The Windshield Wiper Sign, An Instability-Related Osteochondral Defect of the Anterolateral Femoral Head.

PURPOSE: To investigate a radiographic sign believed to be indicative of hip instability and acetabular suction seal disruption in the native hip, coined the "windshield wiper" (WSW) sign. MATERIALS AND METHODS: A retrospective review was performed for patients who underwent periacetabular osteotomy (PAO) with the senior author between March 2021 and September 2023. A WSW sign was identified on plain films as a concave or flat osteochondral defect on the anterolateral femoral head extending medial to the head-neck junction with resultant loss of femoral head sphericity in the native hip. Every patient underwent a standardized series of radiographs, as well as computed tomography and magnetic resonance imaging. All patients underwent arthroscopy prior to PAO to address intra-articular pathology and other indicated procedures. The osteochondral defect and resultant suction seal disruption were verified during arthroscopy. These patients were then compared with a control group of arthroscopically treated hips without hip instability. RESULTS: Of 250 patients reviewed, a total of 19 hips in 17 patients (prevalence of 7.6%) demonstrated radiographic evidence of the WSW sign. All patients with a WSW sign presented with symptomatic clinical hip instability requiring a PAO. The mean patient age was 31.2 years, with a mean lateral center edge angle (LCEA) of 14.3 degrees. There were 13 hips (68.4%) with dysplasia, 4 (21.1%) with borderline dysplasia, and 2 (10.5%) with a normal LCEA. All patients with a WSW sign and LCEA ≥20° displayed significant femoral antetorsion abnormalities. All arthroscopic videos and images demonstrated a compromised suction seal. Of the 50 control group hips reviewed, the WSW sign was not identified. CONCLUSIONS: The WSW sign is an uncommon radiographic finding in patients with hip instability. When identified, it can be predictive of substantial instability, especially in cases which are otherwise considered borderline dysplasia or normal based on LCEA. LEVEL OF EVIDENCE: III, case-control study.

Following Anterior Cruciate Ligament Reconstruction With Bone-Patellar Tendon-Bone Autograft, the Incidence of Anterior Knee Pain Ranges From 5.4% to 48.4% and the Incidence of Kneeling Pain Ranges From 4.0% to 75.6%: A Systematic Review of Level I Studies.

Purpose: To (1) perform a systematic review of level I randomized controlled trials (RCTs) detailing the incidence of anterior knee pain and kneeling pain following anterior cruciate ligament reconstruction (ACLR) with bone-patellar tendon-bone (BPTB) autograft and (2) investigate the effect of bone grafting the patellar harvest site on anterior knee and kneeling pain. Methods: A systematic review of level I studies from 1980 to 2023 was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The primary outcome evaluated was the presence of donor site morbidity in the form of anterior knee pain or kneeling pain. A secondary subanalysis was performed to assess for differences in the incidence of postoperative pain between patient groups undergoing ACLR with BPTB receiving harvest site bone grafting and those in whom the defect was left untreated. Results: Following full-text review, 15 studies reporting on a total of 696 patients met final inclusion criteria. Patients were followed for an average of 4.78 years (range, 2.0-15.3), and the mean age ranged from 21.7 to 38 years old. The incidence of anterior knee pain, calculated from 354 patients across 10 studies, ranged from 5.4% to 48.4%. The incidence of postoperative pain with kneeling was determined to range from 4.0% to 75.6% in 490 patients from 9 studies. Patients treated with bone grafting of the BPTB harvest site had no significant difference in incidence of any knee pain compared with those who were not grafted, with incidences of 43.3% and 40.2%, respectively. Conclusions: Based on the current level I RCT data, the incidences of anterior knee pain and kneeling pain following ACLR with BPTB autograft range from 5.4% to 48.4% and 4.0% to 75.6%, respectively. Level of Evidence: Level I, systematic review of RCTs.

Arthroscopic Femoral Head Allograft With Proximal Femoral/Periacetabular Osteotomies for Sequelae of Perthes: A Case Report.

CASE: We describe the unique case of a 20-year-old man with a history of Legg-Calve-Perthes disease, hip dysplasia, and osteochondral fragmentation of the medial femoral head. We performed arthroscopic femoroplasty and femoral head allografting, followed by a valgus-producing derotational femoral osteotomy (DFO) and periacetabular osteotomy (PAO). At 1-year follow-up, the patient achieved osseous union and complete femoral head healing with return to his active hobbies. CONCLUSION: We describe the successful utilization of arthroscopic allografting for medial femoral head osteochondral fragmentation. To our knowledge, this is the first report on femoral head arthroscopic allografting before DFO and PAO.

Patients Undergoing Postless Hip Arthroscopy Demonstrate Significantly Better Patient-Reported Outcomes and Clinically Significant Outcomes Compared to Conventional Post-Assisted Hip Arthroscopy at Short-Term Follow-Up.

PURPOSE: To prospectively compare the short-term clinical outcomes of patients undergoing hip arthroscopy with versus without the use of a perineal post. METHODS: A prospective, single-surgeon cohort study was performed on a subset of patients undergoing hip arthroscopy between 2020 and 2022. A post-free hip distraction system was used at 1 center at which the senior author operates, and a perineal post was used at another surgical location. An electronic survey of patient-reported outcome measures (PROMs) was completed by each patient at a minimum of 1 year postoperatively. PROMs included a visual analog scale for pain; University of California, Los Angeles (UCLA) Activity Scale; modified Harris Hip Score (mHHS); Hip Outcome Score-Sports-Specific Subscale (HOS-SSS); and a Single Assessment Numeric Evaluation. Postoperative scores and clinically significant outcomes, including the minimal clinically important difference, substantial clinical benefit, and patient acceptable symptom state, for each PROM were compared between groups. RESULTS: Sixty-nine patients were reached for follow-up (41 post, 28 postless) of 87 patients eligible for the study (79%). No significant differences were found between groups in terms of sex (post: 61% female, postless: 54% female, P = .54), age (post: 34 years, postless: 29 years, P = .11), body mass index (post: 26, postless: 24, P = .23), or follow-up duration (post: 24.4 months, postless: 21.3 months, P = .16). There was a significantly higher visual analog scale (3.1 vs 1.4, P = .01), a significantly lower UCLA Activity Scale score (7.0 vs 8.4, P = .02), and a significantly lower mHHS (73.7 vs 82.2, P = .03) in the post-assisted group. A significantly higher proportion of patients in the postless group achieved a patient acceptable symptom state for the UCLA (89.3% vs 68.3%, P = .04), mHHS (84.6% vs 61.0%, P = .04), and HOS-SSS (84.0% vs 61.0%, P = .048) and a substantial clinical benefit for HOS-SSS (72.0% vs 41.5%, P = .02). One patient (2.6%) in the post group underwent revision hip arthroscopy, and another was indicated for total hip arthroplasty by the time of follow-up. CONCLUSIONS: Postless hip arthroscopy may result in better clinical outcomes compared with post-assisted hip arthroscopy. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Medial Ulnar Collateral Ligament Reconstruction With Allograft Provides Excellent Clinical Outcomes, High Rates of Return to Play, and a Low Incidence of Postoperative Complications: A Systematic Review.

PURPOSE: To perform a systematic review evaluating clinical outcomes in patients undergoing medial ulnar collateral ligament reconstruction (MUCLR) with soft-tissue allograft. METHODS: A systematic review of the literature was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The primary outcomes evaluated were patient-reported outcome scores, return to play (RTP) rates, incidence of postoperative complications, and rates of graft rupture or mechanical failure. RESULTS: The literature search identified 395 articles, and 5 studies met final inclusion criteria after full-text review. A total of 274 patients were analyzed in the included studies and follow-up ranged from 3.0 to 7.6 years. Two studies (number of patients = 141) reported outcomes exclusively of MUCLR with allograft, whereas 3 studies (number of patients = 133) reported outcomes in patients undergoing MUCLR with either allograft or autograft. Allograft sources included gracilis, semitendinosus, plantaris, peroneus longus, and palmaris longus. Level of patient athletic competition ranged from recreational athletes to the professional level; however, nonathletes in the setting of trauma were also included. The RTP rate after MUCLR with soft-tissue allograft was 95.3%, and 89.3% of patients returned to a similar or greater level of play postoperatively. The Timmerman-Andrews score was reported in 2 studies, and the means postoperatively ranged from 94.55 to 97. Postoperative complication rates were low (range, 0% to 20%), and there were no reported incidences of allograft rupture or mechanical failure. CONCLUSIONS: Based on the available data, soft-tissue allograft for MUCLR in athletic patient populations provides excellent clinical outcomes, high rates of RTP, and low rates of postoperative complications and graft failure at short-term follow-up. There remains a lack of high-quality evidence directly comparing autograft versus allograft outcomes in elite overhead-throwing athletes to support allograft as an acceptable alternative for MUCLR in this patient population. LEVEL OF EVIDENCE: Level IV, systematic review of Level III-IV studies.

The Everted Acetabular Labrum: Outcomes of Surgical Management.

BACKGROUND: An everted acetabular labrum (EL) is a pathologic variant in which the labrum is flipped to the capsular side of the acetabular rim. An iatrogenic EL is a known complication of a poorly executed labral repair, and a recent study described the native acetabular EL. PURPOSE: To analyze surgical outcomes after advancement or reconstruction of an EL in a native hip. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: This was a multicenter retrospective review of prospectively collected data on primary hip arthroscopic surgeries performed between 2013 and 2023. An EL was identified arthroscopically as a labrum-femoral head gap while off traction in the native hip. All patients with EL who were analyzed in this study underwent arthroscopic labral repair and advancement or labral augmentation or reconstruction. Patients with hip dysplasia also underwent periacetabular osteotomy with or without a derotational femoral osteotomy. Patient-reported outcomes (PROs) were assessed using the 12-item International Hip Outcome Tool (iHOT-12) and the Nonarthritic Hip Score. PROs were obtained preoperatively and up to 24 months after surgery. PROs were compared with those of a case-matched control cohort in a 1:2 ratio. Only patients with PROs available at ≥1 year postoperatively were included in the outcome analysis. RESULTS: A total of 111 patients (129 hips) with EL during the study period were identified, with PROs available in 96 hips. The mean age of patients with EL was 30.5 years, and women made up 87% of the cohort. Of the 129 hips with an EL, an isolated diagnosis of an EL was present in 11.6% of hips. Deficient acetabular coverage (lateral center-edge angle <25°) was seen in 40.6% of EL hips. No difference was seen in iHOT-12 scores between EL and control groups at 12- or 24-month follow-up (P = .18 and .94, respectively). Patients with EL reported a significant improvement of PROs at latest follow-up (P < .001 for iHOT-12 and Nonarthritic Hip Score). CONCLUSION: Surgical management of a native EL with restoration of the labral seal on the femoral head and correction of concomitant pathologies resulted in significant clinical improvement, with postoperative outcome scores comparable to those of patients without an EL. These findings provide evidence supporting surgical intervention for a native EL.

Virtual and Augmented Reality Simulators Show Intraoperative, Surgical Training, and Athletic Training Applications: A Scoping Review.

PURPOSE: To review published literature to identify and evaluate the effect of virtual reality (complete immersion) and augmented reality (overlay of digital information onto the physical world) simulators on intraoperative use for orthopaedic surgeons, orthopaedic surgical education, and athletic training. METHODS: A systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify studies, published since 2014, that evaluated the role of augmented/virtual reality on intraoperative use for orthopaedic surgeons, orthopaedic surgical education, and athletic training. RESULTS: Virtual reality (VR) simulators provide 3-dimensional graphical simulation of the physical world, and augmented reality (AR) simulators overlay digital information onto the physical world. Simulators can include interactive features (i.e., replication of intraoperative bleeding), haptic feedback, and unrestricted task repetition, and they can record, compare, and analyze performance while being easily accessible and eliminating the need for the presence of a mentor or coach. Four studies reported on VR for intraoperative use, 47 studies on surgical education, and 10 studies on athletic training. Two studies revealed the advantages of using VR simulation during intraoperative procedures, specifically showcasing its benefits for elbow arthroscopy, while 2 studies demonstrated similar positive outcomes for hip arthroscopy. Seventeen studies demonstrated that a VR simulator could be a beneficial tool to assist in surgical education for the knee, while 12 studies found that VR simulation is a valuable tool for aiding in surgical education of shoulder arthroscopy. Ten studies demonstrated that VR simulation improves skills in the operating room. Three studies revealed that individuals with more experience exhibit superior performance on these simulators compared to those with less experience. In the realm of athletic training, 10 studies showcased the potential of VR simulation to play a significant role in athletic performance and injury rehabilitation. CONCLUSIONS: VR simulation shows benefits in the operating room, is a valuable tool for surgical education resulting in improved skills, and can be used to enhance athletic performance and injury rehabilitation. CLINICAL RELEVANCE: Understanding that VR simulators can improve surgical outcomes, surgical skill training, and athletic training and rehabilitation could facilitate development and adoption of this advanced technology.

The Addition of a Pericapsular Nerve Group Block for Postoperative Pain Control Does Not Result in Less Narcotic Use After Hip Arthroscopy: A Systematic Review.

Purpose: To perform a systematic review of clinical studies evaluating the pericapsular nerve group (PENG) block in patients undergoing hip arthroscopy. Methods: A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify comparative studies of patients undergoing the PENG block before hip arthroscopy. The search phrase used was hip arthroscopy pericapsular nerve block. Patients were evaluated based on analgesic consumption, time to discharge from the postanesthesia care unit (PACU), and pain scores (Numeric Rating Scale and visual analog scale). The Modified Coleman Methodology Score was used to evaluate study methodology quality. Results: Five studies (2 Level I, 3 Level III) met inclusion criteria. The 5 studies included the following comparison groups: 0.9% normal saline injection, general anesthesia alone, and general anesthesia with intraoperative pericapsular bupivacaine injection. The 2 randomized controlled trials included in this review reported no significant difference between groups regarding opioid consumption. One of these did not find any statistically significant differences in their secondary outcomes either, including patient satisfaction with analgesia, opioid-related adverse events, or persistent opioid use at 1 week. However, the other 3 studies found significantly lower opioid consumption in patients receiving the PENG block versus the control group intraoperatively, in the PACU, and/or postoperatively. Four studies reported significantly lower pain levels in the PENG block group compared with the control groups, measured differently in each study: 24 hours postoperatively, initial pain score in the PACU, mean score in the PACU, and highest score in the PACU. None of the studies found significantly worse outcomes in the PENG block group compared to the comparison group. Conclusions: Systematic review of randomized controlled trials shows that patients undergoing hip arthroscopy who receive a PENG block do not consume fewer opioids for postoperative pain control than patients who do not receive the block. Level of Evidence: Level III, systematic review of Level I-III studies.

Insufficient Evidence for Anterior Cruciate Ligament Reconstruction Utilizing Suture Tape Augmentation: A Systematic Review of Clinical Outcomes at Minimum 1-Year Follow-up.

PURPOSE: To perform a systematic review of clinical studies to directly compare clinical outcomes of patients undergoing anterior cruciate ligament reconstruction (ACLR) with versus without suture tape (ST) augmentation. METHODS: A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify comparative studies directly comparing outcomes of ACLR with versus without ST augmentation with a minimum follow-up of 12 months. The search terms used were anterior cruciate ligament suture tape. Patients were evaluated based on graft failure rates, return to sport (RTS), anteroposterior (AP) laxity, and patient-reported outcomes (PROs). RESULTS: Five studies (all Level III) met inclusion criteria, including a total of 246 patients undergoing ACLR with ST augmentation (SA group) and 282 patients undergoing ACLR without augmentation (control group). Patient age ranged from 14.9 to 29.7 years. The mean follow-up time ranged from 24.0 to 48.6 months. The mean body mass index ranged from 25.3 to 26.3 kg/m2 and the overall percentage of males ranged from 43.4% to 69.0%. Overall, the graft failure rate ranged from 1.0% to 25.0% in the SA group and 8.0% to 20.0% in the control group. Among the studies that reported RTS rates, the rate ranged from 69.2% to 88.9% in the SA group and 51.5% to 87.5% in the control group. Among all PROs, 2 studies found a significant difference in the Tegner score favoring the SA group. Otherwise, no significant differences were found between groups in terms of PROs. No significant differences in AP laxity were found between groups within any particular study. There was heterogeneity between studies regarding surgical techniques, postoperative rehabilitation protocols, and reported PROs. CONCLUSIONS: There is insufficient evidence to suggest that patients undergoing ACLR with ST augmentation may experience favorable clinical outcomes compared with ACLR alone. LEVEL OF EVIDENCE: Level III, systematic review of Level III studies.

Single-Strand "Short Isometric Construct" Medial Collateral Ligament Reconstruction Restores Valgus and Rotational Stability While Isolated Deep MCL and Superficial MCL Reconstruction Do Not.

BACKGROUND: Historical MCL (medial collateral ligament) reconstruction (MCLR) techniques have focused on the superficial MCL (sMCL) to restore valgus stability while frequently ignoring the importance of the deep MCL (dMCL) in controlling tibial external rotation. The recent recognition of the medial ligament complex importance has multiple studies revisiting medial anatomy and questioning contemporary MCLR techniques. PURPOSE: To assess whether (1) an isolated sMCL reconstruction (sMCLR), (2) an isolated dMCL reconstruction (dMCLR), or (3) a novel single-strand short isometric construct (SIC) would restore translational and rotational stability to a knee with a dMCL and sMCL injury. STUDY DESIGN: Controlled laboratory study. METHODS: Biomechanical testing was performed on 14 fresh-frozen cadaveric knee specimens using a custom multiaxial knee activity simulator. The specimens were divided into 2 groups. The first group was tested in 4 states: intact, after sectioning the sMCL and dMCL, isolated sMCLR, and isolated dMCLR. The second group was tested in 3 states: intact, after sectioning the sMCL and dMCL, and after single-strand SIC reconstruction (SICR). In each state, 4 loading conditions were applied at 0°, 20°, 40°, 60°, and 90° of knee flexion: 8-N·m valgus torque, 5-N·m external rotation torque, 90-N anterior drawer, and combined 90-N anterior drawer plus 5-N·m tibial external rotation torque. Anterior translation, valgus rotation, and external rotation of the knee were measured for each state and loading condition using an optical motion capture system. RESULTS: sMCL and dMCL transection resulted in increased laxity for all loading conditions at all flexion angles. Isolated dMCLR restored external rotation stability to intact levels throughout all degrees of flexion, yet valgus stability was restored only at 0° of flexion. Isolated sMCLR restored valgus and external rotation stability at 0°, 20°, and 40° of flexion but not at 60° or 90° of flexion. Single-strand SICR restored valgus and external rotation stability at all flexion angles. In the combined anterior drawer plus external rotation test, isolated dMCL and single-strand SICR restored stability to the intact level at all flexion angles, while the isolated sMCL restored stability at 20° and 40° of flexion but not at 60° or 90° of flexion. CONCLUSION: In the cadaveric model, single-strand SICR restored valgus and rotational stability throughout the range of motion. dMCLR restored rotational stability to the knee throughout the range of motion but did not restore valgus stability. Isolated sMCLR restored external rotation and valgus stability in early flexion. CLINICAL RELEVANCE: In patients with anteromedial rotatory instability in the knee, neither an sMCLR nor a dMCLR is sufficient to restore stability.

Rotator Cuff Repair With or Without Acromioplasty: A Systematic Review of Randomized Controlled Trials With Outcomes Based on Acromial Type.

BACKGROUND: It is unclear whether the use of concomitant acromioplasty during rotator cuff repair (RCR) improves clinical outcomes and whether the outcomes are affected by acromial type. PURPOSE: To perform a systematic review of randomized controlled trials comparing clinical outcomes of RCR with and without acromioplasty, with a subanalysis of outcomes based on acromial type. STUDY DESIGN: Systematic review; Level of evidence, 2. METHODS: A systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines by searching PubMed, the Cochrane Library, and Embase to identify randomized controlled trials that directly compared outcomes between RCR with versus without acromioplasty. A subanalysis was performed on the studies that provided outcomes based on acromial type. The search phrase used was rotator cuff repair (acromioplasty OR subacromial decompression) randomized. Patients were evaluated based on retear rate, reoperation rate, and patient-reported outcomes (PROs). RESULTS: Application of inclusion criteria yielded 5 studies (2 studies were level 1, and 3 studies were level 2) including a total of 409 patients, with 211 patients undergoing RCR alone (group A) and 198 patients undergoing RCR with acromioplasty (group B). The mean patient age was 58.5 and 58.3 years in groups A and B, respectively. The mean follow-up time was 52.9 months, and the overall percentage of male patients was 54.1%. The rotator cuff tear size was 20.7 mm and 19.8 mm for groups A and B, respectively. No significant differences were found between groups for any of the PROs at final follow-up. Overall retear rates did not significantly differ between groups based on acromial type. Between 2 studies that measured reoperation rate, a significantly higher reoperation rate was found for the nonacromioplasty group (15%) versus the acromioplasty group (4.1%) (P = .031). One of these studies found that 5 of 9 patients (56%) with a type III acromion in the nonacromioplasty group underwent reoperation compared with 0 of 4 patients with a type III acromion in the acromioplasty group. CONCLUSION: There is some evidence that acromioplasty during RCR reduces the risk for later reoperation. This may be particularly true for patients with type III acromions, although further studies with larger sample sizes are needed to corroborate these data.

A High Incidence of Perineal Post-Related Complications After Hip Arthroscopy Is Self-Reported by Patients in Anonymous Online Forums.

Purpose: To evaluate online, self-reported pudendal nerve or perineal injuries related to the use of a perineal post during hip arthroscopy. Methods: Public posts on Reddit and the Health Organization for Pudendal Education were searched to identify anonymous individuals reporting symptoms of pudendal nerve or perineal injury following hip arthroscopy. Included posts were by any individual with a self-reported history of hip arthroscopy who developed symptoms of pudendal nerve injury or damage to the perineal soft tissues. Demographic information and details about a person's symptoms and concerns were collected from each post. Descriptive statistics were used to analyze the data. Results: Twenty-three online posts reported on a perineal post-related complication following hip arthroscopy. Sex information was available in 16 (70%) posts (8 male, 8 female). Twenty-two posts reported a sensory injury, and 4 posts reported a motor injury with sexual consequences (sexual dysfunction, dyspareunia, impotence). Symptom duration was available in 15 (65%) posts (8 temporary, 7 permanent). Permanent symptoms included paresthesia of the perineum or genitals (7) and sexual complaints (5). Two posts stated they were counseled preoperatively about the possibility of this injury. Zero patients reported that a postless hip arthroscopy alternative was an option made available to them before surgery. Conclusions: A high incidence of permanent pudendal nerve, perineal skin, and genitourinary/sexual complications are self-reported and discussed online by patients who have undergone post-assisted hip arthroscopy. These patients report being uninformed and undereducated about the possibility of sustaining a post-related complication. No patient reported being informed of postless hip arthroscopy preoperatively. Clinical Relevance: Identifying and evaluating self-reported patient information in online medical forums can provide important information about patient experiences and outcomes.

Autograft Demonstrates Superior Outcomes for Revision Anterior Cruciate Ligament Reconstruction When Compared With Allograft: A Systematic Review.

BACKGROUND: Multiple studies have compared outcomes among patients undergoing revision anterior cruciate ligament reconstruction (ACLR) with autograft versus allograft, but these data are inconsistently reported and long-term outcomes depending on graft type are yet to be determined. PURPOSE: To perform a systematic review of clinical outcomes after revision ACLR (rACLR) with autograft versus allograft. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: A systematic review of the literature was performed by searching PubMed, the Cochrane Library, and Embase to identify studies that compared the outcomes of patients undergoing rACLR with autograft versus allograft. The search phrase used was autograft allograft revision anterior cruciate ligament reconstruction. Graft rerupture rates, return-to-sports rates, anteroposterior laxity, and patient-reported outcome scores (subjective International Knee Documentation Committee, Tegner, Lysholm, and Knee injury and Osteoarthritis Outcome Score) were evaluated. RESULTS: Eleven studies met inclusion criteria, including 3011 patients undergoing rACLR with autograft (mean age, 28.9 years) and 1238 patients undergoing rACLR with allograft (mean age, 28.0 years). Mean follow-up was 57.3 months. The most common autograft and allograft types were bone-patellar tendon-bone grafts. Overall, 6.2% of patients undergoing rACLR experienced graft retear, including 4.7% in the autograft group and 10.2% in the allograft group (P < .0001). Among studies that reported return-to-sports rates, 66.2% of patients with an autograft returned to sports as opposed to 45.3% of patients with an allograft (P = .01). Two studies found significantly greater postoperative knee laxity in the allograft group as compared with the autograft group (P < .05). Among all patient-reported outcomes, 1 study found 1 significant difference between groups: patients with an autograft had a significantly higher postoperative Lysholm score when compared with patients with an allograft. CONCLUSION: Patients undergoing revision ACLR with an autograft can be expected to experience lower rates of graft retear, higher rates of return to sports, and less postoperative anteroposterior knee laxity when compared with patients undergoing revision ACLR with an allograft.

Microfracture of Acetabular Chondral Lesions Is Not Superior to Other Cartilage Repair Techniques in Patients With Femoroacetabular Impingement Syndrome: A Systematic Review.

PURPOSE: To perform a systematic review to compare clinical outcomes of hip arthroscopy patients undergoing microfracture (MFx) versus other cartilage repair procedures for chondral lesions of the acetabulum. METHODS: A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines by searching PubMed, the Cochrane Library, and Embase to identify comparative studies that directly compared outcomes between MFx and other cartilage repair procedures for full-thickness chondral lesions of the acetabulum identified during hip arthroscopy. The search phrase used was: hip AND arthroscopy AND microfracture. Patients were evaluated based on reoperation rates and patient-reported outcomes. RESULTS: Six studies (all Level III evidence) met inclusion criteria, including a total of 202 patients undergoing microfracture (group A) and 327 patients undergoing another cartilage repair procedure (group B). Mean patient age ranged from 35.0 to 45.0 years. Mean follow-up time ranged from 12.0 to 72.0 months. Significantly better patient-reported outcomes (PROs) were found in patients undergoing treatment with bone marrow aspirate concentrate, microfragmented adipose tissue concentrate, autologous matrix-induced chondrogenesis, and a combination of autologous matrix-induced chondrogenesis and bone marrow aspirate concentrate compared with MFx. No studies found significantly better postoperative PROs in group A. The reoperation rate ranged from 0% to 34.6% in group A and 0% to 15.9% in group B. Three of 5 studies reporting on reoperation rate found a significantly greater reoperation rate in group A, with no difference in the other 2 studies. CONCLUSIONS: The literature on MFx of acetabular chondral lesions is limited and heterogeneous. Based on the available data, MFx alone results in a greater or equivalent reoperation rate and inferior or equivalent PROs compared with other cartilage repair procedures for acetabular chondral lesions in patients with femoroacetabular impingement syndrome. LEVEL OF EVIDENCE: Level III, systematic review of level III studies.

Rotator Cuff Repair With Patch Augmentation Is Associated With Lower Retear Rates for Large Tears: A Systematic Review of Randomized Controlled Trials.

PURPOSE: To perform a systematic review of randomized controlled trials comparing clinical outcomes of rotator cuff repair with and without patch augmentation. METHODS: A systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines by searching PubMed, the Cochrane Library, and Embase to identify randomized controlled trials that directly compared outcomes between rotator cuff repair (RCR) with versus without patch augmentation. Patients were evaluated based on retear rate, histological outcomes, radiological outcomes, and patient-reported outcomes (Constant score; American Shoulder and Elbow Surgeons [ASES] score; University of California-Los Angeles shoulder scale; Simple Shoulder Test; EuroQol-visual analog scale; Disabilities of the Arm, Shoulder and Hand score; and PENN shoulder score questionnaire). RESULTS: Six studies (1 level I, 5 level II) met inclusion criteria, including 188 patients undergoing RCR alone (Control) and 193 patients undergoing RCR with patch augmentation (Patch). Patient age ranged from 56.0 to 68.0 years. The mean follow-up time ranged from 14.0 to 68.4 months. The average body mass index ranged from 24.4 to 29.4, and the overall percentage of males ranged from 32.5% to 82.3%. Three studies found significantly decreased retear rates with patch augmentation. The retear rate ranged from 34.0% to 65.4% in the Control group and 9.1% to 52.9% in the Patch group. One study found a significant difference for the Constant score favoring the Patch group. Two studies found a significant difference for the ASES score favoring the Patch group. One study found significantly better results with patch augmentation in terms of repaired tendon thickness and footprint coverage, based on magnetic resonance imaging. CONCLUSIONS: Patch augmentation of rotator cuff repairs may be associated with lower retear rates for large tears. There is limited evidence to suggest that patch augmentation is associated with improved patient-reported outcomes. LEVEL OF EVIDENCE: Level II, systematic review of level I and II studies.

During Postless Hip Arthroscopy, Male Patients, High Body Mass Index, Low Beighton Scores, and Limited Range of Motion Require High Traction Force.

PURPOSE: To determine the effects of demographic and anatomic factors on traction force required during postless hip arthroscopy. METHODS: A prospectively collected database was retrospectively analyzed on patients undergoing hip arthroscopy by the senior author, including patient sex, age, body mass index (BMI), Beighton Hypermobility Score, hip range of motion in clinic and under anesthesia, hip dysplasia, acetabular version, and femoral version. All patients underwent postless hip arthroscopy under general anesthesia. At the initiation of hip arthroscopy, the traction force required to distract the hip joint was measured before and following interportal capsulotomy. Multiple regression analysis was performed to determine the effects of demographic and anatomic factors on measured distraction force. RESULTS: In total, 352 hips (114 male, 238 female) were included with a mean age of 32.6 years and a mean BMI of 24.1 kg/m2. Mean initial traction force was 109 lbs and decreased to 94.3 lbs following capsulotomy (P < .0001). The starting traction force was significantly greater in male patients (P < .001), patients with a lack of hypermobility (Beighton Hypermobility Score of 0-2) (P = .026), and in patients with lower abduction (P < .001), lower internal rotation (P = .002), and lower external rotation (P = .012) on multiple regression analysis. When performing a subanalysis divided by sex, male patients with elevated BMI required significantly greater starting traction force (P = .014). Lateral center edge angle, sourcil angle, and the presence of hip dysplasia did not demonstrate a significant correlation with traction force. CONCLUSIONS: Male patients, patients with reduced preoperative hip range of motion, patients with a lack of joint hypermobility, and male patients with an elevated BMI require greater initial traction force during postless hip arthroscopy. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Virtual Interviews Are Not Adequate Replacements for In-Person Interviews for Orthopaedic Sports Medicine Fellowship Program Directors and Applicants.

Purpose: To understand the opinions of both orthopaedic sports medicine fellowship program directors (PDs) and applicants regarding the utility of virtual interviews in comparison to in-person interviews following the 2022-2023 application cycle. Methods: An anonymous online survey was distributed through the American Orthopaedic Society for Sports Medicine to applicants and PDs of orthopaedic sports medicine fellowship programs. Questions in the survey included how the virtual format affected the applicants' personal connection to the program, the interview day structure, and costs associated with the interview process. Results: Responses were received from 69 of 93 PDs (74%) and 97 of 266 applicants (36%). Ninety-five percent of PDs (59 of 62) preferred in-person interviews, compared to 79% of applicants (70 of 89). Ninety-eight percent of PDs (60 of 61) and 82% of applicants (72 of 88) thought it was important/very important to interview in-person. Sixty-one percent of PDs (35 of 57) and 49% of applicants agreed/strongly agreed that conducting virtual interviews negatively affected their personal connection with the fellowship interviewee/program. The presence of virtual interviews allowed 50% (43 of 86) of applicants to go on more interviews. Thirty-two percent (18 of 57) of fellowship programs saved up to $5,000 conducting virtual interviews, and 85% (69 of 81) of applicants saved up to $5,000 on travel expenses by attending virtual interviews. Conclusions: Virtual interviews allow fellowship applicants to complete more interviews and presented financial savings for both programs and applicants. However, both PDs and applicants stated that interviewing in-person is essential for applicants to meet faculty and tour the facilities. Clinical Relevance: This study may be valuable to fellowship programs considering continued use of virtual interviews.