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.

Predictive factors influencing internal rotation following reverse total shoulder arthroplasty.

BACKGROUND: Reverse total shoulder arthroplasty (RTSA) is increasingly used as a treatment modality for various pathologies. The purpose of this review is to identify preoperative risk factors associated with loss of internal rotation (IR) after RTSA. METHODS: A systematic review was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Ovid MEDLINE, Ovid Embase, and Scopus were queried. The inclusion criteria were as follows: articles in English language, minimum 1-year follow-up postoperatively, study published after 2012, a minimum of 10 patients in a series, RTSA surgery for any indication, and explicitly reported IR. The exclusion criteria were as follows: articles whose full text was unavailable or that were unable to be translated to English language, a follow-up of less than 1 year, case reports or series of less than 10 cases, review articles, studies in which tendon transfers were performed at the time of surgery, procedures that were not RTSA, and studies in which the range of motion in IR was not reported. RESULTS: The search yielded 3792 titles, and 1497 duplicate records were removed before screening. Ultimately, 16 studies met the inclusion criteria with a total of 5124 patients who underwent RTSA. Three studies found that poor preoperative functional IR served as a significant risk factor for poor postoperative IR. Eight studies addressed the impact of subscapularis, with 4 reporting no difference in IR based on subscapularis repair and 4 reporting significant improvements with subscapularis repair. Among studies with sufficient power, BMI was found to be inversely correlated with degree of IR after RTSA. Preoperative opioid use was found to negatively affect IR. Other studies showed that glenoid retroversion, component lateralization, and individualized component positioning affected postoperative IR. CONCLUSIONS: This study found that preoperative IR, individualized implant version, preoperative opioid use, increased body mass index and increased glenoid lateralization were all found to have a significant impact on IR after RTSA. Studies that analyzed the impact of subscapularis repair reported conflicting results.

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.

Editorial Commentary: Rotator Cuff Repairs Fail at an Alarmingly High Rate During Long-Term Follow-Up: Graft Augmentation and Biologics May Improve Future Outcomes.

Rotator cuff repairs (RCR) frequently fail to heal, particularly those with advanced fatty infiltration, supraspinatus and infraspinatus atrophy, narrowed acromiohumeral distance, and large-to-massive tear size. Unfortunately, the longer the follow up, the more sobering the statistics, with some reported retear rates ranging up to 94%. Importantly, recent long-term radiographic assessments after primary RCR reveal direct correlations between failure and patient-reported outcomes, functional deterioration, and ultimately, progression of glenohumeral arthritis and/or frank cuff tear arthropathy. As shoulder surgeons, we must continue to seek out novel approaches to improve tendon to bone healing and recapitulate the native rotator cuff enthesis. In doing so, we hope to engender more sustained subjective and objective results for our patients over time. Investigations are ongoing into several biomechanical and biological or structural adjuncts, from platelet-rich plasma and bone marrow aspirate concentrate to autograft or allograft structural augments. We must continue to push the envelope and refuse to settle for the current reality and alarmingly high failure rates following RCR.

Medial Patellofemoral Complex Reconstruction Techniques Are Not Equivalent at Lower Flexion in the Setting of Patella Alta: A Biomechanical Comparison.

PURPOSE: To (1) determine the effect of severe patella alta on lateral patellar displacement after medial patellofemoral ligament (MPFL) reconstruction and medial quadriceps tendon-femoral ligament (MQTFL) reconstruction and (2) determine whether lateral displacement significantly differs between MPFL and MQTFL reconstructions in the setting of severe patella alta (Caton-Deschamps Index [CDI] of 1.6). METHODS: Eight cadaveric specimens were included. High-tensile strength suture was used to create a model of adjustable patellar height. Patellar height was set using fluoroscopy to CDI ratios of 1.0 (normal) and 1.6 (alta). Specimens underwent testing (1) with MPFL reconstruction, (2) with MQTFL reconstruction, and (3) in a medial patellofemoral complex (MPFC)-deficient control state, in randomized order, at both CDI settings: 1.0 and 1.6. Lateral patellar translation was measured at 0°, 10°, 20°, 30°, 45°, 60°, and 90° of knee flexion with 10 N of laterally directed load. RESULTS: At a CDI of 1.6, MPFL reconstruction showed significantly lower lateral displacement than MQTFL reconstruction at 0° and 20°. When compared with MPFC-deficient controls at a CDI of 1.6, MPFL reconstruction showed significantly lower displacement at 0° and 20° whereas MQTFL reconstruction was not significantly different at any degree of flexion. CONCLUSIONS: In the setting of severe patella alta (CDI of 1.6), MPFL reconstruction results in less lateral patellar displacement than MQTFL reconstruction at 0° and 20° of knee flexion. At higher flexion angles (≥30°), there is no difference between the 2 reconstruction techniques and the CDI no longer has an effect. At a CDI of 1.0, MPFL reconstruction shows lower displacement than MQTFL reconstruction in full extension only. Surgeons performing MPFC reconstruction should evaluate patients for patella alta and consider patellar height when deciding on the reconstruction technique. CLINICAL RELEVANCE: This study suggests that MQTFL reconstruction may be less stable than MPFL reconstruction in the setting of patella alta, without other known pathoanatomic factors, at early knee flexion angles. Patellar height should be considered when choosing the appropriate reconstruction technique in the absence of a distalization procedure.

Editorial Commentary: Arthroscopic-Assisted Coracoclavicular Ligament Reconstruction Leads to Improved Patient-Reported Outcomes, But Patient Satisfaction Is a Harder Threshold to PASS.

There are numerous described techniques for surgical management of high-grade acromioclavicular (AC) joint injuries, and the associated clinical outcomes can be quite variable. Contemporary techniques are typically directed at anatomic reconstruction of the coracoclavicular (CC) ligaments through either an arthroscopy-assisted or an open approach. Most patients treated with acute surgery improve, whereas in chronic cases, the majority improve, but a significant number have persistent recurrent deformity due to loss of anatomic reduction. In addition, whether acute or chronic, over one quarter of patients do not have a PASS (patient acceptable symptomatic state). Of interest, PASS may not primarily be related to the final deformity in terms of coracoclavicular distance, and investigation is still required in terms of the effect of anteroposterior or rotational instability of the AC joint after injury and surgery. Finally, PASS values for AC separation are not well established, resulting in a current limitation of the strength of applying threshold values to this pathology.

Biological strategies for osteoarthritis: from early diagnosis to treatment.

PURPOSE: To provide an updated review of the literature on the use of orthobiologics as a potential treatment option to alleviate symptoms associated with osteoarthritis (OA), slow the progression of the disease, and aid in cartilage regeneration. METHODS: A comprehensive review of the literature was performed to identify basic science and clinical studies examining the role of orthobiologics in the diagnosis and management of osteoarthritis. RESULTS: Certain molecules (such as interleukin-6 (IL-6), interleukin-8 (IL-8), matrix metalloproteinase (MMPs), cartilage oligomeric matrix protein (COMP), and tumor necrosis factor (TNF), microRNAs, growth differentiation factor 11 (GDF-11)) have been recognized as biomarkers that are implicated in the pathogenesis and progression of degenerative joint disease (DJD). These biomarkers have been used to develop newer diagnostic applications and targeted biologic therapies for DJD. Local injection therapy with biologic agents such as platelet-rich plasma or stem cell-based preparations has been associated with significant improvement in joint pain and function in patients with OA and has increased in popularity during the last decade. The combination of PRP with kartogenin or TGF-b3 may also enhance its biologic effect. The mesenchymal stem cell secretome has been recognized as a potential target for the development of OA therapies due to its role in mediating the chondroprotective effects of these cells. Recent experiments have also suggested the modification of gut microbiome as a newer method to prevent OA or alter the progression of the disease. CONCLUSIONS: The application of orthobiologics for the diagnosis and treatment of DJD is a rapidly evolving field that will continue to expand. The identification of OA-specific and joint-specific biomarker molecules for early diagnosis of OA would be extremely useful for the development of preventive and therapeutic protocols. Local injection therapies with HA, PRP, BMAC, and other stem cell-based preparations are currently being used to improve pain and function in patients with early OA or those with progressed disease who are not surgical candidates. Although the clinical outcomes of these therapies seem to be promising in clinical studies, future research will determine the true role of orthobiologic applications in the field of DJS.

Does Bone Plug and Graft Orientation (Inferior Versus Posterior) Alter Native Femoral Footprint Coverage in Bone Patellar Tendon Bone Anterior Cruciate Ligament Reconstruction?

PURPOSE: The purpose of this study was to compare the percentage of native femoral anterior cruciate ligament (ACL) footprint covered by the 2 most clinically relevant bone plug/graft orientations used with interference screw fixation in ACL reconstruction. A secondary purpose was to assess whether a transtibial or tibia-independent drilling technique would affect this outcome. METHODS: Five matched pairs of cadaver knees were used. Each matched pair had 1 knee assigned to a 10-mm femoral socket prepared via a transtibial (TT) drilling technique and the other via an anteromedial (AM) drilling technique. The bone plug of each graft was press-fitted into the femoral socket with the graft collagen in 2 distinct clinically relevant orientations (collagen inferior or posterior). The digitized graft collagen cross-sectional area (CSA) in each orientation was overlaid onto the native femoral ACL footprint CSA to generate a percentage of native ACL footprint covered by graft collagen. RESULTS: The average native ACL femoral footprint CSA was 110.5 ± 9.1 mm2, with no difference between knees assigned to TT or AM drilling (112.6 ± 2.7 vs 108.4 ± 13.0 mm2, P = .49). The average femoral socket CSA was 95.4 ± 8.7 mm2, with no difference between TT and AM tunnels (95.5 ± 9.9 vs 95.3 ± 8.4 mm2, P = .96). There was no difference between the percentage of native footprint covered between TT and AM sockets (76.8% ± 7.8% vs 82.2% ± 13.7%, P = .47). Irrespective of drilling technique, there was significantly greater native ACL footprint covered by graft collagen when the bone plug was oriented with graft collagen inferior rather than posterior (75.6% ± 6.3% vs 65.4% ± 11.4%, P = .02). CONCLUSION: Orienting the femoral bone plug such that the graft collagen is inferior rather than posterior significantly increases native ACL femoral footprint coverage in bone-patellar tendon-bone ACL reconstruction. This effect is consistent across AM and TT drilling techniques. CLINICAL RELEVANCE: Surgeons attempting to restore an anatomic ACL footprint should consider bone plug-graft orientation when performing ACL reconstruction. STUDY DESIGN: Controlled laboratory study.

Are Orthopaedic Surgeons Performing Fewer Arthroscopic Partial Meniscectomies in Patients Greater Than 50 Years Old? A National Database Study.

PURPOSE: To report the trends in arthroscopic partial meniscectomy (APM) for degenerative meniscal tears in a large private insurance database among patients older than 50 years. METHODS: The Humana database between 2007 and 2015 was queried for this study. Patients meeting the inclusion criteria with degenerative meniscal tears who underwent APMs were identified by International Classification of Diseases, Ninth Revision codes, followed by Current Procedural Terminology codes. A linear regression analysis was performed with a significance level set at F < 0.05. RESULTS: A total of 21,759 APMs were performed between 2007 and 2015 in patients older than 50 years. Normalized data for total yearly enrollment showed a significant increase in APMs performed from 2007 to 2010 (R2 = 0.986, P = .007). The average percentage increase per year from 2007 to 2010 was 18.59%. However, there was a significant decrease in APMs performed from 2010 to 2015 (R2 = 0.748, P = .026). The average percentage decrease per year from 2010 to 2015 was 7.74%. The percentage decrease overall from 2010 to 2015 was 71.68%. No difference in statistical significance was found when age was broken into 5-year age intervals. We found a significant difference in APM based on region (P < .001). CONCLUSIONS: The rate of APMs in patients older than 50 years increased from 2007 until 2010. Since 2010, the rate of APMs in patients older than 50 years has significantly decreased. These trends are likely multifactorial. Regardless of cause, it appears that the orthopaedic surgery community is performing fewer APMs in this patient population. LEVEL OF EVIDENCE: Level III, retrospective database epidemiological study.

Injections Prior to Rotator Cuff Repair Are Associated With Increased Rotator Cuff Revision Rates.

PURPOSE: To determine whether shoulder injections prior to rotator cuff repair (RCR) are associated with deleterious surgical outcomes. METHODS: Two large national insurance databases were used to identify a total of 22,156 patients who received ipsilateral shoulder injections prior to RCR. They were age, sex, obesity, smoking status, and comorbidity matched to a control group of patients who underwent RCR without prior injections. The 2 groups were compared regarding RCR revision rates. RESULTS: Patients who received injections prior to RCR were more likely to undergo RCR revision than matched controls (odds ratio [OR], 1.52; 95% confidence interval [CI], 1.38-1.68; P < .0001). Patients who received injections closer to the time of index RCR were more likely to undergo revision (P < .0001). Patients who received a single injection prior to RCR had a higher likelihood of revision (OR, 1.25; 95% CI, 1.10-1.43; P = .001). Patients who received 2 or more injections prior to RCR had a greater than 2-fold odds of revision (combined OR, 2.12; 95% CI, 1.82-2.47; P < .0001) versus the control group. CONCLUSIONS: This study strongly suggests a correlation between preoperative shoulder injections and revision RCR. There is also a frequency dependence and time dependence to this finding, with more frequent injections and with administration of injections closer to the time of surgery both independently associated with higher revision RCR rates. Presently, on the basis of this retrospective database study, orthopaedic surgeons should exercise due caution regarding shoulder injections in patients whom they are considering to be surgical candidates for RCR. LEVEL OF EVIDENCE: Level III, therapeutic study.

Spinopelvic Motion and Impingement in Total Hip Arthroplasty.

The stability of a total hip arthroplasty relies on proper positioning of the acetabular cup. Recent research has shown that this cup position is more dynamic than previously thought. The 3-dimensional orientation of the acetabular cup changes when the pelvis tilts anteriorly or posteriorly. These changes in pelvic tilt are directly related to the biomechanics of the lumbosacral junction. In normal physiology, the lumbar spine straightens with sitting and becomes more lordotic with standing. This directly translates to posterior or anterior pelvic tilt due to the rigid sacroiliac attachments. During sitting, increased posterior pelvic tilt opens the acetabulum to accommodate flexion and internal rotation of the hip. This helps prevent anterior impingement and posterior hip dislocation. During standing, anterior pelvic tilt increases superior coverage of the acetabulum. This helps prevent posterior impingement and anterior hip dislocations. When lumbosacral motion becomes pathologic, spinopelvic motion changes and acetabular cup orientation is affected. In cases of decreased lumbosacral motion, patients rely on greater hip motion to reach standing or sitting positions. This can cause pathologic impingement. In addition, traditional safe zones for cup position may not apply in the presence of pathologic spinopelvic motion. This article discusses the normal physiology of spinopelvic motion, the patterns of pathologic change, and the clinical implications therein.

The Opioid Crisis and the Orthopedic Surgeon.

Opioid use and abuse has become a national crisis in the United States. Many opioid abusers become addicted through an initial course of legal, physician-prescribed medications. Consequently, there has been increased pressure on medical care providers to be better stewards of these medications. In orthopedic surgery and total joint arthroplasty, pain control after surgery is critical for restoring mobility and maintaining patient satisfaction in the early postoperative period. Before the opioid misuse epidemic, orthopedic surgeons were frequently influenced to "treat pain with pain medications." Long-acting opioids, such as OxyContin were used commonly. In the past decade, there has been a paradigm shift in favor of multimodal pain control with limited opioid use. This review will discuss 4 major topics. First, we will describe the pressures on orthopedic surgeons to prescribe narcotic pain medications. We will then discuss the major and minor complications and side effects associated with these prescriptions. Second, we will review how these factors motivated the development of alternative pain management strategies and a multimodal approach. Third, we will look at perioperative interventions that can reduce postoperative opioid consumption, including wound injections and peripheral nerve blocks, which have shown superb clinical results. Finally, we will recommend an evidence-based program that avoids parenteral narcotics and facilitates rapid discharge home without readmissions for pain-related complaints.

Identification and Characterization of a Synthetic Osteogenic Peptide.

Osteoporosis is the most common metabolic bone disorder and its management represents a tremendous public health encumbrance. While several classes of therapeutics have been approved to treat this disease, all are associated with significant adverse effects. An algorithm was developed and utilized to discover potential bioactive peptides, which led to the identification of an osteogenic peptide that mapped to the C-terminal region of the calcitonin receptor and has been named calcitonin receptor fragment peptide (CRFP). In vitro treatment of human mesenchymal stem cells with CRFP resulted in dose-specific effects on both proliferation and osteoblastic differentiation. Similarly, in vitro treatment of rat RCJ3.1C5.18 cells led to dose- and species-specific effects on proliferation. A rat ovariectomy (OVX) model was used to assess the potential efficacy of CRFP in treating osteoporosis. MicroCT analysis of distal femoral samples showed that OVX rats treated with CRFP were significantly protected from losses of 55 % in trabecular bone volume fraction (BVF), 42 % in connectivity density, and 18 % in trabecular thickness in comparison to vehicle-treated controls. MicroCT analyses of vertebrae revealed CRFP to significantly prevent a 25 % reduction in BVF. MicroCT evaluation of femoral and vertebral cortical bone found a significant reduction of 2 % in vertebral bone mineral density. In summary, our in vitro studies indicate that CRFP is both bioactive and osteogenic and our in vivo studies indicate that CRFP is skeletally bioactive. These promising data indicate that further in vitro and in vivo evaluation of CRFP as a new treatment for osteoporosis is warranted.

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.

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.

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.