Femoroacetabular Impingement Measurements Obtained From Two-Dimensional Radiographs Versus Three-Dimensional-Reconstructed Computed Tomography Images Result in Different Values.

Purpose: To compare the reliability and accuracy of radiographic measurements obtained from 2-dimensional (2D) radiographs and 3-dimensional (3D)-reconstructed computed tomography (CT) images in the assessment of femoroacetabular impingement syndrome (FAIS). Methods: Consecutive patients with FAIS from January 2018 to December 2020 were identified and included in this study. Two fellowship-trained surgeons and 2 fellows performed blinded radiographic measurements. Lateral center-edge angle (LCEA) and Tönnis angles were measured on anteroposterior pelvic radiographs, and alpha angles were measured on frog lateral radiographs. Reliability coefficients for individual measurement accuracy were performed using the Cronbach alpha and intra- and inter-rater intraclass correlation coefficients (ICCs). Composite measurements for LCEA, Tönnis angle, and alpha angle were compared with the corresponding 3D value using paired sample t-tests. Results: Fifty-three patients with FAIS with standardized 2D radiographic and 3D-reconstructed CT imaging were included. All reliability metrics met thresholds for internal reliability. Inter-rater ICCs for LCEA, Tönnis angle, and alpha angle were (0.928, 0.888, 0.857, all P < .001). When we compared 2D radiographic measurements with 3D-reconstructed CT values, there was a significant difference in the LCEA for 2 authors: surgeon 1 (mean [M] = -9.14, standard deviation [SD] = 5.7); t(52) = -11.6, P < .001, and surgeon 2 (M = -5.9°, SD = 4.7); t(52) = -9.2, P < .001. Significant differences were seen for Tönnis angle for 2 authors: fellow 2 (M = 3.9°, SD = 5.6); t(52) = 5.1, P < .001, and surgeon 2 (M = -2.6°, SD = 4.1); t(52) = -4.6, P < .001. Alpha angle measurements compared to the 3D-reconstructed alpha angle at 2 o'clock was significantly different for 3 authors: fellow 1 (M = 11.9°, SD = 16.2); t(52) = 5.3, P < .001; fellow 2 (M = 10.4°, SD = 18.6); t(52) = 4.1, P = .002; and surgeon 2 (M = -6.5°, SD = 16.2); t(52) = -2.9, P = .005. Positive mean values indicate 2D radiographic measurements overestimated 3D reconstruction values and negative mean values indicate underestimation. Conclusions: The use of 2D radiographs alone for preoperative planning of FAIS may lead to inaccuracies in radiographic measurements. Level of Evidence: Level, III retrospective cohort study.

Two Intramedullary and 1 Extramedullary Cortical Button, With or Without Interference Screw, Show Biomechanical Properties Superior to Native Tendon in Repair of the Distal Biceps Tendon: A Systematic Review and Network Meta-analysis of Biomechanical Performance.

PURPOSE: The aim of this study was to use a systematic review and network meta-analysis (NMA) to compare the failure strength, maximum strength, stiffness, and displacement of available constructs for distal biceps repair. METHODS: An NMA was conducted to determine the performance of 2 all-suture suture anchors (2x ASA), 2 intramedullary cortical buttons (2x IM CB), 2 suture anchors (2x SA), extramedullary cortical buttons (EM CB), extramedullary cortical button plus interference screw (EM CB+IFS), interference screw (IFS), single intramedullary cortical button (IM CB), single suture anchor (SA), transosseous suture (TOS), tension slide technique (TST), and tension slide technique plus suture tape (TST+ST). Analysis consisted of arm-based network meta-analysis under Bayesian random-effects model with Markov Chain Monte Carlo (MCMC) sampling. Biomechanical outcomes were summarized as treatment effects and their corresponding 95% confidence intervals (CI). Rank probabilities were calculated and used to generate each treatment's surface under the cumulative ranking (SUCRA) curve. Biomechanical properties were compared to native tendon. Displacement >10 mm was defined as clinical failure. RESULTS: Twenty-one studies were included. For failure strength, no construct outperformed the native tendon but 2× SA, IFS, SA, and TOS demonstrated poorer failure strength. For the maximum load to failure, EM CB+IFS outperformed the native tendon. Compared to native tendon, EM CB+IFS, EM CB, and 2×IM CB were stiffer, while 2x SA and IFS were less stiff. No construct demonstrated >10 mm of displacement, but constructs with displacement above the mean (3.5 mm) included 2× ASA, 2xIM CB, and TOS. CONCLUSIONS: The fixation constructs that consistently demonstrated comparable or better biomechanical properties (failure strength, maximum strength, and stiffness) to native tendon in distal biceps tendon repair were the extramedullary cortical button with or without interference screw and two intramedullary cortical buttons. No construct demonstrated displacement beyond standard definitions for clinical failure. CLINICAL RELEVANCE: This network meta-analysis of biomechanical studies suggests that extramedullary cortical button and two intramedullary cortical buttons may be the most stable construct for distal biceps repair fixation, with equivalent or better biomechanical properties compared to native tendon.

Time to Achieving Clinically Significant Outcomes After Meniscal Allograft Transplantation.

PURPOSE: To determine the time to achieving minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) for commonly administered patient-reported outcome (PRO) measures and risk factors affecting achievement of clinically significant outcomes in patients undergoing meniscal allograft transplantation (MAT). METHODS: A prospectively maintained MAT registry was retrospectively reviewed from April 2014 to May 2019. Patients who underwent revision MAT or did not complete preoperative PROs or one post operative time point were excluded. Patients who underwent concomitant procedures were included in the analysis. PROs were administered preoperatively and at 6 months, 1 year, and 2 years postoperatively. Previously defined MCID and PASS thresholds were utilized and Kaplan-Meier survival curve analysis with interval censoring was used to calculate the cumulative percentages of MCID and PASS achievement at each follow-up time interval (5-7, 11-13, and 23-25 months). RESULTS: Eighty patients (age: 28.35 ± 9.76, 50% male) who completed preoperative, 6-month (n = 69, 86% compliance), and 1-year (n = 76, 95% compliance) PROs were included. The majority of patients (>50%) achieved MCID and PASS on most included PROs. Workers' compensation status was found to significantly delay achievement of MCID and PASS on all PROs except for PASS on Knee Injury and Osteoarthritis Outcome Score (KOOS) quality of life (QoL). Higher body mass index (BMI) significantly delayed time to achieving MCID on KOOS Pain and activities of daily living (ADL), as well as PASS on KOOS Symptoms and KOOS QoL. CONCLUSION: This study suggests that the majority of patients have clinically significant improvements in pain and function after MAT, with more than 50% of patients experiencing clinically significant improvement within the first postoperative year. Workers' compensation status and high BMI may prolong time to achievement of MCID and PASS after MAT.

Effect of Mechanical Mincing on Minimally Manipulated Articular Cartilage for Surgical Transplantation.

BACKGROUND: Point-of-care treatment options for medium to large symptomatic articular cartilage defects are limited. Minced cartilage implantation is an encouraging single-stage option, providing fresh viable autologous tissue with minimal morbidity and cost. PURPOSE: To determine the histological properties of mechanically minced versus minimally manipulated articular cartilage. STUDY DESIGN: Controlled laboratory study. METHODS: Remnant articular cartilage was collected from fresh femoral condylar allografts. Cartilage samples were divided into 4 groups: cartilage explants with or without fibrin glue and mechanically minced cartilage with or without fibrin glue. Samples were cultured for 42 days. Chondrocyte viability was assessed using live/dead assay. Cellular migration and outgrowth were monitored using bright-field microscopy. Extracellular matrix deposition was assessed via histological staining. Proteoglycan content and synthesis were assessed using dimethylmethylene blue assay and radiolabeled 35S-sulfate, respectively. Type II collagen (COL2A1) gene expression was analyzed via polymerase chain reaction. RESULTS: The mean viability of minced cartilage particles (34% ± 14%) was not significantly reduced compared with baseline (46% ± 13%) on day 0 (P = .90). After culture, no significant difference in the percentage of live cells was appreciated between mechanically minced (58% ± 23%) and explant (73% ± 14%) cartilage in the presence of fibrin glue (P = .52). The addition of fibrin glue did not significantly affect the viability of cartilage samples. The qualitative assessment revealed comparable cellular migration and outgrowth between groups. Proteoglycan synthesis was not significantly different between groups. Histological analysis findings were positive for COL2A1 in all groups, and matrix formation was appreciated in all groups. COL2A1 expression in minced cartilage (1.72 ± 1.88) was significantly higher than in explant cartilage (0.15 ± 0.07) in the presence of fibrin glue (P = .01). CONCLUSION: Mechanically minced articular cartilage remained viable after 42 days of culture in vitro and was comparable with cartilage explants with regard to cellular migration, outgrowth, and extracellular matrix synthesis. CLINICAL RELEVANCE: Mechanically minced articular cartilage is an encouraging intervention for the treatment of symptomatic cartilage defects. Further translational work is warranted to determine the viability of minced cartilage implantation as a single-stage therapeutic intervention in vivo.

Posterolateral Corner Reconstruction: Surgical Technique and Postoperative Rehabilitation.

Anatomic posterolateral corner (PLC) reconstruction is utilized for ligamentous knee instability associated with PLC injury in patients who desire a return to active lifestyles1,2. The fibular collateral ligament (FCL) and popliteal tendon (PLT) are reconstructed in anatomic fashion according to techniques described by LaPrade et al.3-7. Description: Various PLC reconstruction techniques have been described; however, the preferred reconstruction technique of the senior author is the method developed by LaPrade et al. that restores the anatomy of the 3 primary stabilizers of the PLC, including the FCL, PLT, and popliteofibular ligament3,5,6. Alternatives: Alternative nonoperative treatments include knee immobilization for 4 weeks and physical therapy. Surgical alternatives include PLC repair, which involves repair of the lateral collateral ligament, PLT, and/or popliteofibular ligament if structures can be anatomically reduced to their attachment site. However, repair of acute grade-III PLC injuries with staged treatment of concurrent cruciate injuries is associated with a substantially higher postoperative PLC failure rate8-10. Rationale: Clinical outcomes have demonstrated that primary repairs have significantly higher rates of reoperation compared with reconstruction; therefore, reconstruction is recommended. Treatment of grade-III PLC injuries with reconstruction of midsubstance tears and any associated cruciate ligament tears results in significantly improved objective stability11. In addition, anatomic PLC reconstruction has demonstrated improved subjective and objective patient outcomes compared with nonsurgical treatment or repair5,11,12. Expected Outcomes: Reconstruction of the PLC offers excellent outcomes after surgery. Studies have shown that the fibular-based technique for treatment of a chronic isolated PLC injury showed good results in terms of clinical outcome, restoring knee varus and rotational stability13. Important Tips: Patients with associated proximal tibiofibular joint instability will benefit from this reconstruction because this technique will add stability to the joint.This surgical approach is technically demanding, requiring proficiency with surgical dissection.Damage to the common peroneal nerve can potentially occur. Careful dissection and placement of retractors should be observed.Risks include surgical failure due to unrecognized malalignment; especially in chronic cases, the patient should have a complete evaluation of the standing alignment and tibial slope12. Acronyms and Abbreviations: FCL = fibular collateral ligamentPFL = popliteofibular ligamentPLC = posterolateral cornerIT = iliotibialIKDC = International Knee Documentation CommitteeACL = anterior cruciate ligamentPCL = posterior cruciate ligamentPEEK = polyetheretherketonePROM = passive range of motion.

Editorial Commentary: Axial Stress Examination Under Anesthesia Provides a Highly Reliable Test for Measurement of Hip Distraction.

Symptomatic hip microinstability is now recognized as one of the most common surgical indications for revision hip arthroscopy. Hip microinstability can be difficult to diagnose, particularly because of the multifactorial etiology and limited physical examination maneuvers that provide objective testing of gross hip stability. One measure of hip stability is axial stability evaluated under traction intraoperatively. Recent research has suggested that average axial stability of the hip is decreased after primary hip arthroscopy-although not in all cases. Recognizing that there are many additional factors that may contribute to hip microinstability, as well as the fact that axial stability is only one assessment of overall stability of the hip, is important in the evaluation of microinstability in the setting of prior hip arthroscopy.

Establishing Clinically Significant Outcomes After Anterior Cruciate Ligament Reconstruction in Pediatric Patients.

PURPOSE: The purpose of this study was to establish clinically significant outcome values for the minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) after anterior cruciate ligament reconstruction (ACLR) in the pediatric and adolescent populations and to assess factors that were associated with achieving these outcomes. METHODS: Patients between the age of 10 to 21 who underwent ACLR between 2016 and 2018 were identified and patient-reported outcomes (PROs) were collected preoperatively and postoperatively. Intraoperative variables collected included graft choice, graft size (diameter), graft fixation method, and concomitant procedures. PROs collected for analysis were the International Knee Documentation Committee Score (IKDC) and Knee Injury and Osteoarthritis Outcome Score (KOOS). MCID and PASS were calculated using receiver operating characteristic with area under the curve analyses for delta (ie, baseline-to-postoperative change) and absolute postoperative PRO scores, respectively. RESULTS: A total of 59 patients were included in the analysis. Of the entire study population, 53 (89.8%) reported satisfaction with their surgical outcome. The established MCID threshold values based on the study population were 33.3 for IKDC, 28.6 for (KOOS) Symptoms, 19.4 for Pain, 2.9 for activities of daily living (ADL), 45.0 for Sport, and 25.0 for Quality of Life (QoL). Postoperative scores greater than the following values corresponded to the PASS: 80.5 for IKDC, 75.0 (KOOS) Symptoms, 88.9 for Pain, 98.5 for ADL, 75.0 for Sport, and 68.8 for QoL. CONCLUSION: Clinically meaningful outcomes including MCID and PASS were established for pediatric ACLR surgery using selected PRO measures, IKDC, and KOOS. Patient age, sex, graft type, and graft size were not associated with greater achievement of these outcomes. In contrast, collision sports, fixed-object high-impact rotational landing sports, and concomitant meniscectomy surgery were associated with a decreased likelihood of achieving clinically significant improvement. However, findings must be interpreted with caution due to limitations in follow-up and sample size. LEVEL OF EVIDENCE: Level IV: case series.

Physical Therapy Combined With Subacromial Cortisone Injection Is a First-Line Treatment Whereas Acromioplasty With Physical Therapy Is Best if Nonoperative Interventions Fail for the Management of Subacromial Impingement: A Systematic Review and Network Meta-Analysis.

PURPOSE: To construct an algorithm to optimize clinical outcomes in subacromial impingement based on current, high-level evidence. METHODS: A systematic review of all clinical trials on subacromial impingement published from 1999 to 2020 was performed. Demographic, clinical, range of motion (ROM), and patient-reported outcome measure (PROM) data were collected. Interventions were compared via arm-based Bayesian network meta-analysis in a random-effects model and treatments ranked via surface under the cumulative ranking curves with respect to 3 domains: pain, PROMs, and ROM. RESULTS: A total of 35 studies comprising 3,643 shoulders (42% female, age 50 ± 5 years) were included. Arthroscopic decompression with acromioplasty ranked much greater than arthroscopic decompression alone for pain relief and PROM improvement, but the difference in absolute PROMs was not statistically significant. Corticosteroid injection (CSI) alone demonstrated inferior outcomes across all 3 domains (pain, PROMs, and ROM) with low cumulative rankings. Physical therapy (PT) with CSI demonstrated moderate-to-excellent clinical improvement across all 3 domains whereas PT alone demonstrated excellent ROM and low-moderate outcomes in pain and PROM domains. PT with nonsteroidal anti-inflammatory drugs or alternative therapies ranked highly for PROM outcomes and moderate for pain and ROM domains. Finally, platelet-rich plasma injections demonstrated moderate outcomes for pain, forward flexion, and abduction with very low-ranking outcomes for PROMs and external rotation. CONCLUSIONS: Arthroscopic decompression with acromioplasty and PT demonstrated superior outcomes whereas CSI demonstrated poor outcomes in all 3 domains (pain, PROMs, and ROM). For patients with significant symptoms, the authors recommend PT with CSI as a first-line treatment, followed by acromioplasty and PT if conservative treatment fails. For patients with symptoms limited to 1 to 2 domains, the authors recommend a shared decision-making approach focusing on treatment rankings within domains pertinent to individual patient symptomatology. LEVEL OF EVIDENCE: I, systematic review and network meta-analysis of Level I studies.

The Efficacy of Platelet-Rich Plasma for Ligament Injuries: A Systematic Review of Basic Science Literature With Protocol Quality Assessment.

BACKGROUND: Despite the existence of many clinical studies on platelet-rich plasma (PRP) interventions for ligamentous pathology, basic science consensus regarding the indications, mechanisms, and optimal composition of PRP for treating ligament injuries is lacking. PURPOSE: To (1) compare the efficacy of PRP in animal models of ligament injury with placebo and (2) describe the potential variability in PRP preparation using accepted classification systems. STUDY DESIGN: Systematic review. METHODS: The Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, PubMed, Embase, and Ovid MEDLINE were queried in April 2020 for in vivo and in vitro basic science studies regarding PRP use for ligament injury. Study design, results, PRP composition, and analyzed cellular and molecular markers were extracted, and outcomes relative to control models were documented. Bias was assessed using the SYRCLE risk-of-bias tool. RESULTS: Included were 43 articles (31 in vivo and 12 in vitro studies) investigating the anterior cruciate ligament/cranial cruciate ligament (n = 32), medial collateral ligament (n = 6), suspensory ligament (n = 3), patellar ligament (n = 1), and Hock ligament (n = 1). Platelet concentration was reported in 34 studies (77.3%); leukocyte composition, in 12 (27.3%); and red blood cell counts, in 7 (15.9%). With PRP treatment, 5 of 12 in vitro studies demonstrated significant increases in cell viability, 6 of 12 in gene expression, 14 of 32 in vivo studies reported superior ligament repair via histological evaluation, and 13 in vivo studies reported superior mechanical properties. Variability in PRP preparation methods was observed across all articles, and only 1 study reported all necessary information to be classified by the 4 schemes we used to evaluate reporting. Among the in vivo studies, detection and performance bias were consistently high, whereas selection, attrition, reporting, and other biases were consistently low. CONCLUSION: Conflicting data on the cellular and molecular effects of PRP for ligament injuries were observed secondary to the finding that included studies were heterogeneous, limiting interpretation across studies and the ability to draw meaningful conclusions. Clinical trials and any causal relationship between PRP use in ligament injuries and its potential for regeneration and healing should be pursued with caution if based solely on basic science data.

Comparison of Long-term Radiographic Outcomes and Rate and Time for Conversion to Total Knee Arthroplasty Between Repair and Meniscectomy for Medial Meniscus Posterior Root Tears: A Systematic Review and Meta-analysis.

BACKGROUND: Previous meta-analyses have demonstrated superior outcomes in patients undergoing arthroscopic repair of medial meniscus posterior root tears (MMPRTs) compared with meniscectomy. However, these analyses have considered only short- or midterm outcomes and low-quality evidence. PURPOSE: To compare the mid- to long-term rates of radiographic osteoarthritis (OA) between repair and meniscectomy for MMPRT. STUDY DESIGN: Systematic review and meta-analysis; Level of evidence, 4. METHODS: PubMed, EMBASE, Ovid/MEDLINE, and Cochrane Central Register of Controlled Trials databases were queried for articles evaluating repair and meniscectomy for MMPRT. Articles were eligible if they had a minimum mean 4-year follow-up for radiographic OA or conversion to total knee arthroplasty (TKA) and were at least level 3 evidence. Radiographic OA was assessed using Kellgren-Lawrence (KL) progression. Rates of conversion to TKA and International Knee Documentation Committee (IKDC) scores were also extracted. DerSimonian-Laird binary random-effects models were created to evaluate differences in radiographic OA and TKA conversion rates, with odds ratios (ORs) representing pooled estimates. Continuous random-effects models with standardized mean differences (SMDs) were used to compare postoperative IKDC scores. RESULTS: Repair and meniscectomy cohorts were followed for a mean of 64.8 months and 62.5 months, respectively, for KL progression; and 82.8 months and 73.8 months, respectively, for TKA rates and IKDC scores. Overall, 59 of 144 (41%) patients undergoing surgical intervention for MMPRT demonstrated OA progression; 18 of 82 (22%) who underwent repair for MMPRT exhibited OA progression compared with 41 of 62 (66%) who underwent meniscectomy (OR, 0.17; 95% CI, 0.03-0.83; P = .029). Overall, 30 of 143 (21%) patients converted to TKA; 9.8% (8/82) of patients who underwent repair converted to TKA (range, 47-131 months), while 36% (22/61) who underwent meniscectomy converted to TKA (range, 17.8-101 months) (OR, 0.15; 95% CI, 0.05-0.44; P < .001). No significant differences between postoperative IKDC scores were observed (SMD, 0.51; 95% CI, -0.02 to 1.05; P = .06). CONCLUSION: Medial meniscus posterior root repair results in significantly lower rates of radiographic OA progression and conversion to TKA at >60-month follow-up. On the basis of these findings, we recommend consideration of repair of MMPRTs when degenerative changes are not severe, as it can yield improved outcomes.

The Effect of Rim Preparation, Labral Augmentation, and Labral Reconstruction on the Suction Seal of the Hip.

PURPOSE: To evaluate the biomechanical properties of the labral suction seal in the native labrum and after rim preparation, labral augmentation, and labral reconstruction. METHODS: Eight hemi-pelvises were dissected to the level of labrum and mounted for biomechanical testing. Each specimen was tested in axial distraction starting with the native labrum and then sequentially following rim preparation from 12 to 3 o'clock, labral augmentation, and segmental labral reconstruction using the iliotibial band allograft. In each condition, the specimens were compressed to 250 N and then distracted at 10 mm/s with force and displacement continuously recorded. Each test was repeated 3 times, and the mean peak force, displacement at peak force, and work were calculated. Data were reported as a percentage of the intact values to account for sex and size differences. Statistical testing was performed via a repeated-measures analysis of variance with a post hoc Tukey analysis. RESULTS: Peak loads occurred within 2.21 to 3.11 mm of displacement. The mean peak force, displacement at peak force, and work relative to the intact condition were the following: rim preparation (91.1% ± 8.5%, 94.4% ± 14.3%, 93.4% ± 23.5%, respectively), augmentation (66.1% ± 27.6%, 78.2% ± 16.3%, 55.7% ± 30.7%, respectively), and reconstruction (55.6% ± 25.7%, 64.7% ± 31.4%, 38.7% ± 27.2%, respectively). There was no significant difference in peak force following the rim preparation (P = .807), but peak force was significantly decreased after augmentation and reconstruction (P = .010 and P < .001, respectively). There was no significant difference in displacement at peak force following rim preparation or augmentation (P = .936 and P = .125, respectively), but displacement at peak force was significantly decreased after reconstruction (P = .005). The work from the suction seal was significantly less in both augmentation and reconstruction states compared to the intact labrum (P = .004 and P < .001, respectively) and rim preparation (P = .017 and P < .001, respectively). CONCLUSIONS: The results show that the suction seal is not significantly changed following rim preparation. Relative to the rim preparation, labral augmentation may re-create the labral suction seal better than labral reconstruction. CLINICAL RELEVANCE: This study provides a biomechanical basis for surgical decision making and clinical management of patients with labral tears of the hip.

Incidence and risk factors for symptomatic venous thromboembolism following anterior cruciate ligament reconstruction.

PURPOSE: To determine the incidence of symptomatic venous thromboembolism (VTE) following anterior cruciate ligament (ACL) reconstruction using a large national database and to identify corresponding independent risk factors. METHODS: The Humana administrative claims database was reviewed for patients undergoing ACL reconstruction from 2007 to 2017. Patient demographics, medical comorbidities, as well as concurrent procedures were recorded. Postoperative incidence of VTE was measured by identifying symptomatic deep vein thrombosis (DVT) and pulmonary embolism (PE) at 30 days, 90 days, and 1 year postoperatively. Univariate analysis and binary logistic regression were performed to determine independent risk factors for VTE following surgery. RESULTS: A total of 11,977 patients were included in the study. The incidence of VTE was 1.01% (n = 120) and 1.22% (n = 146) at 30 and 90 days, respectively. Analysis of VTE events within the first postoperative year revealed that 69.6% and 84.3% of VTEs occurred within 30 and 90 days of surgery, respectively. Logistic regression identified age ≥ 45 (odds ratio [OR] = 1.88; 95% confidence interval [CI] 1.32-2.68; p < 0.001), inpatient surgery (OR = 2.07; 95% CI 1.01-4.24; p = 0.045), COPD (OR = 1.51; 95% CI 1.02-2.24; p = 0.041), and tobacco use (OR = 1.75; 95% CI 1.17-2.62; p = 0.007), as well as concurrent PCL reconstruction (OR = 3.85; 95% CI 1.71-8.67; p = 0.001), meniscal transplant (OR = 17.68; 95% CI 3.63-85.97; p < 0.001) or osteochondral allograft (OR = 15.73; 95% CI 1.79-138.43; p = 0.013) as independent risk factors for VTE after ACL reconstruction. CONCLUSIONS: The incidence of symptomatic postoperative VTE is low following ACL reconstruction, with the majority of cases occurring within 90 days of surgery. Risk factors include age ≥ 45, inpatient surgery, COPD, tobacco use and concurrent PCL reconstruction, meniscal transplant or osteochondral allograft. LEVEL OF EVIDENCE: III.

Distal tibial osteotomy to address internal tibial torsion: Should the fibula be cut?

Background Rotational tibial osteotomy seeks to address pathologic tibial torsion. Inclusion of fibular osteotomy during this procedure remains controversial. This study aimed to determine how external rotation through a tibial osteotomy, with or without a fibular osteotomy, would influence tibiofibular joint congruity. Methods Eight cadaveric legs underwent distal tibial osteotomies. Pins were placed to designate neutral, 10°, 20°, 30° of external rotation. Computed tomography (CT) imaging was performed at each rotation without, then with a fibular osteotomy. Magnetic Resonance Imaging was performed prior to fibular osteotomy to confirm that ligaments remained intact. Custom software calculated tibial torsion using CT scan 3D reconstructions. Proximal tibiofibular joint rotation, distal tibiofibular gapping and ankle mortise were measured on each CT exam. Groups without and with fibular osteotomy were compared. Findings There was no difference between tibial osteotomy rotation magnitude with or without the fibular osteotomy (P = 0.2). The group without the fibular osteotomy had greater proximal fibular rotation at the tibiofibular joint at 20°, 30° (P < 0.05), greater posterior distal tibiofibular gap at 10°, 20°, 30° (P < 0.05) and less anterior distal tibiofibular gap at 20°, 30° (P < 0.05). The medial tibiotalar space was narrowed without the fibular osteotomy at 20°, 30° (P < 0.05) compared to pre-rotation. Interpretation Deformity at the proximal tibiofibular and ankle joints become most pronounced at >20° of tibial rotation without a fibular osteotomy. The first joint to be affected is the distal tibiofibular joint. To limit ankle and proximal tibiofibular articular deformation during tibia rotational osteotomy, a fibular osteotomy is recommended when correcting over 20° of rotation.

Two-Year Clinical Outcomes and Survivorship After Isolated Biceps Tenodesis.

PURPOSE: The purpose of this study was to evaluate clinical outcomes and survivorship of isolated biceps tenodesis (BT) at a minimum of 2 years and to identify patient-specific factors associated with these outcomes in patients undergoing BT without concomitant rotator cuff repair (RCR). We hypothesized that patient-reported outcomes would be significantly improved on American Shoulder and Elbow Surgeons Survey (ASES) and Single Assessment Numeric Evaluation (SANE), with a high rate of survivorship (>90%) at 2-year follow-up. METHODS: A retrospective review of an institutional registry was performed to identify patients who underwent BT from July 2016 to December 2017. Patients >18 years old who underwent an open or arthroscopic BT procedure using an interference screw, button, or anchor for underlying bicipital pathology, without a concomitant RCR or shoulder arthroplasty, and were a minimum of 2 years postoperative were included. Patients were administered ASES and SANE questionnaires preoperatively and at final follow-up. Survivorship was evaluated using Kaplan-Meier analysis. Failure was defined as any patient who underwent reoperation related to the index surgery. RESULTS: A total of 110 patients (mean ± standard deviation age, 48.60 ± 12.14 years) who underwent isolated BT with a follow-up of 24.90 ± 3.95 months were included in analysis. There was a significant improvement in ASES and SANE at final follow-up (P < .001), with 81% to 84% of patients achieving minimal clinically important difference (MCID), 72% to 82% achieving substantial clinical benefit (SCB), and 72% to 80% achieving patient-acceptable symptom state (PASS). Worker's Compensation (WC) patients had a decreased likelihood of achieving PASS on ASES (P = .015) and SANE (P = .012). Four cases were deemed failures (3 revision BTs and 1 capsular debridement) at 15.09 ± 9.57 months. WC did not have a significant effect on likelihood of BT failure. CONCLUSION: Biceps tenodesis provided significant clinical improvement and high rates of survivorship 2 years postoperatively. WC was associated with a decreased likelihood of achieving PASS. These results support the continued use of isolated BT for treating biceps pathology. LEVEL OF EVIDENCE: IV, case series.

The Natural Course of Recovery After Hip Arthroscopy for Femoroacetabular Impingement According to the International Hip Outcome Tool-12 and Hip Outcome Score Sports Subscale.

BACKGROUND: A paucity of literature exists regarding trajectories of functional and sports-specific recovery after hip arthroscopy for femoroacetabular impingement syndrome (FAIS). PURPOSE: To determine if subgroups of patients exist based on the recovery trajectory of patient-reported outcomes (PROs) after hip arthroscopy for FAIS in the short-term period and to determine clinical predictors for these subgroups of patients. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: A prospectively maintained repository was queried for patients who had undergone primary hip arthroscopy for the treatment of FAIS between January 2012 and May 2018. Patients who completed the preoperative, 1-year, and 2-year International Hip Outcome Tool-12 (iHOT-12) or the Hip Outcome Score Sports Subscale (HOS-SS) were included. The latent class growth analysis (LCGA) and growth mixture models (GMMs) were used to identify subgroups of patients based on trajectories of recovery for the iHOT-12 and the HOS-SS utilizing preoperative, 1-year, and 2-year follow-ups. LCGA and GMM models using 1 to 6 classes for each PRO were performed, and the best-fit model for each PRO was selected. After final model selection, a multivariable multinomial logistic regression was performed, with the largest class being the reference group to determine clinical predictors of subgroup membership. RESULTS: A total of 443 and 556 patients were included in the iHOT-12 and HOS-SS analyses, respectively. For the iHOT-12, we identified the following 3 subgroups: early progressors (70%), late regressors (22.3%), and late progressors (7.7%). Predictors of late regression were workers' compensation status, psychiatric history, preoperative chronic pain, and lower preoperative iHOT-12 scores; and late progressors were less likely to participate in sports. For the HOS-SS, we identified the following 4 subgroups: early progressors (47.7%), late regressors (17.4%), late progressors (6.8%), and steady progressors (28.1%). Predictors of less favorable recovery trajectories (late regressors and late progessors) were older age, male sex, back pain, psychiatric history, preoperative chronic pain, greater alpha angle, and lower preoperative HOS-SS scores. CONCLUSION: Using the growth mixture modeling, 3 natural courses of health-related quality of life (early progression, late regression, and late progression) and 4 natural courses of recovery of athletic function (steady progression, late regression, late progression, and early progression) were identified. Preoperative psychiatric conditions, chronic pain, workers' compensation status, and lower iHOT-12 scores were predictive of less than favorable trajectories of recovery according to the iHOT-12, and male sex, older age, back pain, preoperative narcotic use, and lower preoperative HOS-SS were predictors of less favorable recovery trajectories according to the HOS-SS.

Traumatic Leg Fractures in UEFA Football Athletes: A Matched-Cohort Analysis of Return to Play, Reinjury, Player Retention, and Performance Outcomes.

BACKGROUND: The average professional soccer team experiences 1 to 2 traumatic leg fractures per season, with unknown effects on player performance. PURPOSE: To (1) determine the rate and time to return to play (RTP) following leg fracture, (2) investigate the rate of reinjury following RTP, and (3) investigate long-term effects that lower extremity (LE) fracture may have on elite soccer player performance. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Using publicly available records, we identified athletes sustaining a traumatic leg fracture across the 5 major European soccer leagues (English Premier League, Bundesliga, La Liga, Ligue 1, and Serie A) between 2000 and 2016. Athletes with leg fracture (femur, tibia, and/or fibula) were matched 1:2 to controls by demographic characteristics and performance metrics 1 season before the index timepoint. Investigations included the RTP rate, reinjury rate, player characteristics associated with RTP within 2 seasons, long-term player retention, performance metrics during the 4 following seasons, and subgroup analysis by player position. RESULTS: A total of 112 players with LE fracture and 224 controls were identified. Players with LE fractures were absent for a mean of 157 days (range, 24-601 days) and 21 games (range, 2-68 games). The rate of RTP within 1 season was 80%, with 4% experiencing subsequent refracture. Injured players remained active in the league at a higher rate than their uninjured counterparts. As compared with controls, injured athletes played 309 fewer total minutes (P < .05), scored 0.09 more assists per game (P < .01) 1 season after injury, and scored 0.12 more points per game 4 seasons after injury (P < .01). Defenders were most affected by an LE fracture, playing 5.24 fewer games (P < .05), 603 fewer total minutes (P < .01), and recording 0.19 more assists per 90 minutes of play as compared with controls 1 season after injury (P < .001). Attackers and midfielders demonstrated no significant difference in metrics after RTP when compared with controls. CONCLUSION: Most players sustaining an LE fracture returned to elite soccer at the same level after a significant loss of playing time, with a 4% rate of refracture. Player retention was higher for those sustaining an LE fracture versus uninjured controls. Overall, injured players did not experience a decline in performance after recovery from an LE fracture.

Patellar Tendon Shortening for Treatment of Patella Alta in Skeletally Immature Patients With Patellar Instability.

Aberrant anatomy, such as patella alta, can be a risk factor for recurrent patellar instability or inferior clinical outcomes after medial patellofemoral ligament reconstruction. In patients with significant patella alta (Caton Deschamps Index >1.2), tibial tubercle distalization may be considered to improve outcomes. However, despite patellar instability commonly affecting pediatric patients, a distalization osteotomy is not feasible in this patient population due to the presence of open physes. Our article presents a technique describing an alternative soft-tissue distalization approach whereby patellar height is decreased by shortening the patellar tendon.

High rate of return to tennis after hip arthroscopy for patients with femoroacetabular impingement syndrome.

OBJECTIVE: The purpose of this study was to evaluate return to sport (RTS) outcomes in tennis athletes following hip arthroscopy for femoroacetabular impingement syndrome (FAIS). It was hypothesized that there would be a high rate of return to tennis after hip arthroscopy. STUDY DESIGN: Level IV, Retrospective Analysis. SETTING: Outpatient sports medicine clinic at a single institution. PARTICIPANTS: A total of 28 patients (60.8% female; mean age, 36.2 ± 9.2 years; mean BMI, 22.8 ± 2.1 kg/m2) with self reported tennis activity prior to hip arthroscopy. MAIN OUTCOME MEASURES: A postoperative return to sport and minimum two-year patient reported outcomes. RESULTS: There was a high rate of return to tennis, with 78% of patients eventually returning to tennis. An additional 9% of patients had the necessary hip function to return, but did not return due to lack of interest or resources. The patients returned to tennis at an average of 8.0 ± 3.3 months after surgery. The majority of athletes (66.7%) were able to continue competing at the same or higher levels following surgery. CONCLUSIONS: Patients return to tennis 78% of the time at a mean of 8.0 ± 3.3 months following hip arthroscopy for FAIS.

Intraoperative Computer Vision Integrated Interactive Fluoroscopy Correlates With Successful Femoroplasty on Clinic-Based Radiographs.

PURPOSE: To quantitatively evaluate computer vision interface (CVI)-guided femoroplasty in the arthroscopic treatment of femoroacetabular impingement syndrome and compare those results with traditional unguided resections. METHODS: Consecutive patients undergoing hip arthroscopy for femoroacetabular impingement syndrome between July 2019 and October 2019 were evaluated. Cases with CVI were identified along with controls, consisting of patients from the same study period who underwent surgery without the CVI and were balanced for age, sex, laterality, and preoperative alpha angles. Alpha angles were measured on pre- and postoperative clinic radiographs, as well as intraoperatively for the CVI group. Cam resections were quantified by measuring pre- and postresection alpha angles and compared between groups. The correlation between CVI views and office-based radiographs was assessed, and the 3 CVI views that best correlated with each of the 3 standard clinic radiographs were evaluated for accuracy and performance in detection of cam deformity with alpha angle ≥48° with the clinic-based films as the reference. RESULTS: A total of 49 patients (51 hips) (average age, 28.7; 33 female patients) in the CVI group, and 51 patients (51 hips) (average age: 29.9; 35 female patients) in the control group. There were no significant differences between groups with respect to age, sex, laterality, or preoperative alpha angle (all P > .05). Significant alpha angle reduction occurred on all intraoperative and postoperative clinic views (all P < .01). The CVI views that best correlated with the clinic radiographs were 11:45 with the anteroposterior (ρ = 0.588, P = .0025), 12:30 with the Dunn lateral (ρ = 0.632, P = .0009), and 1:45 with the false-profile (ρ = 0.575, P = .0033). Greater reliability was observed with 12:30/Dunn (accuracy = 83.33%, P < .0001; sensitivity = 77.14%; specificity = 87.76%) and 1:45/false-profile (accuracy = 82.35%, P = .0051; sensitivity = 81.82%; specificity = 82.61%) than with 11:45/anteroposterior (accuracy = 69.15%, P = .0077; sensitivity = 56.10%; specificity = 79.25%). CONCLUSIONS: CVI-guided cam resection results in successful resection of proximal femur cam lesions and represents a femoroplasty templating method that does not require preoperative computed tomography imaging or additional invasive intraoperative referencing modules. The accuracy and adequacy of this resection was validated by comparison with routine clinic radiographs. LEVEL OF EVIDENCE: Therapeutic Level III: retrospective comparative analysis.