Injectable therapeutic peptides-an adjunct to regenerative medicine and sports performance?

High level athletes and bodybuilders are constantly seeking novel therapies to enhance recovery and expedite return from injury-injectable peptides are a new and trending therapy that may be the wave of the future of in the realm of regenerative medicine research in treating joint injuries and osteoarthritis. Very early in vivo research of the pharmacokinetics suggests the possibility of Body Protection Compound 157 (BPC-157) appears to be at the forefront of therapeutic peptides with early demonstration of these experimental peptides optimizing endurance training, metabolism, recovery and tissue repair. While uUnregulated, yetand readily available for purchase over the internet, there is scarce orthopaedic literature investigating the clinical use and outcomes of these therapeutic peptides in tendon, muscle and cartilage injury. However, this has not slowed the recent exponential growth of the multi-billion-dollar industry in development of therapeutic peptides. As orthopaedic surgeons and team physicians, we should stay up-to-date with the latest pharmacokinetic, safety, ethical, and legal profilesregulations regarding synthetic peptide supplementation for injury recovery and sports performance optimization from our elite athletes to our fitness fanatics as these patients will continue to seek the latest and greatest in treatment options and will be approaching us with questions on their results, risks and benefits..

Editorial Commentary: Experts in Shoulder Surgery Do Not Consistently Detect Artificial Intelligence-Generated Scientific Abstracts.

There has been exponential growth in the number of artificial intelligence (AI)- and machine learning (ML)-related publications in recent years. For example, in the field of shoulder and elbow surgery, there was a 6-fold increase in the number of publications between 2018 and 2021. AI shows the potential to improve diagnostic precision, generate precise surgical templates, direct personalized treatment plans, and reduce administrative costs. However, although AI and ML technology has the ability to positively impact biomedical research, it should be closely monitored and used with extreme caution in the realm of research and scientific writing. Current large language models raise concerns regarding the veracity of AI-generated content, copyright and ownership infringement, fabricated references, lack of in-text citations, plagiarism, and questions of authorship. Recent research has shown that even the most experienced surgeons are unable to consistently detect AI-generated scientific writing. Of note, AI detection software is more adept in this role. AI should be used with caution in the development and production of scholarly work.

Neuromuscular Choristoma of the Brachial Plexus Presenting as a Supraclavicular Mass in a Pediatric Patient: A Case Report.

CASE: This case demonstrates a 2-year-old boy with a rare benign supraclavicular mass diagnosed as neuromuscular choristoma through open biopsy. Postoperatively, he underwent semiannual surveillance with ultrasound without development of neurological complaints, limb deformity, or recurrence at 2-year follow-up. CONCLUSION: Neuromuscular choristoma involving the brachial plexus is a rare tumor that should be in the differential diagnosis of pediatric peripheral nerve-based tumors. The intimate association with neural elements limits complete resection. Therefore, open biopsy with partial resection is recommended. While postoperative fibromatosis may occur, open biopsy remains the gold standard for definitive diagnosis. Ultrasound can be used to monitor recurrence.

Functional Anatomy and Biomechanics of Shoulder Instability.

The glenohumeral joint is the least congruent and least constrained joint with a complex relationship of static and dynamic stabilizers to balance its native mobility with functional stability. In the young athlete, anterior shoulder instability is multifactorial and can be a challenge to treat, requiring a patient-specific treatment approach. Surgical decision-making must consider patient-specific factors such as age, sport activity and level, underlying ligamentous laxity, and goals for return to activity, in addition to careful scrutiny of the underlying pathology to include humeral and glenoid bone loss and surrounding scapular bone morphology.

Reverse Total Shoulder Arthroplasty in the Setting of an Intramuscular Lipoma With Extension Into the Glenoid: A Case Report.

Glenoid bone loss from an infiltrating intramuscular lipoma causing erosive changes is a rare occurrence. A 71-year-old woman with symptomatic rotator cuff arthropathy in the setting of an intramuscular infiltrating lipoma and secondary glenoid bone loss was treated with single-stage tumor excision and reverse total shoulder arthroplasty (rTSA) using an injectable, hard self-setting calcium phosphate as structural bone graft substitute. The patient demonstrated excellent clinical and radiographic outcomes at 2-year follow-up. Infiltrating lipomas resulting in functional rotator cuff arthropathy and erosive osseous glenoid changes are exceedingly rare, yet significant glenoid bony defects present a challenge in the setting of shoulder arthroplasty. This report describes the use of structural bone graft substitute for the management of a glenoid bone defect from a rare case of an intramuscular infiltrating lipoma, while maintaining excellent improvement in functional outcomes and pain after rTSA.

Lack of Consensus on the Management of Medial Collateral Ligament Tears in the Setting of Concomitant Anterior Cruciate Ligament Injury: A Critical Analysis.

¼ There is no clear agreement on the optimal timing or superior type of fixation for medial collateral ligament (MCL) tears in the setting of anterior cruciate ligament (ACL) injury.¼ Anatomic healing of medial knee structures is critical to maintain native knee kinematics, supported by biomechanical studies that demonstrate increased graft laxity and residual valgus rotational instability after ACL reconstruction (ACLR) alone in the setting of concomitant ACL/MCL injury.¼ Historically, most surgeons have favored treating acute combined ACL/MCL tears conservatively with MCL rehabilitation, followed by stress radiographs at 6 weeks after injury to assess for persistent valgus laxity before performing delayed ACLR to allow for full knee range of motion, and reduce the risk of postoperative stiffness and arthrofibrosis.¼ However, with the advancement of early mobilization and aggressive physical therapy protocols, acute surgical management of MCL tears in the setting of ACL injury can have benefits of avoiding residual laxity and further intra-articular damage, as well as earlier return to sport.¼ Residual valgus laxity from incomplete MCL healing at the time of ACLR should be addressed surgically, as this can lead to an increased risk of ACLR graft failure.¼ The treatment of combined ACL/MCL injuries requires an individualized approach, including athlete-specific factors such as level and position of play, timing of injury related to in-season play, contact vs. noncontact sport, and anticipated longevity, as well as consideration of the tear pattern, acuity of injury, tissue quality, and surgeon familiarity with the available techniques.

Glenoid augmentation for subcritical bone loss: a narrative review.

Background and Objective: Anterior shoulder instability can be debilitating for young, active individuals, and increasing magnitudes of glenoid bone loss (GBL) predisposes patients to recurrent instability and increases the likelihood of failure of soft-tissue only repairs. It is widely accepted that GBL >25% should be treated with a glenoid bone grafting procedure. However, consensus is lacking on the optimal management in the setting of subcritical GBL, typically classified as >13.5%. This article reviews the pathoanatomy relevant to anterior shoulder instability and subcritical GBL, while highlighting existing evidence regarding open augmentation procedures in comparison to other treatment options for this subpopulation. Methods: A narrative review of the current literature was conducted focusing on subcritical GBL in anterior glenoid stabilization procedures, including review of forward citation and reference lists of selected articles. Key Content and Findings: Computed tomography (CT) is the modality of choice for obtaining precise measurements of subcritical GBL, defined as <13.5%, using the best-fit circle method. There is debate surrounding the optimal surgical management of subcritical GBL. Arthroscopic Bankart repair (ABR) remains the predominate surgery performed for primary anterior shoulder instability, while glenoid augmentation and open Bankart repair continue to be used sparingly in the United States. Historically, the Latarjet procedure was considered for substantial glenoid defects, but the illumination of subcritical GBL has expanded its indications. Arthroscopic, soft tissue-only repairs with the addition of remplissage, has been shown to have similar 2-year outcomes to the Latarjet in patients with >15% GBL, which has been limited in the study of subcritical GBL. Additionally, utilization of distal tibial allograft and local autograft is becoming increasingly prevalent. However, again, with limited prospective studies in the subcritical GBL population. Conclusions: There is no consensus regarding the optimal treatment approach to recurrent shoulder instability in the setting of subcritical GBL. Conversely, there is a growing agreement that isolated ABR is likely inadequate and subcritical GBL should prompt consideration of a more robust operation. To this end, interest in glenoid bone augmentation continues to grow as a reliable technique for recreating the native architecture and restoring glenohumeral stability are developed.

Novel 3D MRI-based volumetric assessment of rotator cuff musculature demonstrates stronger correlation with preoperative functional status when compared to the Goutallier grading scheme.

BACKGROUND: The Goutallier classification (GC) is used to assess fatty atrophy in rotator cuff (RC) tears, yet limitations exist. A battery of 3-dimensional (3D) magnetic resonance imaging (MRI) volumetric scores (VSs) was developed to provide comprehensive characterization of RC pathology. The purposes of this study were to (1) describe the correlation between GC and VSs for supraspinatus changes in RC tears, (2) characterize the chronicity of RC tears using a battery of 12 VS measurements, and (3) compare GC and VSs to determine which method most closely corresponds with preoperative patient-reported outcome measures (PROMs). METHODS: Preoperative shoulder MRIs were reviewed after arthroscopic RC repair. Preoperative GC stage and Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) and pain interference (PI) scores were collected. The battery of VSs included fat infiltration (FIS), muscle size (MSS), and relative volume contribution (RCS) for each RC muscle. Backward linear regression was performed to compare GC stage with preoperative PROMIS PF and PI to determine which VS measurement most closely correlated with preoperative PROMs. RESULTS: Eighty-two patients underwent RC repair (mean age 55 ± 8.2 years, 63% male, 68% GC stage ≤1). In evaluation of the supraspinatus, there was a moderate positive correlation between GC and FIS (r = 0.459, P < .001); strong negative correlations were observed between MSS (r = -0.800, P < .001) and RCS (r = -0.745, P < .001) when compared to GC. A negligible linear correlation was observed between GC and preoperative PROMIS PF (r = -0.106, P = .343) and PI (r = -0.071, P = .528). On multivariate analysis, subscapularis MSS (ß >0, P = .064) was a positive predictor and subscapularis FIS (ß <0, P = .137), teres minor MSS (ß <0, P = .141), and FIS (ß <0, P = .070) were negative predictors of preoperative PF (r = 0.343, P = .044); in contrast, supraspinatus MSS (ß >0, P = .009) and FIS (ß >0, P = .073), teres minor FIS (ß >0, P = .072), and subscapularis FIS (ß >0, P = .065) were positive predictors of preoperative PI (r = 0.410, P = .006). CONCLUSION: Although the criterion standard in evaluation of RC pathology, GC demonstrated negligible correlation with preoperative functional disability. Alternatively, a battery of 3D VSs showed strong correlation with GC through a quantitative, comprehensive evaluation of the RC unit including several moderate predictors of preoperative functional disability.

Minimal important clinical difference values are not uniformly valid in the active duty military population recovering from shoulder surgery.

BACKGROUND: There are multiple methods for calculating the minimal clinically important difference (MCID) threshold, and previous reports highlight heterogeneity and limitations of anchor-based and distribution-based analyses. The Warfighter Readiness Survey assesses the perception of a military population's fitness to deploy and may be used as a functional index in anchor-based MCID calculations. The purpose of the current study in a physically demanding population undergoing shoulder surgery was to compare the yields of 2 different anchor-based methods of calculating MCID for a battery of PROMs, a standard receiver operating characteristic (ROC) curve-based MCIDs and baseline-adjusted ROC curve MCIDs. METHODS: All service members enrolled prospectively in a multicenter database with prior shoulder surgery that completed pre- and postoperative PROMs at a minimum of 12 months were included. The PROM battery included Single Assessment Numeric Evaluation (SANE), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Patient Reported Outcome Management Information System (PROMIS) physical function (PF), PROMIS pain interference (PI), and the Warfighter Readiness Survey. Standard anchor-based and baseline-adjusted ROC curve MCIDs were employed to determine if the calculated MCIDs were both statistically and theoretically valid (95% confidence interval [CI] either completely negative or positive). RESULTS: A total of 117 patients (136 operations) were identified, comprising 83% males with a mean age of 35.7 ± 10.4 years and 47% arthroscopic labral repair/capsulorrhaphy. Using the standard, anchor-based ROC curve MCID calculation, the area under the curve (AUC) for SANE, ASES, PROMIS PF, and PROMIS PI were greater than 0.5 (statistically valid). For ASES, PROMIS PF, and PROMIS PI, the calculated MCID 95% CI all crossed 0 (theoretically invalid). Using the baseline-adjusted ROC curve MCID calculation, the MCID estimates for SANE, ASES, and PROMIS PI were both statistically and theoretically valid if the baseline score was less than 70.5, 69, and 65.7. CONCLUSION: When MCIDs were calculated and anchored to the results of standard, anchor-based MCID, a standard ROC curve analysis did not yield statistically or theoretically valid results across a battery of PROMs commonly used to assess outcomes after shoulder surgery in the active duty military population. Conversely, a baseline-adjusted ROC curve method was more effective at discerning changes across a battery of PROMs among the same cohort.

Arthroscopic Management of Arthrofibrosis After Hemiarthroplasty for Proximal Humerus Fracture Dislocation.

Poor functional outcomes after hemiarthroplasty for proximal humerus fractures are common, yet revision surgery is relatively rare. Arthroscopic treatment for postoperative stiffness can be considered in the setting of functional limits to glenohumeral range of motion impacting activities of daily living after adequate conservative treatment with physical therapy and in the setting of healed, well-positioned tuberosities and humeral components. This Technical Note illustrates a stepwise approach to an arthroscopic lysis of adhesions and capsular release for the treatment of arthrofibrosis of the shoulder. The advantages of this technique include an alternative approach to entering the glenohumeral joint under direct subacromial visualization and a 2-posterior portal approach to the inferior and anteroinferior capsule, which can be challenging to achieve in the setting of severe postsurgical arthrofibrosis.

Distal Femoral Stress Fractures Has High Operation Rates in Adolescent and Young Adult Athletes.

BACKGROUND: Although stress fractures of the distal femur are rare, symptoms can overlap with other peri-articular knee pathology, delaying diagnosis. Untreated stress fractures have the potential to progress into completed fractures with a higher likelihood for requiring surgery and longer recovery times in otherwise healthy adolescents and young adults. This case series represents the largest cohort of adolescent athletes with distal femoral stress fractures who presented with activity-related knee pain. METHODS: Patients treated nonoperatively and operatively for metaphyseal distal femur stress fractures at a tertiary referral center over a four-year period were retrospectively identified from the medical record. RESULTS: Eight patients (mean age 16.8 y; range 14 to 22 y; 87.5% male; mean body mass index [BMI] 20.9) with a total of 10 distal femur stress fractures were identified. All patients were involved in competitive sports or military training. There was an average of 3.8 encounters with a medical provider between presentation with activity-related knee pain and diagnosis with distal femur stress fracture. All except 1 patient (87.5%) were initially incorrectly diagnosed with another type of peri-articular knee pathology. Six stress fractures (60%) were treated conservatively with protected weight bearing, activity modification, and gradual return to activity. Four completed stress fractures (40%) required operative fixation-3 healed uneventfully, while 1 had an asymptomatic delayed union. Vitamin D insufficiency (<30 ng/mL) was identified in 7 of 8 patients (87.5%) and 3 patients (37.5%) had an underweight BMI (<18.5). The mean clinical follow-up was 13.1 weeks (range, 2.8 to 32.0 wk). CONCLUSIONS: High clinical suspicion for distal femoral stress fractures is needed to avoid misdiagnosis or delayed diagnosis in young, active individuals with activity-related knee pain refractory to conservative management. In this patient population, activity-related knee pain recalcitrant to activity modification, rest, and physical therapy warrants further workup with magnetic resonance imaging and orthopaedic evaluation. Though rare, misdiagnosis can result in catastrophic fractures with prolonged rehabilitation needs. An open line of communication and streamlined access for referral between primary care providers and orthopaedic surgeons is critical in preventing misdiagnosis and delayed treatment. Furthermore, the treatment of concomitant metabolic disorders and nutritional deficiency should not be neglected when treating distal femoral stress fractures. LEVEL OF EVIDENCE: Level-IV (case series).

Knee Joint Preservation in Tactical Athletes: A Comprehensive Approach Based upon Lesion Location and Restoration of the Osteochondral Unit.

The unique physical demands of tactical athletes put immense stress on the knee joint, making these individuals susceptible to injury. In order to ensure operational readiness, management options must restore and preserve the native architecture and minimize downtime, while optimizing functionality. Osteochondral lesions (OCL) of the knee have long been acknowledged as significant sources of knee pain and functional deficits. The management of OCL is predicated on certain injury characteristics, including lesion location and the extent of subchondral disease. Techniques such as marrow stimulation, allograft and autologous chondrocyte implantation are examined in detail, with a focus on their application and suitability in tactical athlete populations. Moreover, the restoration of the osteochondral unit (OCU) is highlighted as a central aspect of knee joint preservation. The discussion encompasses the biomechanical considerations and outcomes associated with various cartilage restoration techniques. Factors influencing procedure selection, including lesion size, location, and patient-specific variables, are thoroughly examined. Additionally, the review underscores the critical role of post-operative rehabilitation and conditioning programs in optimizing outcomes. Strengthening the surrounding musculature, enhancing joint stability, and refining movement patterns are paramount in facilitating the successful integration of preservation procedures. This narrative review aims to provide a comprehensive resource for surgeons, engineers, and sports medicine practitioners engaged in the care of tactical athletes and the field of cartilage restoration. The integration of advanced preservation techniques and tailored rehabilitation protocols offers a promising avenue for sustaining knee joint health and function in this demanding population.

Treatment of Tendon Injuries in the Servicemember Population across the Spectrum of Pathology: From Exosomes to Bioinductive Scaffolds.

Tendon injuries in military servicemembers are one of the most commonly treated nonbattle musculoskeletal injuries (NBMSKIs). Commonly the result of demanding physical training, repetitive loading, and frequent exposures to austere conditions, tendon injuries represent a conspicuous threat to operational readiness. Tendon healing involves a complex sequence between stages of inflammation, proliferation, and remodeling cycles, but the regenerated tissue can be biomechanically inferior to the native tendon. Chemical and mechanical signaling pathways aid tendon healing by employing growth factors, cytokines, and inflammatory responses. Exosome-based therapy, particularly using adipose-derived stem cells (ASCs), offers a prominent cell-free treatment, promoting tendon repair and altering mRNA expression. However, each of these approaches is not without limitations. Future advances in tendon tissue engineering involving magnetic stimulation and gene therapy offer non-invasive, targeted approaches for improved tissue engineering. Ongoing research aims to translate these therapies into effective clinical solutions capable of maximizing operational readiness and warfighter lethality.

Patient Resilience Does Not Conclusively Affect Clinical Outcomes Associated With Arthroscopic Surgery but Substantial Limitations of the Literature Exist.

Purpose: To determine whether low resilience is predictive of worse patient-reported outcomes (PROs) or diminished improvements in clinical outcomes after joint preserving and arthroscopic surgery. Methods: A comprehensive search of PubMed, Medline, Embase, and Science Direct was performed on September 28, 2022, for studies investigating the relationship between resilience and PROs after arthroscopic surgery in accordance with the Preferred Reported Items for Systematic Reviews and Meta-analyses guidelines. Results: Nine articles (level II-IV studies) were included in the final analysis. A total of 887 patients (54% male, average age 45 years) underwent arthroscopic surgery, including general knee (n = 3 studies), ACLR-only knee (n = 1 study), rotator cuff repair (n = 4 studies), and hip (n = 1 study). The Brief Resilience Scale was the most common instrument measuring resilience in 7 of 9 studies (78%). Five of 9 studies (56%) stratified patients based on high, normal, or low resilience cohorts, and these stratification threshold values differed between studies. Only 4 of 9 studies (44%) measured PROs both before and after surgery. Three of 9 studies (33%) reported rates of return to activity, with 2 studies (22%) noting high resilience to be associated with a higher likelihood of return to sport/duty, specifically after knee arthroscopy. However, significant associations between resilience and functional outcomes were not consistently observed, nor was resilience consistently observed to be predictive of subjects' capacity to return to a preinjury level of function. Conclusions: Patient resilience is inconsistently demonstrated to affect clinical outcomes associated with joint preserving and arthroscopic surgery. However, substantial limitations in the existing literature including underpowered sample sizes, lack of standardization in stratifying patients based on pretreatment resilience, and inconsistent collection of PROs throughout the continuum of care, diminish the strength of most conclusions that have been drawn. Level of Evidence: Level IV, systematic review of level II-IV studies.

The Psychology of ACL Injury, Treatment, and Recovery: Current Concepts and Future Directions.

CONTEXT: Interest in the relationship between psychology and the outcomes of anterior cruciate ligament (ACL) reconstruction (ACLR) continues to grow as variable rates of return to preinjury level of activity continue to be observed. EVIDENCE ACQUISITION: Articles were collected from peer-reviewed sources available on PubMed using a combination of search terms, including psychology, resilience, mental health, recovery, and anterior cruciate ligament reconstruction. Further evaluation of the included bibliographies were used to expand the evidence. STUDY DESIGN: Clinical review. LEVEL OF EVIDENCE: Level 4. RESULTS: General mental health and wellbeing, in addition to a host of unique psychological traits (self-efficacy, resilience, psychological readiness and distress, pain catastrophizing, locus of control, and kinesiophobia) have been demonstrated convincingly to affect treatment outcomes. Moreover, compelling evidence suggests that a number of these traits may be modifiable. Although the effect of resilience on outcomes of orthopaedic surgical procedures has been studied extensively, there is very limited information linking this unique psychological trait to the outcomes of ACLR. Similarly, the available information related to other parameters, such as pain catastrophizing, is limited with respect to the existence of adequately sized cohorts capable of accommodating more rigorous and compelling analyses. A better understanding of the specific mechanisms through which psychological traits influence outcomes can inform future interventions intended to improve rates of return to preinjury level of activity after ACLR. CONCLUSION: The impact of psychology on patients' responses to ACL injury and treatment represents a promising avenue for improving low rates of return to preinjury activity levels among certain cohorts. Future research into these areas should focus on specific effects of targeted interventions on known, modifiable risk factors that commonly contribute to suboptimal clinical outcomes. STRENGTH-OF-RECOMMENDATION TAXONOMY (SORT): B.

Acute Anterior Cruciate Ligament Reconstruction Performed Within 10 Days of Injury Does Not Increase Risk of Postoperative Arthrofibrosis: A Systematic Review and Meta-analysis.

BACKGROUND: The optimal timing of anterior cruciate ligament (ACL) reconstruction (ACLR) remains a controversial topic. Previous reviews have demonstrated that there are no differences between early and delayed ACLR; however, these studies have been limited by heterogeneous definitions of acute ACL injury. PURPOSE: To evaluate postoperative patient functional outcomes and risk for arthrofibrosis after acute arthroscopic ACLR performed ≤10 days after injury. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: A systematic review was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using multiple medical databases. Inclusion criteria were studies that evaluated postoperative range of motion outcomes for patients undergoing ACLR ≤10 days after initial ACL injury. For included comparative studies comparing patient groups undergoing ACLR ≤10 days and patients undergoing "delayed" ACLR after ≥3 weeks of initial injury, quantitative analysis was performed to assess for differences in postoperative arthrofibrosis, reoperation rates, and patient-reported outcomes between groups. DerSimonian-Laird binary random-effects models were constructed to quantitatively describe the association between the ACLR time period and patient outcomes by generating effect estimates in the form of odds ratios with 95% CIs. Qualitative analysis was performed to describe variably reported patient outcomes and the risk of arthrofibrosis after ACLR for noncomparative studies. RESULTS: Screening yielded 6 full-text articles with 448 patients who underwent ACLR (296 ACLR <10 days, 152 ACLR >3 weeks), with a pooled mean age of 28.1 years. For studies amenable to quantitative analysis, there were no significant differences between ACLR performed ≤10 days and ACLR performed at the 3-week point or after in terms of postoperative stiffness (3 studies; odds ratio, 1.27; P = .508), Tegner scores (2 studies; mean difference, -0.056; P = .155), or reoperation for stiffness (3 studies; odds ratio, 0.869; P = .462). The overall incidence of postoperative arthrofibrosis after 12 months of follow-up was 11 of 296 (3.7%) for ACLRs performed ≤10 days versus 6 of 152 (3.9%) for those performed at the 3-week point or after. CONCLUSION: ACLR performed ≤10 days after the inciting injury does not increase the risk of postoperative arthrofibrosis and demonstrates similar patient-reported outcomes compared with ACLR performed at the 3-week point or after.

No Difference in Recurrent Instability Between Knotted and Knotless Repair Techniques in Arthroscopic Treatment of Isolated Posterior Labral Tears: A Systematic Review.

Purpose: To compare clinical failure, recurrent instability, patient-reported outcome measures (PROMs), and return to sport (RTS) between knotted and knotless fixation methods in arthroscopic posterior labral repair for isolated posterior shoulder instability (PSI). Methods: Multiple databases were queried according to Preferred Reported Items for Systematic Reviews and Meta-Analyses guidelines for clinical studies with Level I to IV evidence, including knotted and knotless suture anchors for arthroscopic posterior labral repair. Combined anterior and posterior instability, multidirectional instability, SLAP injuries, unspecified repair techniques, majority open procedures, and revision surgery were excluded. Results: Screening yielded 17 full-text articles reporting on 852 shoulders undergoing posterior labral repair. Recurrent instability ranged from 0% to 21%, and the rate of revision surgery ranged from 0% to 11% in knotted only, 0% in knotless only, and 2.0% to 8.1% in knotted and knotless studies. Six studies with both pre- and postoperative visual analog scale scores and 7 studies with both pre- and postoperative American Shoulder and Elbow Score scores all showed improvement in scores after intervention regardless of repair technique. Thirteen studies reported RTS or duty rates with a minimum of 79%. Conclusions: Overall recurrent instability after posterior labral repair for isolated PSI was low with improvement in PROMs and favorable RTS rates regardless of fixation method. There was no clear difference in recurrent instability or revision surgery between knotted and knotless fixation methods for isolated posterior labral repair. However, the current literature is predominantly limited by Level III and IV evidence. The quality of literature and lack of standardization on the definition of clinical failure and recurrent instability among surgeons preclude any definitive conclusion regarding one clinically superior fixation method. Level of Evidence: Level IV, systematic review of Level III and IV studies.

Free Functional Muscle Transfer and One Bone Forearm for Upper-Extremity Limb Salvage After High-Energy Ballistic Trauma.

Upper-extremity limb salvage following high-energy trauma poses unique challenges of massive soft tissue injury in the setting of large bone defects, traumatic segmental neurovascular injuries, and functional deficits. These complex injuries require multidisciplinary care to achieve requisite revascularization, bone stabilization, and preservation of remaining options for soft tissue coverage. This case presents a 45-year-old man who sustained a high-velocity gunshot resulting in a dysvascular limb. Through shared decision-making, upper-extremity limb salvage was pursued. Successful initial limb salvage included a reversed great saphenous vein graft from the brachial artery to the radial artery, followed by one bone forearm with nonvascularized graft from the ipsilateral distal ulna, latissimus dorsi free functioning muscle transfer with an end-to-side anastomosis to the brachial artery proximal to the vein graft, and coaptation of the anterior interosseous donor nerve from the proximal median nerve stump to the thoracodorsal recipient nerve.

What to Do When It Is Anterior Cruciate Ligament Reconstruction Number Two.

Several factors contribute to the greater complexity of revision anterior cruciate ligament reconstruction compared with primary anterior cruciate ligament reconstructive surgery. Prior tunnels and hardware may compromise revision tunnel placement and secure fixation. This may necessitate two-stage revision or specific techniques to achieve anatomic revision tunnels. Prior autograft use may limit graft options. Individuals with a failed anterior cruciate ligament reconstruction are more likely to have risk factors for further failure. These may include malalignment, occult instability, knee hyperextension, or increased tibial slope. There are also higher rates of meniscus and cartilage injuries in revision anterior cruciate ligament reconstruction that may require intervention. Successful revision anterior cruciate ligament reconstruction requires thoughtful preoperative planning along with multiple potential intraoperative plans depending on the pathology encountered. It is important to provide the orthopaedic surgeon with an up-to-date, evidence-based overview of how to approach and execute a successful revision anterior cruciate ligament reconstruction.

Biomechanical comparison of anterior cruciate ligament reconstruction fixation methods and implications on clinical outcomes.

Anterior cruciate ligament reconstruction (ACLR) is one of the more common surgeries encountered by orthopaedic surgeons, which has its inherent challenges due to the complex anatomy and biomechanical properties required to reproduce the function and stability of the native ACL. Multiple biomechanical factors from graft choice and tunnel placement to graft tensioning and fixation methods are vital in achieving a successful clinical outcome. Common methods of ACLR graft fixation in both the primary and revision setting are classified into compression/interference, suspensory, or hybrid fixation strategies with multiple adjunct methods of fixation. The individual biomechanical properties of these implants are crucial in facilitating early post-operative rehabilitation, while also withstanding the shear and tensile forces to avoid displacement and early graft failure during graft osseointegration. Implants within these categories include the use of interference screws (IFSs), as well as suspensory fixation with a button, posts, surgical staples, or suture anchors. Outcomes of comparative studies across the various fixation types demonstrate that compression fixation can decrease graft-tunnel motion, tunnel widening, and graft creep, at the risk of damage to the graft by IFSs and graft slippage. Suspensory fixation allows for a minimally invasive approach while allowing similar cortical apposition and biomechanical strength when compared to compression fixation. However, suspensory fixation is criticized for the risk of tunnel widening and increased graft-tunnel motion. Several adjunct fixation methods, including the use of posts, suture-anchors, and staples, offer biomechanical advantages over compression or suspensory fixation methods alone, through a second form of fixation in a second plane of motion. Regardless of the method or implant chosen for fixation, technically secure fixation is paramount to avoid displacement of the graft and allow for appropriate integration of the graft into the bone tunnel. While no single fixation technique has been established as the gold standard, a thorough understanding of the biomechanical advantages and disadvantages of each fixation method can be used to determine the optimal ACLR fixation method through an individualized patient approach.