR rehabilitation. LEVEL OF EVIDENCE: Level II, systematic review and meta-analysis of Level I and II studies.

Inlay Scaffold Augmentation of Rotator Cuff Repairs Enhances Histologic Resemblance to Native Enthesis in Animal Studies: A Systematic Review.

PURPOSE: To investigate the outcomes of inlay positioned scaffolds for rotator cuff healing and regeneration of the native enthesis after augmentation of rotator cuff tendon repairs in preclinical studies. METHODS: A literature search was performed using the PubMed, Embase, and Cumulative Index to Nursing and Allied Health Literature databases according to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Preclinical studies reporting on outcomes after inlay tendon augmentation in rotator cuff repair were included. Preclinical study quality was assessed using an adapted version of the Gold Standard Publication Checklist for animal studies. The level of evidence was defined based on the inclusion of clinical analyses (grade A), biomechanical analyses (grade B), biochemical analyses (grade C), semiquantitative analyses (grade D), and qualitative histologic analyses (grade E). RESULTS: Thirteen preclinical studies met the inclusion criteria. Quality assessment scores ranged from 4 to 8 points, and level-of-evidence grades ranged from B to E. Sheep/ewes were the main animal rotator cuff tear model used (n = 7). Demineralized bone matrix or demineralized cortical bone was the most commonly investigated scaffold (n = 6). Most of the preclinical evidence (n = 10) showed qualitative or quantitative differences regarding histologic, biomechanical, and biochemical outcomes in favor of interpositional scaffold augmentation of cuff repairs in comparison to controls. CONCLUSIONS: Inlay scaffold positioning in preclinical studies has been shown to enhance the healing biology of the enthesis while providing histologic similarities to its native 4-zone configuration. CLINICAL RELEVANCE: Although onlay positioned grafts and scaffolds have shown mixed results in preclinical and early clinical studies, inlay scaffolds may provide enhanced healing and structural support in comparison owing to the ability to integrate with the bone-tendon interface.

Fatty Infiltration, Tear Size, and Retraction Size Are Significant Risk Factors for Retear After Arthroscopic Rotator Cuff Repair: A Systematic Review.

PURPOSE: To assess the consistency and quality of risk factor reporting for rotator cuff repair (RCR) retear and identify risk factors most frequently associated with retear. METHODS: A systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Of the initial 3,158 studies, a total of 31 met the following inclusion criteria: (1) clinical studies regarding RCR failure, (2) arthroscopic procedures involving RCR, (3) reporting of clinical outcomes, (4) publication within the past 5 years, and (5) studies investigating preoperative risk factors for retear. After full-text review, 18 risk factors were analyzed. RESULTS: The most consistently significant risk factors were acromiohumeral distance (80%), critical shoulder angle (67%), tear size (63%), anterior-posterior dimension (60%), fatty infiltration (FI) (58%), and retraction size (56%). FI was analyzed using different methods among studies, with 63% finding significant results and 50% of all studies performing ordinal analysis. Tear size was inconsistently analyzed quantitatively or qualitatively, with 58% of studies finding significant results and 63% of all studies performing quantitative analysis. Risk factors consistently found to be nonsignificant included age, sex, diabetes mellitus, symptom duration, hand dominance, repair technique, smoking, and body mass index. CONCLUSIONS: Tear size, FI, and retraction size were found to be significant risk factors in most of the included studies evaluating rotator cuff retear. Risk factors less likely reported as predictive included repair technique, age, sex, diabetes mellitus, symptom duration, hand dominance, repair technique, smoking, and body mass index. Risk factors that require further investigation include critical shoulder angle, acromiohumeral distance, and anterior-posterior tear dimension. LEVEL OF EVIDENCE: Level III, systematic review of Level III-IV studies.

Preoperative Depression Negatively Impacts Pain and Functionality Outcomes After Anterior Cruciate Ligament Reconstruction: A Systematic Review.

PURPOSE: To systematically investigate the influence of preoperative depression diagnosis and symptom severity on outcomes after anterior cruciate ligament reconstruction (ACLR). METHODS: A literature search was performed using the PubMed, Scopus, and Embase databases according to the 2020 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. Studies evaluating the impact of depression on clinical outcomes after ACLR were included. Clinical outcomes, changes in depression, and complications were aggregated. RESULTS: Nine studies comprising 308,531 patients (mean age, 28.1 years; age range, 14-50 years) were included. The depression incidence ranged from 3.8% to 42%. Seven studies showed postoperative improvement in depression scores, with 5 reporting statistical significance. Assessment of depression exhibited substantial variability, with Patient-Reported Outcomes Measurement Information System (PROMIS) scores being the most common method. Patients with depression, despite showing greater improvements in scores, experienced significantly higher PROMIS Pain Interference scores preoperatively (range, 59.1-65.7 vs 56.8-59.2) and postoperatively (range, 46.3-52.3 vs 46.3-47.4) than patients without depression. They also showed significantly lower preoperative (range, 33-38.1 vs 39.7-41.5) and postoperative (range, 51.6-56.7 vs 56.7-57.6) PROMIS Physical Function scores, regardless of greater score improvement. Patients affected by depression had significantly higher rates of minimal clinically important difference achievement for the PROMIS Physical Function score (71%-100% vs 80%) and similar rates for the PROMIS Pain Interference score (71%-81% vs 68%) compared with patients without depression in 3 studies. Depression was associated with reduced adherence to rehabilitation protocols and increased postoperative complications, including infection, graft failure, arthrofibrosis, and readmission. CONCLUSIONS: ACLR yields favorable outcomes for patients with and without preoperative depression. Individuals with preoperative depression may report inferior outcomes in terms of pain and functionality; nevertheless, despite these challenges, they exhibit significant improvements across all outcome measures after surgery, including reductions in depression levels. LEVEL OF EVIDENCE: Level IV, systematic review of Level II to IV studies.

Lower Range of Recurrent Instability Rates Following Bankart Repair and Remplissage Compared to Isolated Bankart Repair in Patients With "Nonengaging/On-Track" Hill-Sachs Lesions and <20% Glenoid Bone Loss.

PURPOSE: To compare recurrent instability and return-to-sport rates along with external rotation differences between on-track (nonengaging) Hill-Sachs lesion patients undergoing either an isolated Bankart repair (IBR) or a Bankart repair augmented with a remplissage procedure (B+R). METHODS: A search was conducted using 3 databases (PubMed, EMBASE, CINAHL) in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Only clinical comparative (level of evidence I-III) studies were considered for inclusion. Quality assessment was performed using the Methodological Index for Non-Randomized Studies criteria. RESULTS: Six level of evidence III studies, totaling 537 patients (202 B+R and 335 IBR) were included for analysis. All patients had <20% glenoid bone loss and a nonengaging, on-track Hill-Sachs lesion. At a median final follow-up of 34.7 months, recurrent dislocation rates ranged from 0% to 7.7% and 3.5% to 30% in the B+R and IBR groups, respectively. Moreover, subjective instability and revision surgery rates presented lower ranges in the B+R upon comparison with the IBR cohort (0%-32% vs 5%-71.4% and 0%-5% vs 0%-35%, respectively). Furthermore, return to preinjury level of sports ranged from 64% to 100% in the remplissage-augmented group and 50% to 90% in the IBR cohort. Postoperative external rotation at side varied from 50° to 63° in the B+R and 55° to 63° in the IBR arm. Additional subgroup analysis revealed recurrent dislocation rates in athletes and patients with near-track Hill-Sachs lesions undergoing remplissage augmentation to be 0% to 5% and 2% to 47% while ranging from 8.8% to 30% and 9% to 66% for IBR patients, respectively. CONCLUSIONS: Upon qualitative analysis, ranges of recurrent instability measures, including recurrent dislocation rates, are higher in patients undergoing IBR in comparison to B+R. Activity level influences outcomes as athletes were found to have a higher range of recurrent dislocation rates in the IBR group. The addition of remplissage showed a higher range of return-to-sport rates with comparable postoperative external rotation between groups. LEVEL OF EVIDENCE: Level III, systematic review of Level III studies.

Isolated Primary Latarjet Procedures for Anterior Shoulder Instability Results in High Rates of Graft Resorption and Glenohumeral Degenerative Changes With Low Rates of Failure at a Minimum 2-Year Follow-Up: A Systematic Review.

PURPOSE: To evaluate the incidence of postoperative complications after an isolated primary Latarjet procedure for anterior shoulder instability at a minimum 2-year follow-up. METHODS: A systematic review was performed in accordance with 2020 PRISMA guidelines. EMBASE, Scopus, and PubMed databases were queried from database inception through September 2022. The literature search was limited to human clinical studies reporting on postoperative complications and adverse events after a primary Latarjet procedure with a minimum 2-year follow-up. Risk of bias was measured using the Newcastle-Ottawa Scale. RESULTS: Twenty-two studies, consisting of 1,797 patients (n = 1,816 shoulders), with a mean age of 24 years were identified. The overall postoperative complication rate ranged from 0% to 25.7%, with the most common complication being persistent shoulder pain (range: 0%-25.7%). Radiological changes included graft resorption (range: 7.5%-100%) and glenohumeral degenerative changes (range: 0%-52.5%). Recurrent instability following surgery was documented in 0% to 35% of shoulders, while the incidence of bone block fractures ranged from 0% to 6% of cases. Postoperative nonunion, infection, and hematomas had a reported incidence rate ranging from 0% to 16.7%, 0% to 2.6%, and 0% to 4.4%, respectively. Overall, 0% to 7.5% of surgeries were reported failures, and 0% to 11.1% of shoulders required reoperation, with a revision rate ranging from 0% to 7.7%. CONCLUSIONS: The incidence of complications following the primary Latarjet procedure for shoulder instability was variable, ranging from 0% to 25.7%. High rates of graft resorption, degenerative changes, and nonunion were present while failure and revision rates remained low at a minimum 2-year follow-up. LEVEL OF EVIDENCE: Level III, systematic review of Level I-III studies.

Platelet-Rich Plasma, Bone Marrow Aspirate Concentrate, and Hyaluronic Acid Injections Outperform Corticosteroids in Pain and Function Scores at a Minimum of 6 Months as Intra-Articular Injections for Knee Osteoarthritis: A Systematic Review and Network Meta-analysis.

PURPOSE: To compare the efficacy of common intra-articular injections used in the treatment of knee osteoarthritis, including corticosteroid (CS), hyaluronic acid (HA), platelet-rich plasma (PRP), and bone marrow aspirate concentrate (BMAC), with a minimum follow-up of 6-months. METHODS: A literature search was conducted using the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines in August 2022 in the following databases: PubMed/MEDLINE, Scopus, Cochrane Database of Controlled Trials, and the Cochrane Database of Systematic Reviews. Level I to II randomized clinical trials with a minimum follow-up of 6 months that investigated the treatments of interest were included. Patient-reported outcome scores for pain and function at baseline and at latest follow-up were extracted, and the change in scores was converted to uniform 0 to 100 scales. Arm-based Bayesian network meta-analysis using a random-effects model was created to compare the treatment arms in pain and function. RESULTS: Forty-eight studies comprising a total of 9,338 knees were included. The most studied intra-articular injection was HA (40.9%), followed by placebo (26.2%), PRP (21.5%), CS (8.8%), and then BMAC (2.5%). HA and PRP both led to a significant improvement in pain compared with placebo. HA, PRP, and BMAC all led to a significant improvement in function scores when compared with placebo. Surface under the cumulative ranking curves (SUCRAs) of the interventions revealed that PRP, BMAC, and HA were the treatments with the highest likelihood of improvement in both pain and function, with overall SUCRA scores of 91.54, 76.46, and 53.12, respectively. The overall SUCRA scores for CS and placebo were 15.18 and 13.70, respectively. CONCLUSIONS: At a minimum 6-month follow-up, PRP demonstrated significantly improved pain and function for patients with knee osteoarthritis compared with placebo. Additionally, PRP exhibited the highest SUCRA values for these outcomes when compared with BMAC, HA, and CS. LEVEL OF EVIDENCE: Level II, meta-analysis of Level I to II studies.

Greater Postoperative Biceps Tendon Migration After Arthroscopic Suprapectoral or Open Subpectoral Biceps Tenodesis Correlates With Lower Patient-Reported Outcome Scores.

PURPOSE: To assess the relation between tendon migration, as measured by radiostereometric analysis, and patient-reported outcome measures (PROMs) after biceps tenodesis (BT); to determine the likelihood of achieving clinically significant outcomes (CSOs) after BT; and to identify factors that impact CSO achievement. METHODS: Patients undergoing arthroscopic suprapectoral or open subpectoral BT at a single, high-volume academic medical center were prospectively enrolled. A tantalum bead sutured to the tenodesis construct was used as a radiopaque marker. Biceps tendon migration was measured on calibrated radiographs at 12 weeks postoperatively. PROMs (Constant-Murley, Single Assessment Numeric Evaluation [SANE], and Patient-Reported Outcomes Measurement Information System-Upper Extremity [PROMIS-UE] scores) were collected preoperatively and at minimum 2-year follow-up. RESULTS: Of 115 patients enrolled, 94 (82%) were included (median age, 52 years; median body mass index, 31.4). At a mean follow-up of 2.9 years, the median Constant-Murley, SANE, and PROMIS-UE scores were 33 (interquartile range [IQR], 26-35), 90 (IQR, 80-99), and 47 (IQR, 42-58), respectively. Median tantalum bead migration was 6.5 mm (IQR, 1.8-13.8 mm). There were significant correlations between migration and Constant-Murley score (r2 = 0.222; ß = -0.554 [95% confidence interval (CI), -1.027 to -0.081]; P = .022), SANE score (r2 = 0.238; ß = -0.198 [95% CI, -0.337 to -0.058]; P = .006), and PROMIS-UE score (r2 = 0.233; ß = -0.406 [95% CI, -0.707 to -0.104]; P = .009). On univariable analysis, higher body mass index was associated with achievement of substantial clinical benefit (unadjusted odds ratio [OR], 1.078 [95% CI, 1.007 to 1.161]; P = .038). Greater bead migration was negatively associated with achievement of the minimal clinically important difference (unadjusted OR, 0.969 [95% CI, 0.943 to 0.993]; P = .014) and patient acceptable symptomatic state (unadjusted OR, 0.965 [95% CI, 0.937 to 0.989]; P = .008) on all 3 instruments. CONCLUSIONS: A 1-cm increase in post-tenodesis biceps tendon migration was associated with a decrease in the Constant-Murley, SANE, and PROMIS-UE scores of 6, 2, and 4 points, respectively, at a mean of 2.9 years after surgery. Most patients achieved CSOs for these PROMs by latest follow-up, and greater biceps tendon construct migration was negatively associated with the likelihood of CSO achievement. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Geniculate Artery Embolization for the Treatment of Mild to Moderate Knee Osteoarthritis Improves Pain and Function: A Systematic Review.

PURPOSE: To evaluate procedural heterogeneity, patient reported outcomes (PRO), and complications following geniculate artery embolization (GAE) for knee OA. METHODS: A literature search was performed using PubMed, Embase, and Scopus databases from inception to August 2023 according to the 2020 PRISMA guidelines. Human clinical studies reporting PROs following GAE for treatment of knee OA were included and a qualitative comparison across PROs, procedural descriptions and complications was performed. Study quality was assessed using the Cochrane Collaboration's risk of bias tool and the MINORS criteria. The primary outcome measures included changes in PROs at 12 months and variances in procedural methodology. RESULTS: A total of 17 studies, consisting of 533 patients and 620 knees were identified. The reported mean improvement at 12 months for VAS pain and WOMAC scores ranged from 10-59 and 35.3-47, respectively. At 12 months, median improvements were observed in KOOS subscales such as Pain (range, 8.3-19.5), QOL (15.49-25.0), Sport (7.5-26.3) and Symptoms (1.8-25.0). Decreasing MCID achievement was observed between the 3 month and 6 month follow-up points. Patients with advanced OA and degenerative findings on MRI exhibited lower rates of MCID achievement. Transient adverse events occurred in up to 80% of patients. Limited evidence from serial MRI assessments suggests that GAE improves levels of synovitis. Significant heterogeneity exists among the GAE methodology as 4 different definitions of technical success, 4 distinct embolization targets and use of 5 embolization agents were noted. CONCLUSION: GAE results in short-term improvements in pain and function with decreasing MCID achievement observed after 3 to 6 months. Patients with severe OA also demonstrate lower rates of MCID achievement. A high rate of transient complications are reported including skin discoloration and access site hematomas. Significant protocol heterogeneity exists which contributes to variable outcomes. LEVEL OF EVIDENCE: IV; Systematic Review of Level IV Studies.

ACL Reconstruction in Patients Over Fifty Years of Age Results in Improvements in Functional Outcomes and Broad Complication Rates: A Systematic Review.

PURPOSE: To assess the patient-reported outcomes measures (PROMs), functional knee measures, and incidence of complications in patients aged 50 and older undergoing anterior cruciate ligament reconstruction (ACLR). METHODS: A literature search was conducted across PubMed, Embase, and Scopus databases, spanning from their inception to November 2023, in accordance with the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Inclusion criteria consisted of clinical studies reporting PROMs, measures of knee stability, and complication rates, following ACLR in patients aged ≥ 50 with minimum 2 year follow-up. The Methodological Index for Non-Randomized Studies (MINORS) criteria was used to assess study quality. Primary outcome measures consisted of changes PROMs and complication rates following ACLR. RESULTS: A total of 17 studies, consisting of 1,163 patients undergoing ACLR were identified. Autografts were utilized in 90.3% of patients, compared to 9.7% of patients treated using allografts. At minimum 24-month follow-up, the mean International Knee Documentation Score (IKDC) ranged from 67.4 to 92.96, while mean Lysholm scores ranged from 84.4 to 94.8, and mean Tegner scores ranged from 0.3 to 5.4. The mean side to side difference at final follow-up ranged from 1.2 to 2.4mm while the rates of recurrent instability ranged from 0 to 18%. Complications and revisions ranged from 0% to 40.4% and 0% to 37.5% of cases, with the highest rates observed in studies noting a high incidence of intraoperative cartilage lesions. CONCLUSION: Anterior cruciate ligament reconstruction in patients above the age of 50 results in favorable IKDC, Lysholm and Tegner activity scores and improvements in functional knee measures. However, a wide range of reoperation and complications are reported, attributed to varying levels of chondral injury and osteoarthritis which warrant consideration when discussing expectations in patients 50 and above undergoing ACLR. LEVEL OF EVIDENCE: IV, Systematic Review of Level II-IV studies.

Anterior Cruciate Ligament Repair Results in Similar Patient Reported Outcome Measures as Anterior Cruciate Ligament Reconstruction: A Systematic Review of Prospective Comparative Studies.

PURPOSE: To investigate the patient-reported outcomes (PROs), knee stability, and complications in prospective comparative studies of patients undergoing augmented anterior cruciate ligament (ACL) repair compared to ACL reconstruction (ACLR). METHODS: A literature search was performed according to the 2020 PRISMA guidelines. Human clinical studies of level I-II evidence comparing PROs, knee stability and complications following ACL repair and reconstruction were included, and a qualitative analysis was performed. Excluded studies included those lacking reporting outcomes, studies that performed open ACLR or repair, studies published prior to the year 2000 and studies with evidence levels III-IV. Study quality was assessed using the Cochrane Collaboration's risk of bias tool. RESULTS: Seven level of evidence I-II studies were retained including 190 ACLR and 221 repairs (75 Bridge-Enhanced ACL Repair (BEAR), 49 Suture Augmentation (SA), and 97 Dynamic Intraligamentary Stabilization (DIS)). At final follow-up, re-rupture rates varied between 0-14% (BEAR) vs 0-6% (ACLR) and mean side-to-side differences measured using KT-1000 testing ranged from 1.6-1.9mm (BEAR) vs 1.7-3.14mm (ACLR). For DIS vs ACLR, mean anterior tibial translation values at final follow-up were 1.7mm (DIS) vs. 1.4mm (ACLR), and re-rupture rates ranged from 20.8%-29% (DIS) vs. 17%-27.2% (ACLR). For SA vs ACLR, the mean side to side difference ranged from 0.2-0.39mm (SA) vs 0.33-0.4mm (ALCR), while the re-rupture rates were 10% (SA) vs. 0% (ACLR). International Knee Documentation Committee (IKDC), Tegner, Lysholm and Knee Injury and Osteoarthritis Outcome (KOOS) scores across both cohorts exhibited statistically significant, and comparable improvement, from baseline to final follow-up ranging from 1 to 5 years. CONCLUSION: Augmented ACL repair results in similar patient reported outcomes measures in comparison to ACL reconstruction. However, augmented ACL repair may be associated with higher rates of failure given re-rupture rates of up to 14%, 29% and 10% for BEAR, DIS and SA, respectively. LEVEL OF EVIDENCE: II; Systematic review of level I-II studies.

3-dimensionally printed patient-specific glenoid drill guides vs. standard nonspecific instrumentation: a randomized controlled trial comparing the accuracy of glenoid component placement in anatomic total shoulder arthroplasty.

BACKGROUND: Traditional, commercially sourced patient-specific instrumentation (PSI) systems for shoulder arthroplasty improve glenoid component placement but can involve considerable cost and outsourcing delays. The purpose of this randomized controlled trial was to compare the accuracy of glenoid component positioning in anatomic total shoulder arthroplasty (aTSA) using an in-house, point-of-care, 3-dimensionally (3D) printed patient-specific glenoid drill guide vs. standard nonspecific instrumentation. METHODS: This single-center randomized controlled trial included 36 adult patients undergoing primary aTSA. Patients were blinded and randomized 1:1 to either the PSI or the standard aTSA guide groups. The primary endpoint was the accuracy of glenoid component placement (version and inclination), which was determined using a metal-suppression computed tomography scan taken between 6 weeks and 1 year postoperatively. Deviation from the preoperative 3D templating plan was calculated for each patient. Blinded postoperative computed tomography measurements were performed by a fellowship-trained shoulder surgeon and a musculoskeletal radiologist. RESULTS: Nineteen patients were randomized to the patient-specific glenoid drill guide group, and 17 patients were allocated to the standard instrumentation control group. There were no significant differences between the 2 groups for native version (P = .527) or inclination (P = .415). The version correction was similar between the 2 groups (P = .551), and the PSI group was significantly more accurate when correcting version than the control group (P = .042). The PSI group required a significantly greater inclination correction than the control group (P = .002); however, the 2 groups still had similar accuracy when correcting inclination (P = .851). For the PSI group, there was no correlation between the accuracy of component placement and native version, native inclination, or the Walch classification of glenoid wear (P > .05). For the control group, accuracy when correcting version was inversely correlated with native version (P = .033), but accuracy was not correlated with native inclination or the Walch classification of glenoid wear (P > .05). The intraclass correlation coefficient was 0.703 and 0.848 when measuring version and inclination accuracy, respectively. CONCLUSION: When compared with standard instrumentation, the use of in-house, 3D printed, patient-specific glenoid drill guides during aTSA led to more accurate glenoid component version correction and similarly accurate inclination correction. Additional research should examine the influence of proper component position and use of PSI on clinical outcomes.

Suture Anchor-Based Quadriceps Tendon Repair May Result in Improved Patient-Reported Outcomes but Similar Failure Rates Compared to the Transosseous Tunnel Technique.

PURPOSE: The purpose of this study was to compare failure rates and patient-reported outcomes between transosseus (TO) suture and suture anchor (SA) quadriceps tendon repairs. METHODS: Following institutional review board approval, patients who underwent primary repair for quadriceps tendon rupture with TO or SA techniques between January 2009 and August 2018 were identified from an institutional database and retrospectively reviewed. Patients were contacted for satisfaction (1-10 scale), current function (0-100 scale), failure (retear), and revision surgeries; International Knee Documentation Committee (IKDC) score and Knee Injury and Osteoarthritis Outcomes Score (KOOS) were also collected to achieve a minimum of 2-year follow-up. RESULTS: Sixty-four patients (34 SA, 30 TO) were available by phone or e-mail at a mean of 4.81 ± 2.60 years postoperatively. There were 10 failures, for an overall failure rate of 15.6%. Failure incidence did not significantly differ between treatment groups (P = .83). Twenty-seven patients (47% of nonfailed patients) had completed patient-reported outcomes. The SA group reported higher subjective function (SA: 90 [85-100] vs TO: 85 [60-93], 95% CI of difference: -19.9 to -2.1 × 10-5, P = .042), final IKDC (79.6 [50.0-93.6] vs 62.1 [44.3-65.5], 95% CI of difference: -33.0 to -0.48, P = .048), KOOS Pain (97.2 [84.7-97.2] vs 73.6 [50.7-88.2], 95% CI of difference: -36.1 to -3.6 × 10-5, P = .037), Quality of Life (81.3 [56.3-93.8] vs 50.0 [23.4-56.3], 95% CI of difference: -50.0 to -6.2, P = .026), and Sport (75.0 [52.5-90.0] vs 47.5 [31.3-67.5], 95% CI of the difference: -45.0 to -4.1 × 10-5, P = .048). CONCLUSIONS: There is no significant difference in failure rate between transosseus and suture anchor repairs for quadriceps tendon ruptures (P = .83). Most failures occur secondary to a traumatic reinjury within the first year postoperatively. Despite the lack of difference in failure rates, at final follow-up, patients who undergo suture anchor repair may report significantly greater subjective function and final IKDC, KOOS Pain, Quality of Life, and Sport scores. LEVEL OF EVIDENCE: III, retrospective cohort study.

Suture Augmentation in Orthopaedic Surgery Offers Improved Time-Zero Biomechanics and Promising Short-Term Clinical Outcomes.

Ligament and tendon ruptures have historically been addressed with varying techniques involving either repair or reconstruction. More recently, the potential biomechanical benefits of suture augmentation (SA), also known as internal brace, have attracted substantial attention and helped renew interest in ligament repair surgery. We evaluated the biomechanical and clinical outcomes of SA-based techniques in the following sports medicine procedures: medial ulnar collateral ligament repair of the elbow, thumb collateral ligament repair, anterior cruciate ligament repair, Achilles' tendon repair, and deltoid ligament repair. Published data on the use of SA to augment repairs of the ulnar collateral ligament, thumb collateral ligament, anterior cruciate ligament, Achilles' tendon, and deltoid ligament repair demonstrate improved time-zero biomechanical and promising short- to mid-term clinical outcomes. However, surgeons must be wary of potential complications, including joint overconstraint, nerve paresthesia, and infection. LEVEL OF EVIDENCE: Level V, expert opinion.

Biceps Tenodesis in Patients Age 35 Years and Younger Yields Favorable Clinical Outcomes With Variable Rates of Return to Sport and Complications: A Systematic Review.

PURPOSE: To systematically evaluate reported clinical outcomes, return-to-sport (RTS) rates, and complications following biceps tenodesis in patients aged 35 years and younger and compare outcomes between overhead and nonoverhead athletes. METHODS: A literature search was performed by querying Scopus, EMBASE, and PubMed computerized databases from database inception through August 2022 in accordance with the 2020 Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. Studies that evaluated clinical outcomes following biceps tenodesis in patients aged 35 years or younger were included. Study quality was assessed via the Methodological Index for Non-Randomized Studies criteria. Clinical outcomes, RTS rates, and complications were aggregated. RESULTS: Nine studies from 2011 to 2022 comprising 161 patients (mean age, 25 years; range, 19.7-28.9 years) were included. At an average follow-up of 59 months, postoperative American Shoulder and Elbow Surgeons score ranged from 81.6 to 96 and the mean visual analog scale score ranged from 0 to 2.1. Mean overall RTS rate ranged from 35% to 100% for the entire patient cohort 35% to 86% among overhead athletes, and 46% to 100% among nonoverhead athletes. Among the overhead athletes, 24 were baseball pitchers. 17% to 100% able to return to sport at any level. Complications were reported in 0% to 19% of patients. 0 to 18% of patients underwent revision surgery. CONCLUSIONS: Biceps tenodesis in patients 35 years of age and younger yields a wide variability in reported RTS rates, excellent clinical outcome scores, and low but variable reported rates of complications, reoperations, and failure. LEVEL OF EVIDENCE: IV; Systematic Review of Level III and IV studies.

Medial Collateral Ligament Reconstruction and Repair Show Similar Improvement in Outcome Scores, But Repair Shows Higher Rates of Knee Stiffness and Failure: A Systematic Review.

PURPOSE: To compare patient-reported outcomes and complications in patients with medial collateral ligament (MCL) injuries undergoing repair versus reconstruction with a minimum 2-year follow-up. METHODS: A literature search was conducted using the PubMed, Scopus, and Embase-computerized databases from database inception to November 2022, according to the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies evaluating clinical outcomes and complications at a minimum of 2 years following MCL repair versus reconstruction were included. Study quality was assessed using the MINORS criteria. RESULTS: A total of 18 studies published from 1997 to 2022, consisting of 503 patients were identified. Twelve studies (n = 308 patients; mean age: 32.6 years) reported outcomes following MCL reconstruction, and 8 studies (n = 195 patients; mean age: 28.5 years) reported results following MCL repair. Postoperative International Knee Documentation Committee, Lysholm, and Tegner scores ranged from 67.6 to 91, 75.8 to 94.8, and 4.4 to 8, respectively, in the MCL reconstruction group, compared to 73 to 91, 75.1 to 98.5, and 5.2 to 10, respectively, in the MCL repair group. Knee stiffness was the most commonly reported complication following MCL repair (range: 0% - 50%) and reconstruction (range: 0% - 26.7%). Failures occurred in 0% to 14.6% of patients following reconstruction versus 0% to 35.1% of patients undergoing MCL repair. Manipulation under anesthesia (MUA) for postoperative arthrofibrosis (range: 0% - 12.2%) and surgical debridement for arthrofibrosis (range: 0% - 20%) were the most commonly reported reoperations in the MCL reconstruction and repair groups, respectively. CONCLUSIONS: MCL reconstruction versus repair both demonstrate improved International Knee Documentation Committee, Lysholm, and Tegner scores. MCL repair demonstrates higher rates of postoperative knee stiffness and failure at a minimum 2-year follow-up. LEVEL OF EVIDENCE: Level IV, systematic review of Level III and IV studies.