Partial-Thickness Rotator Cuff Tears: Current Concepts.

¼ Partial-thickness rotator cuff tears (PTRCTs) are a common pathology with a likely high asymptomatic incidence rate, particularly in the overhead athlete.¼ The anatomy, 5-layer histology, and relationship to Ellman's classification of PTRCTs have been well studied, with recent interest in radiographic predictors such as the critical shoulder angle and acromial index.¼ Depending on the definition of tear progression, rates of PTRCT progression range from 4% to 44% and appear related to symptomatology and work/activity level.¼ Nearly all PTRCTs should be managed conservatively initially, particularly in overhead athletes, with those that fail nonoperative management undergoing arthroscopic debridement ± acromioplasty if <50% thickness or arthroscopic conversion repair or in situ repair if >50% thickness.¼ Augmentation of PTRCTs is promising, with leukocyte-poor platelet-rich plasma having the most robust body of supportive data. Mesenchymal signaling cell biologics and the variety of scaffold onlay augments require more rigorous studies before regular usage.

No difference in operative time, outcomes, cosmesis, or return to activity and/or sport after minimally invasive versus open repair of primary Achilles ruptures: a retrospective review.

PURPOSE: To compare clinical outcomes and the rate of return to sport among patients that have undergone minimally invasive repair versus open approach of an acute Achilles tendon rupture. METHODS: Patients who underwent surgical repair of acute Achilles tendon rupture at a single urban academic institution from 2017 to 2020 with minimum 2-year follow-up were reviewed retrospectively. Preinjury sport participation and preinjury work activity information, the Achilles tendon Total Rupture Score (ATRS), the Tegner Activity Scale, Patient-Reported Outcomes Measurement Information System for mobility and pain interference were collected. RESULTS: In total, 144 patients were initially included in the study. Of these, 63 patients were followed with a mean follow-up of 45.3 ± 29.2 months. The mean operative time did not significantly differ between groups (p = 0.938). Patients who underwent minimally invasive repair returned to sport at a rate of 88.9% at a mean of 10.6 ± 5.8 months, compared to return rate of open procedures of 83.7% at 9.5 ± 5.5 months. There were no significant differences in ATRS (p = 0.246), Tegner (p = 0.137) or VAS pain (p = 0.317) scores between groups. There was no difference in cosmetic satisfaction between PARS and open repair groups (88.4 vs. 76.0; p = 0.244). CONCLUSION: Patients who underwent minimally invasive repair of acute Achilles tendon ruptures demonstrate no significant differences with respect to cosmesis, operative time, patient-reported outcomes and the rate and level of return to activities when compared to an open approach. LEVEL OF EVIDENCE: III.

Tunnel Widening Following All-Inside Anterior Cruciate Ligament Reconstruction Varies Depending on Soft Tissue Graft Type.

PURPOSE: Bone tunnel widening (TW) is a well-described complication after anterior cruciate ligament reconstruction (ACLR). The purpose of this study was to evaluate radiographic bone TW and clinical outcomes in patients with ACLR performed with suspensory fixation on both the femoral and tibial tunnels using different soft tissue grafts. METHODS: Patients who underwent primary ACLR with a soft tissue graft (hamstring autograft or allograft or quadriceps autograft) using an all-inside technique were included for analysis. Anterior cruciate ligament tunnel width was measured postoperatively on anteroposterior and lateral plain radiographs at a minimum of 12 months of follow-up. Clinical outcomes were assessed using the International Knee Documentation Committee (IKDC) subjective knee form as well as assessing patient records for complication data. RESULTS: Fifty patients (15 quadriceps autografts, 24 hamstring autografts, 11 hamstring allografts) were included in this study. The quadriceps autograft cohort was the youngest, (16.6 ± 2.8 years), followed by the hamstring autograft cohort (27.7 ± 9.0 years), and the hamstring allograft cohort (48.2 ± 9.4 years; p < 0.001) for all comparisons. Quadriceps autografts experienced less tibial tunnel-widening (0.6 ± 0.6 mm) than hamstring autografts (2.0 ± 1.1 mm; p = 0.011), which, in turn, experienced less widening than hamstring allografts (3.9 ± 2.3 mm; p < 0.001). Quadriceps autografts also experienced less femoral tunnel widening (0.3 ± 0.6 mm) than hamstring autografts (2.1 ± 1.2 mm; p < 0.001) which, in turn, experienced less tunnel-widening than hamstring allografts (4.0 ± 2.1; p < 0.001). At follow-up, mean IKDC for hamstring autografts, quadriceps autografts, and hamstring allografts were 79.9 ± 17.9, 88.5 ± 7.1, and 77.7 ± 20.4, respectively (p = 0.243). There was no statistically significant difference between groups with respect to postoperative complications; p = 0.874. CONCLUSIONS: Anterior cruciate ligament reconstruction with quadriceps autograft resulted in the least tunnel widening compared to hamstring autograft and allograft when using an all-inside suspensory fixation device. Both autograft groups resulted in less widening than the allograft group. Despite the greatest increased radiographic tunnel widening in the allograft group, there was no significant difference in clinical outcomes or knee laxity.

Medial patellofemoral ligament reconstruction with a looped semitendinosus tendon, using knotless anchor fixation on the patella and hybrid fixation on the femur.

Medial patellofemoral ligament (MPFL) reconstruction is a reliable surgical method for stabilizing a dislocating patella, with multiple techniques previously described. Although outcomes are generally favorable, the procedure is technically demanding and relies on precise identification of native MPFL insertion sites, secure fixation of the graft to these sites, and appropriate graft tension. We describe a technique for MPFL reconstruction with a looped semitendinosus tendon. The 2 free limbs of the graft are secured into blind-end patellar sockets with knotless anchors, and the looped end is initially secured into a medial femoral socket with a button on the opposite (lateral) cortex. Use of an adjustable-loop button allows for gradual adjustment of graft tension, as well as re-tensioning after cycling of the knee, before final aperture fixation on the femur with an interference screw.

Leveraging the plate: reliably restoring volar tilt of distal radius fractures.

Restoration of volar tilt is critical when performing open reduction and internal fixation of distal radius fractures. A reproducible technique is required to consistently achieve this goal. A simple technique using the locking plate and an electrocautery scratch pad as reduction tools can reliably generate volar tilt. This technique can be performed with minimal aid from surgical assistants.

Return to sports after shoulder arthroplasty: a survey of surgeons' preferences.

BACKGROUND: Shoulder arthroplasty has become more prevalent, and patients undergoing shoulder arthroplasty are becoming more active. Recommendations for return to athletic activity have not recently been updated and do not consider the newest arthroplasty options. METHODS: A survey was distributed to 310 members of the American Shoulder and Elbow Surgeons, inquiring about allowed participation in 28 different athletic activities after 5 types of shoulder arthroplasty options (total shoulder arthroplasty, hemiarthroplasty, humeral resurfacing, total shoulder resurfacing, and reverse shoulder arthroplasty). RESULTS: The response rate to the survey was 30.3%, with 74.1% of respondents allowing some return to athletic activity after shoulder arthroplasty. The 28 athletic activities were grouped into 4 categories based on the load and possible impact to the shoulder. Only 51% of respondents allowed any participation in contact sports, whereas 90% allowed some participation in noncontact low-load sports. Return to sports after humeral resurfacing was highest, at 92.0% of the respondents, whereas the least percentage of surgeons allowed sports after reverse total shoulder arthroplasty, at 45.2%. CONCLUSION: The majority of surveyed surgeons allowed some return to sports after shoulder arthroplasty. Surgeons were more likely to recommend return to sports if the activities did not involve significant contact, risk of fall or collision, or application of high loads to the shoulder joint. Surgeons were also more likely to recommend return to sports if the arthroplasty did not involve the glenoid. CLINICAL RELEVANCE: The results of this survey may help surgeons counsel patients regarding return to specific athletic activities after various types of shoulder arthroplasty.

Athletic participation after hip and knee arthroplasty.

The issue of athletic participation after hip and knee arthroplasty has become more relevant in recent years, with an increase in the number of young and active patients receiving joint replacements. This article reviews patient-, surgery-, implant-, and sports-related factors, and discusses currently available guidelines that should be considered by the physician when counseling patients regarding a return to athletic activity after total joint arthroplasty. Current evidence regarding appropriate athletic participation after total hip arthroplasty, resurfacing hip arthroplasty, total knee arthroplasty, and unicondylar knee arthroplasty is reviewed.

Arthroscopically Assisted Two-stage Cementation Technique for a Periarticular Knee Lesion.

Managing skeletal metastatic disease can be a challenging task for the orthopedic surgeon. In patients who have poor survival prognoses or are poor candidates for extensive reconstructive procedures, management with intralesional curettage and stabilization with bone cement with or without internal fixation to prevent development or propagation of a pathologic fracture may be the best option. The use of bone cement is preferable over the use of bone graft, as it allows for immediate postoperative weight bearing on the affected extremity.This article describes a case where the combined use of arthroscopy and a 2-stage cementation technique may allow preservation of the articular surface and optimization of short-term functional outcome after curettage of a periarticular metastatic lesion in a patient with an end-stage malignancy. We used knee arthroscopy to identify any articular penetration or intra-articular loose bodies after curettage and initial cementation of the periarticular lesion of the distal femur. Arthroscopic evaluation was carried out again after the lesion was packed with cement to identify and remove any loose intra-articular debris. The applicability of this technique is broad, and it can be used in any procedure involving cement packing in a periarticular location. Performed with caution, this technique can be a useful adjunct to surgical management of both malignant and locally aggressive benign bone lesions in periarticular locations.

Can the Bio-Transfx pin fail during initial ACL graft insertion?

BACKGROUND: The Bio-Transfix pin is a biodegradable device used for femoral tunnel anterior cruciate ligament (ACL) graft fixation. Recent clinical studies have suggested the possibility of the pin's postoperative failure. METHODS: This investigation evaluates the initial strength of several Bio-Transfix pin ACL fixations in a simulated femoral tunnel model. The forces generated by five surgeons during simulated ACL graft tensioning were also measured. RESULTS: Average strengths of the pins ranged from 1075 to 2160 N for 10 and 8 mm tunnels, respectively, whereas the maximum surgeon-generated forces were 535 N. CONCLUSIONS: These results imply that initial fracture of the pin itself is unlikely; however, failure of the supporting bone or a decrease in pin strength due to biodegradation could account for early loss of the fixation.

A new surgical technique for arthroscopic repair of the meniscus root tear.

Injury of the meniscal root can lead to meniscal extrusion and loss of normal hoop stress distribution by the meniscus. This has been shown to result in an excessive tibiofemoral contact pressures and has been associated with development of arthritis in the affected compartment of the knee. Repair of meniscal root avulsion has been shown to restore the normal contact stresses, and several techniques for such repair have been described. We report an all-arthroscopic technique that allows anatomic reattachment of the avulsed meniscal root, applicable to both the medial or lateral menisci. Our technique utilizes a novel retrograde reaming device to create a small intraosseous socket at the meniscal tibial attachment, and may be particularly useful for repairing meniscal root avulsions in knees with multiligamentous injuries.

Cold exposure injuries to the extremities.

Cold exposure injuries comprise nonfreezing injuries that include chilblain (aka pernio) and trench, or immersion, foot, as well as freezing injuries that affect core body tissues resulting in hypothermia of peripheral tissues, causing frostnip or frostbite. Frostbite, the most serious peripheral injury, results in tissue necrosis from direct cellular damage and indirect damage secondary to vasospasm and arterial thromboses. The risk of frostbite is influenced by host factors, particularly alcohol use and smoking, and environmental factors, including ambient temperature, duration of exposure, altitude, and wind speed. Rewarming for frostbite should not begin until definitive medical care can be provided to avoid repeated freeze-thaw cycles, as these cause additional tissue necrosis. Rewarming should be rapid and for an affected limb should be performed by submersion in warm water at 104 degrees to 107.6 degrees F (40 degrees to 42 degrees C) for 15 to 30 minutes. Débridement of necrotic tissues is generally delayed until there is a clear demarcation from viable tissues, a process that usually takes from 1 to 3 months from the time of initial exposure. Immediate escharotomy and/or fasciotomy is necessary when circulation is compromised. In addition to the acute injury, frostbite is associated with late sequelae that include altered vasomotor function, neuropathies, joint articular cartilage changes, and, in children, growth defects caused by epiphyseal plate damage.

Pediatric osteoblastoma of the sternum: a new surgical technique for reconstruction after removal: case report and review of the literature.

Benign osteoblastoma is a rare tumor of bone that has been reported in a variety of skeletal locations. A case of an isolated benign osteoblastoma in the sternum of an 11-year-old boy is described. In the chest wall, osteoblastoma has been reported in the ribs, and rarely in the sternum. To the authors' knowledge, this is the first report of an isolated sternal osteoblastoma in a child presented in the literature. The clinical and radiologic presentation of osteoblastoma is discussed, as well as an approach for reconstruction of the sternal defect following removal of the tumor. Experience with sternal reconstruction in the pediatric population is limited. This case demonstrates that osteoblastoma of the sternum can be successfully treated with wide resection and that sternal defect reconstruction can be accomplished successfully in a child.