Modified Lemaire Lateral Extra-Articular Tenodesis Using an Inlay Technique and All-Suture Knotless Anchor Fixation.

Appreciation of persistent anterolateral rotatory instability and graft failure after anterior cruciate ligament (ACL) reconstruction procedures has led surgeons to adopt the addition of lateral extra-articular tenodesis (LET) in both the revision and primary setting. Multiple techniques have been shown to eliminate anterolateral rotatory instability and reduce forces on the ACL graft, which has translated to lower re-rupture rates and improved patient outcomes. The risk of ACL/LET tunnel convergence can potentially compromise the fixation of one or both graft reconstructions. This article describes a technique for LET fixation which minimizes the depth of the LET femoral bone socket and utilizes low-profile implants thus mitigating this risk.

Primary anterior cruciate ligament repair: Current concepts.

The renewed interest in ACL repair over the last two decades stems from advances in modern arthroscopic techniques and clinical studies that have provided evidence that the ACL can reliably heal, and patients can return to sport at a comparable rate to ACL reconstruction patients. The ability to maintain and utilize native ACL tissue, with proprioceptive capabilities, and the smaller drill tunnels needed to repair an ACL leads to an overall less invasive procedure and improved early rehabilitation. Additionally, repair avoids a variety of comorbidities associated with autograft harvest. This current concept review details modern techniques of ACL repair and their current studies, a review on the use of biologic enhancement in ACL repair, and other considerations to appropriately integrate ACL repair into the sports medicine orthopaedic surgeon's practice.

Refractory shoulder injury related to vaccine administration: correlation with culture presence of Cutibacterium acnes.

Background: Shoulder pain following intramuscular administration of vaccine is common. However, a small number of patients experience prolonged pain and dysfunction atypical to normal transient postvaccination shoulder pain. Shoulder Injury Related to Vaccine Administration (SIRVA) remains incompletely understood, whether a robust immune response to vaccine antigen or inappropriate injection technique with needle placement in synovial or bursal tissue, or some combination of the two. Symptoms overlap with those of Cutibacterium acnes (C. acnes) infection but the relationship between the two, if any, has not been evaluated. Methods: Clinical case files were reviewed for 3 cases of SIRVA with positive cultures for C. acnes were reviewed. Presentation, treatment, and clinical outcomes were compared. Results: In all cases, patients were thin (body mass index < 23), females, who had high injection placement of a vaccine, all patients had positive magnetic resonance imaging findings of increased signal in the subacromial bursa, and/or greater tuberosity. All patients underwent arthroscopic débridement and culture harvest and cultures were positive for C. acnes. A combination of oral and intravenous antibiotics was used, and all patients demonstrated clinical improvement from the preoperative state. Discussion: This case series presents 3 patients with refractory SIRVA who ultimately underwent arthroscopic irrigation and débridement with culture biopsy. Each case had culture results positive for C. acnes and all responded, at least partially, to arthroscopic débridement and intravenous antibiotic therapy. The purpose of this manuscript is to raise awareness of potential coexistence of SIRVA and C. acnes which may be of assistance to surgeons treating refractory cases of SIRVA.

Editorial Commentary: The Timing and Treatment of Combined Anterior Cruciate Ligament-Medial Collateral Ligament Injuries: Conservative Management, Early Repair, Augmentation, and Delayed Reconstruction of the Medial Collateral Ligament.

Medial collateral ligament (MCL) injuries are commonly encountered in conjunction with anterior cruciate ligament injuries. MCL tears do not universally heal, and residual MCL laxity is not always well tolerated. Although residual MCL laxity results in excess stress on an anterior cruciate ligament reconstruction and may require additional treatment, relatively little interest has been paid to concomitant treatment. Adherence to the dogma of universal conservative treatment of MCL tears in this setting squanders opportunities for preservation of native anatomy and improvements in patient outcomes. Although we currently lack the necessary information to provide evidence-based decision making for combined injuries, the time has come to renew both clinical interest and research interest in pursuing better management of these injuries in high-demand patients.

"Triple Package" Modified SpeedBridge Rotator Cuff Repair Technique.

Treatment of full-thickness rotator cuff repairs vary in surgical technique depending on many factors including tear geometry, delamination of soft tissue, tissue quality, and rotator cuff retraction. The described technique presents a reproducible method of addressing tear patterns where the tear may be larger laterally, but the medial footprint exposure is small. This can be addressed with a single medial anchor combined with a knotless lateral-row technique to provide compression for small tears or two medial row anchors for moderate to large tears. In this modification of the standard knotless double row (SpeedBridge) technique, 2 medial row anchors are used, with 1 augmented with additional fiber tape and an additional lateral row anchor to create a triangular repair construct, increasing the size and stability of the footprint of the lateral row.

Harvest of All-Soft Tissue Quadriceps Tendon Autograft for Anterior Cruciate Ligament Reconstruction With or Without Closure of Resulting Defect Has No Effect on Patellar Height.

Purpose: To evaluate the radiographic effect of quadriceps tendon harvest on patellar height and to determine whether closure of a quadriceps graft harvest defect resulted in a significant change in patellar height compared to nonclosure. Methods: We conducted a retrospective review of prospectively enrolled patients. The institutional database was queried and all patients who underwent quadriceps autograft anterior cruciate ligament reconstruction between 2015 and March 2020 were included. Graft harvest length in millimeters and final graft diameter after preparation for implantation were obtained from the operative record and demographic data were obtained from the medical record. Radiographic analysis was performed of eligible patients using standard ratios of patellar height: Insall-Salvati (IS), Blackburn-Peele (BP), and Caton-Deschamps (CD). Measurements were performed using digital calipers on a digital imaging system by 2 postgraduate fellow surgeons. Preoperative and postoperative radiographs were performed at 0° according to a standard protocol. Postoperative radiographs were performed 6 weeks postoperatively in all cases. Preoperative patellar height ratios were compared with postoperative patellar height ratios for all patients using t-tests. Subanalysis was then performed to compare the effect of closure of with nonclosure on patellar height ratios using repeated-measures analysis of variance. Interrater reliability between the 2 reviewers was assessed using an intraclass correlation coefficient calculation. Results: In total, 70 patients met final inclusion criteria. There were no statistically significant changes from pre- to postoperative values for either reviewer for IS (reviewer 1, P = .47; reviewer 2, P = .353), BP (reviewer 1, P = .98; reviewer 2, P = .907), or CD (reviewer 1, P = .107; reviewer, 2 P = .188). The closure and nonclosure groups were adequately powered and no statistically significant demographic differences between the closure and nonclosure groups was identified for sex (P = .066), age (P = .343), weight (P = .881), height (P = .42), laterality (P = 1), meniscal repair (P = .332), graft diameter (P = .068), or graft length (P = .183). According to the repeated measures analysis of variance, closure of the quadriceps defect had no significant impact on any of the knee ratios. However, reviewer identity had a significant influence on the CD ratio. Intraclass correlation coefficient analysis revealed excellent agreement between reviewers for the IS (0.982) and BP (0.954) ratios, but only moderate-to-good agreement for the CD (0.751) ratio. Conclusions: Harvest of quadriceps tendon graft does not result in radiographic changes in patellar height. Furthermore, closure of the quadriceps defect does not appear to result in radiographic changes in patellar height. Level of Evidence: III, retrospective comparative trial.

Modified Bosworth Technique for Medial Collateral Ligament Reconstruction of the Knee Using Semitendinosus Tendon Autograft.

The medial collateral ligament (MCL) is a major contributor to knee joint stability and is the most common ligament involved in knee injuries. When conservative management for high-grade MCL injuries fails, operative treatment is indicated. Various reconstruction techniques are described in the literature. The following report describes a reconstruction technique based on the modified Bosworth. We present a step-by-step technique for using autograft semitendinosus tendon as a double limb to reconstruct the MCL and if necessary, the posterior oblique ligament. The technique is versatile with respect to a spectrum of MCL injury patterns, isometric, incorporates techniques that are common to other knee reconstructions, and uses readily available autograft. It has been used extensively by the senior authors as an adjunct/augmentation to the repair of acute MCL injuries as well as in the reconstruction of chronic MCL laxity. The technique restores stability to rotation and valgus stress while maintaining the distal insertion of the semitendinosus intact.

Osteochondral Allograft Transplantation Of Posterior Femoral Condyle Lesions Utilizing An Open Posterior Approach To The Knee.

Osteochondral allograft transplantation is a viable option for large chondral defects >2 cm squared, as well as in a revision setting after failure of a previous surface chondral restoration procedure. Osteochondral lesions involving the posterior aspect of the femoral condyle, however, are less common and easily underappreciated. Treatment of posterior osteochondral lesions is more technically demanding because they cannot be adequately addressed through standard arthroscopic approaches or an anterior arthrotomy. The challenges of the posterior approach include the relative unfamiliarity for many surgeons and the inherent risks due to the proximity of the neurovascular structures. The following technique reviews relevant anatomy and approach to osteochondral allograft transplant involving the posterior femoral condyles.

Editorial Commentary: Recovery After Anterior Cruciate Ligament Reconstruction Is Optimal About 85% of the Time.

Recovery after anterior cruciate ligament reconstruction is optimal about 85% of the time. Revision surgery, psychiatric history, preoperative chronic knee pain, and subsequent knee injury are associated with suboptimal recovery patterns. Sophisticated growth models can analyze patient recovery trajectories. Growth mixture models (GMM) treat a whole cohort as a single group and characterize that group over time, for example, over the course of knee injury and subsequent recovery after surgical reconstruction. Latent class growth analysis is a subcategory of GMM that sorts the cohort into subgroups and allows analysis regarding groups having, for example, standard, delayed, and suboptimal recoveries. This theoretically allows a physician to anticipate which patients are likely to follow a suboptimal trajectory of recovery, to track that recovery based on the model, and to form a treatment plan accordingly.

Modified Technique for Arthroscopic Bursal Acromial Reconstruction Utilizing Acellular Dermal Allograft.

Treatment options for massive irreparable rotator cuff tears continue to evolve. Recently bursal acromial reconstruction (BAR) has been described as an additional option to reduce pain and improve comfort. As originally described, an acellular dermal allograft is secured to the underside of the acromion as an interposition graft. We describe a modified technique that facilitates suture passage, reduces entanglement, and optimizes contact between the bone-graft interface.

The thermal profile of self-tapping screws: The effect of insertion speed, power insertion, and screw geometry on heat production at the bone-screw interface.

INTRODUCTION: Power insertion of screws using high-speed saves time during operative fixation of fractures compared to manual insertion. Heat production during screw insertion may cause thermal damage at the critical bone-screw interface, reducing fixation strength, delaying healing, or increasing infection risk. Currently, the thermal impact of screw insertion is incompletely understood. This study investigated the thermal profiles of self-tapping screws at varying insertion speeds, utilizing manual versus power insertion, and with differing cutting flute geometries to determine which variables may save time while mitigating thermal injury. METHODS: Thermal and mechanical force profiles were obtained during insertion of 24 mm length, 3.5 mm stainless steel screws into 50 PCF polyurethane after pre-drilling. Power insertion at low (30RPM) and high (300RPM) speed, manual screwdriver insertion versus high-speed power insertion, and two different cutting flute geometries were compared. Infrared thermography was used to measure maximum surface temperatures and mean temperature change (°C). Time (s) was measured to compare manual and power insertion. Means were compared using a two-tailed independent t-test. RESULTS: Maximum surface temperature of high-speed insertion (55.42 ± 5.58 °C) was significantly greater (p < 0.001) than low-speed (41.07 ± 2.33 °C). Similarly, mean temperature rise of high-speed insertion (29.52 ± 5.39 °C) was greater than that of low-speed (15.13 ± 2.63 °C) (p < 0.001). There was no statistical difference in maximum surface temperature between manually inserted screws (56.58 ± 5.53 °C) and high-speed power inserted screws (55.42 ± 5.58 °C) (p = 0.155), while insertion speeds were almost 5 times faster with high-speed power insertion (6.75 ± 1.84 s) than with manual insertion (30.3 ± 4.06 s) (p < 0.001). There were no differences detected between the geometry groups in any outcome measure tested. CONCLUSION: High speeds for screw insertion generate significantly greater maximum temperatures and greater temperature rise than slower speeds. Surprisingly, the thermal profile of manual insertion was similar to high-speed insertion, while requiring significantly longer for insertion. Low-speed insertion generated significantly lower maximal temperatures and temperature rise. Surgeons could consider utilizing low-speed when inserting orthopaedic screws with a power driver to minimize thermal impact to bone while optimizing efficiency.

An Arthroscopic Technique for Release of the Middle Glenohumeral Ligament and the Effect on External Rotation of the Shoulder.

The middle glenohumeral ligament (MGHL) is well recognized as a primary stabilizer of the shoulder. Its role in shoulder pathologies such as adhesive capsulitis, subscapularis tendon tear, and glenohumeral arthritis is less understood. Biomechanically, the MGHL plays an important role in range of motion, specifically involving normal and pathologic external rotation in less than 45° of abduction. In this Technical Note, we present a technique for arthroscopic release of the MGHL in the setting of a stable shoulder with preoperative loss of external rotation and a patient at risk for postoperative restriction of external rotation.

Arthroscopically Assisted Fixation of Terrible Triad Variant Injuries of the Elbow With Small-Bore Needle Arthroscopy.

The range of diagnostic and therapeutic applications of needle arthroscopy (NA) continue to expand due to advances in image quality and resolution. Minimally invasive techniques can be augmented by the smaller camera size and reduced fluid use made possible by NA. Small-bore arthroscopy presents opportunities for use in smaller joints, such as the elbow, where applications of standard arthroscopic equipment may be limited by small anatomic spaces and fluid extravasation. In this Technical Note, we present our technique for NA-assisted treatment of terrible triad injuries, specifically in the setting of an intact radial head. The technique describes a stepwise approach to arthroscopically aided fixation of the coronoid process, followed by open reconstruction of the lateral collateral ligament complex.

Transtendinous Rotator Cuff Tear Repair with Bone Marrow Aspirate Concentrate Dermal Allograft Augmentation.

Rotator cuff tears involving the musculotendinous junction with a significant amount of tendon still attached to the footprint laterally represent a challenging scenario for shoulder arthroscopists. Because of these challenges, adjunctive techniques to bridge tissue gaps may be required, and biologic augmentation may be considered to improve the healing environment. The following technique presents a stepwise approach to accomplishing the dual goals of a stable anatomic repair and biologic augmentation of this difficult pattern of rotator cuff pathology.

Diagnostic and Therapeutic Shoulder Arthroscopy Using a Small-Bore Needle Arthroscope.

As resolution and image quality improve, several potential advantages make needle arthroscopy (NA) appealing for broader therapeutic applications in the operating room. Smaller camera size and weight allow for a minimally invasive approach with smaller incisions than standard arthroscopy and decreased use of arthroscopic fluid. Differences in the technology, such as a 0° optic and less rigid instrumentation, necessitate a modified technique to accommodate thorough diagnostic arthroscopy as well as modified approaches to therapeutic procedures. This article introduces our preferred approach to diagnostic arthroscopy of the glenohumeral joint and subacromial space with needle arthroscopy and small-bore instruments. This technique could increase efficiency and decrease operative time with certain arthroscopic procedures, and it may improve patient outcomes.

Diagnostic Needle Arthroscopy and Partial Medial Meniscectomy Using Small Bore Needle Arthroscopy.

As resolution and image quality improve, several potential advantages make needle arthroscopy (NA) appealing for broader therapeutic applications in the operating room. The smaller camera size and weight allow for a minimally invasive approach with smaller incisions than standard arthroscopy and decreased arthroscopic fluid use. Differences in the technology, such as a 0-degree optic and less rigid instrumentation necessitate a novel technique to accommodate thorough diagnostic arthroscopy as well as new approaches to therapeutic procedures. This manuscript introduces our preferred approach to diagnostic arthroscopy and partial medial meniscectomy with NA and small-bore instruments. The minimally invasive nature of this technology may decrease postoperative pain and improve return of comfort and function.

A Dual-Motor Drill Reduces Plunge, Simultaneously Gauges Depth, and Saves Time When Placing Orthopedic Screws.

The technique for placement of orthopedic hardware remains unchanged despite technological advances. The surgeon controls drill bit speed and advancement, which risks drill bit overpenetration, or plunge. Measurement is performed as an additional step, introducing measurement error and increasing operative time. A dual-motor drill was created to control drill variables and combine drilling and measurement into a single step. The purpose of this study was to determine whether a dual-motor drill could reduce drilling and measurement errors while increasing the speed of placement of orthopedic hardware. Five orthopedic surgeons drilled and measured 10 holes with a standard drill and a dual-motor drill in randomized bicortical bone blocks. The bone blocks were placed on standard ballistic gels, which left a defect from drill bit overpenetration that could be measured with a calibrated gauge. The accuracy of drilling was determined by the depth of the defect in the ballistic gel and was compared between groups. Finally, time for drilling and measurement was collected and compared between groups. Overpenetration for the dual-motor drill (0.5±0.3 mm) was significantly less than for the standard drill (8.4±1.9 mm) (P<.0001). Depth measurement error for the dual-motor drill (0.6±0.3 mm) was significantly less than for the standard drill (2.6±0.5 mm) (P<.0001). Drilling and measurement time for the dual-motor drill (6.0±2.2 seconds) was significantly less than for the standard drill (13.4±3.9 seconds) (P<.0001). Use of a dual-motor drill reduced overpenetration, improved measurement accuracy, and reduced time spent during placement of orthopedic hardware. [Orthopedics. 2020;43(5):e465-e470.].

Editorial Commentary: The Surgeon Is the Method: Be Thoughtful and Methodical When Adopting New Techniques.

Arthroscopic and open Latarjet procedures can achieve similar results with similar complication rates and a low risk of recurrent instability, but these results may not be generalizable to every surgeon or practice. When considering a new procedure, surgeons should thoughtfully consider a stepwise approach to acquiring new skills and avoiding complications.