Beach-Chair Versus Lateral Decubitus Positioning for Primary Arthroscopic Anterior Shoulder Stabilization: A Consecutive Series of 641 Shoulders.

BACKGROUND: There are limited data comparing the beach-chair (BC) versus lateral decubitus (LD) position for arthroscopic anterior shoulder stabilization. PURPOSE: To identify predictors of instability recurrence and revision after anterior shoulder stabilization and evaluate surgical position and glenoid bone loss as independent predictors of recurrence and revision at short- and midterm follow-ups. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A consecutive series of 641 arthroscopic anterior stabilization procedures were performed from 2005 to 2019. All shoulders were evaluated for glenohumeral bone loss on magnetic resonance imaging. The primary outcomes of interest were recurrence and revision. Multivariable logistic regression models were used to assess the relationships of outcomes with age, position, glenoid bone loss group, and track. RESULTS: A total of 641 shoulders with a mean age of 22.3 years (SD, 4.45 years) underwent stabilization and were followed for a mean of 6 years. The overall 1-year recurrent instability rate was 3.3% (21/641) and the revision rate was 2.8% (18/641). At 1 year, recurrence was observed in 2.3% (11/487) and 6.5% (10/154) of BC and LD shoulders, respectively. The 5-year recurrence and revision rates were 15.7% (60/383) and 12.8% (49/383), respectively. At 5 years, recurrence was observed in 16.4% (48/293) and 13.3% (12/90) of BC and LD shoulders, respectively. Multivariable modeling demonstrated that surgical position was not associated with a risk of recurrence after 1 year (odds ratio [OR] for LD vs BC, 1.39; P = .56) and 5 years (OR for LD vs BC, 1.32; P = .43), although younger age at index surgery was associated with a higher risk of instability recurrence (OR, 1.73 per SD [4.1 years] decrease in age; P < .03). After 1 and 5 years, surgical position results were similar in a separate multivariable logistic regression model of revision surgery as the dependent variable, when adjusted for age, surgical position, bone loss group, and track. At 5 years, younger age was an independent risk factor for revision: OR 1.68 per SD (4.1 years) decrease in age (P < .05). CONCLUSION: Among fellowship-trained orthopaedic surgeons, there was no difference in rates of recurrence and revision surgery after performing arthroscopic anterior stabilization in either the BC or the LD position at 1- and 5-year follow-ups. In multivariable analysis, younger age, but not surgical position, was an independent risk factor for recurrence.

In-Season Management of Shoulder Instability: How to Evaluate, Treat, and Safely Return to Sport.

PURPOSE OF REVIEW: Anterior glenohumeral instability is a common injury in contact and collision athletes, and in-season management remains a controversial topic. RECENT FINDINGS: Several recent studies have examined non-operative and operative management of in-season athletes after instability events. Non-operative treatment is associated with faster return to play and higher rates of recurrent instability. Dislocations and subluxations have similar rates of recurrent instability but non-operatively treated subluxations have a quicker return to play than dislocations. Operative treatment is often a season ending decision but is associated with high rates of return to sport and significantly lower rates of recurrent instability. Indications for in-season operative intervention may include critical glenoid bone loss (>15%), an off-track Hill-Sachs lesion, an acutely reparable bony Bankart lesion, high-risk soft tissue injures such as a humeral avulsion of the glenohumeral ligament or displaced anterior labral periosteal sleeve avulsion, recurrent instability, insufficient time remaining in season to rehabilitate from injury, and inability to successfully return to sport with rehabilitation. It is the role of the team physician to appropriately educate athletes on risks and benefits of operative and non-operative treatment strategies and guide athletes through the shared decision-making process that balances these risks against their long-term health and athletic career goals.

Risk Factors for Readmission following Anterior Cruciate Ligament Reconstruction.

The purpose of this study is to identify risk factors for readmission after anterior cruciate ligament (ACL) reconstruction and to determine costs associated with readmission. Using a private insurance claims' database, we identified patients who underwent ACL reconstruction from 2010 to 2015 using the International Classification of Diseases, Version 9 (ICD-9) and Current Procedural Terminology (CPT) codes. Univariate analysis was performed on demographic data, surgical characteristics, and comorbidities. Variables with p < 0.10 were added to a multivariate logistic regression model which was created to identify independent risk factors for all-cause readmission within 90 days postoperatively. Significance was considered at p < 0.05. Overall, 90,263 patients were included (average age: 29 ± 13 years, 44% female), and 1,066 (1.2%) of patients had a hospital readmission within 90 days following surgery. Risk factors for hospital readmission included cerebrovascular disease (odds ratio [OR] = 3.4, 95% confidence interval [CI]: 1.9, 6.2), diabetes mellitus (OR = 2.6, 95% CI: 1.9, 3.5), concomitant medial collateral ligament (MCL) or lateral collateral ligament (LCL) reconstruction (OR = 2.5, 95% CI: 1.9, 3.3), concomitant posterior cruciate ligament (PCL) reconstruction (OR = 2.2, 95% CI: 1.4, 3.3), age between 44 and 65 years (OR = 2.1, 95% CI: 1.6, 2.9), and depression (OR = 1.88, 95% CI: 1.49, 2.38, p < 0.001). Female sex was associated with decreased odds of 90-day hospital readmission (OR = 0.8, 95% CI: 0.7, 0.9). Each hospital readmission accounted for an estimated $17,841 (95% CI: $17,173, 18,509) in gross health care payments, and patients with readmissions had substantially higher 1-year cumulative health care costs. Readmission after ACL reconstruction was 1.2%. The strongest risk factors for 90-day readmission include cerebrovascular disease, diabetes mellitus, concomitant MCL/LCL reconstruction, concomitant PCL reconstruction, and age between 44 and 65 years. Readmission was associated with substantial health care costs.

Recurrent Instability and Surgery Are Common After Nonoperative Treatment of Posterior Glenohumeral Instability in NCAA Division I FBS Football Players.

BACKGROUND: In-season return to play after anterior glenohumeral instability is associated with high rates of recurrent instability and the need for surgical stabilization. We are not aware of previous studies that have investigated in-season return to play after posterior glenohumeral instability; furthermore, as posterior shoulder instability in collision athletes occurs frequently, understanding the expected outcome of in-season athletes may improve the ability of physicians to provide athletes with a better understanding of the expected outcome of their injury and their ability to return to sport. QUESTIONS/PURPOSES: (1) What proportion of athletes returned to play during the season after posterior instability in collegiate football players? (2) How much time did athletes lose to injury, what proportion of athletes opted to undergo surgery, and what proportion of athletes experienced recurrent instability after a posterior instability episode during a collegiate football season? METHODS: A multicenter, prospective, observational study of National Collegiate Athletic Association (NCAA) Division 1 Football Bowl Subdivision athletes was performed at three US Military Service Academies. Ten athletes who sustained a posterior instability event during the regular football season and who pursued a course of nonoperative treatment were identified and prospectively observed through the subsequent season. All athletes in the observed cohort attempted an initial course of nonoperative treatment during the season. All athletes sustained subluxation events initially identified through history and physical examination at the time of injury. None of the athletes sustained a dislocation event requiring a manual reduction. Intraarticular pathology consisting of posterior labral pathology was further subsequently identified in all subjects via MRI arthrogram. Return to play was the primary outcome of interest. Time lost to injury, surgical intervention, and subsequent instability were secondary outcomes. RESULTS: Of the 10 athletes who opted for a trial of initial nonoperative management, seven athletes were able to return to play during the same season. Although these seven athletes returned within 1 week of their injury (median of 1 day), 5 of 7 athletes sustained recurrent subluxation events with a median (range) of four subluxation events per athlete (0 to 8) during the remainder of the season. Seven athletes were treated surgically after the completion of their season, four of whom returned to football. CONCLUSION: This study suggests that although collegiate football players are able to return to in-season sport after a posterior glenohumeral instability event, they will likely sustain multiple recurrent instability events and undergo surgery after the season is completed. The results of this study can help guide in-season management of posterior shoulder instability by allowing more appropriate postinjury counseling and decision making through the identification of those athletes who may require additional attention from medical staff during the season and possible modifications to training regimens to minimize long-term disability. Further prospective studies involving a larger cohort over several seasons should be performed through collaborative studies across the NCAA that better assess function and injury risk factors before beginning collegiate athletics. This would better characterize the natural history and associated functional limitations that athletes may encounter during their collegiate careers. LEVEL OF EVIDENCE: Level IV, prognostic study.

Worsening racial disparities in patients undergoing anatomic and reverse total shoulder arthroplasty in the United States.

BACKGROUND: The most comprehensive health care policy changes aimed at reducing racial disparities were implemented in 2011 and continue today. It is unknown if these initiatives have led to a decrease in racial differences among patients undergoing total shoulder arthroplasty. The purpose of this study is to examine racial differences in procedural rates, complications, and mortality in patients undergoing total shoulder arthroplasty. METHODS: National rates of utilization of primary anatomic (TSA) and reverse total shoulder arthroplasty (RTSA) were analyzed from 2012 to 2017. Population-adjusted and gender-adjusted procedural rates were trended over time and standardized based on insurance status. Multivariable logistic regression was used to determine racial differences in complications and mortality. RESULTS: In 2012, the incidence of TSA and RTSA among white patients was 18.7/100,000 compared to 5.1/100,000 among black patients (difference: 13.6/100,000) and increased to 36.9/100,000 in white patients and 10.8/100,000 in black patients in 2017 (difference: 26.1/100,000). This equated to an increase in the race disparity by 12.5/100,000 over the study period. Blacks underwent lower rates of TSA and RTSA than whites regardless of insurance status. Black patients had a longer length of hospital stay and a higher rate of discharge to facility. Black patients had increased odds of complications, including acute myocardial infarction (odds ratio [OR] 1.43), pulmonary embolism (OR 1.97), acute renal failure (OR 1.40), sepsis (OR 1.68), and surgical site infection (OR 2.19). Black patients had increased odds of mortality compared with white patients (OR 2.88). CONCLUSION: Racial disparities in patients undergoing TSA and RTSA are worsening over time. Black patients undergo TSA and RTSA at lower rates than white patients regardless of insurance status and have increased odds of complications and mortality. Improved initiatives are needed to reduce these racial disparities and further research is warranted to understand their root causes.

The Incidence of Posterior and Combined AP Shoulder Instability Treatment with Surgical Stabilization Is Higher in an Active Military Population than in the General Population: Findings from the US Naval Academy.

BACKGROUND: Anterior instability has consistently been shown to be the most common type of glenohumeral instability. Recent studies have demonstrated a higher percentage of posterior and combined (anterior and posterior) instability than had previously been reported; however, this work has not been replicated recently in a particularly young military population, which may be representative of an especially athletic or high-demand group. QUESTION/PURPOSE: What proportion of arthroscopic shoulder stabilization procedures are performed to address isolated anterior instability, isolated posterior instability, and combined instability in a young, military population? METHODS: Between August 2009 and January 2020, two sports medicine fellowship-trained surgeons performed arthroscopic shoulder surgery on 543 patients at a single institution. During that time, the indication to be treated with arthroscopic stabilization surgery was symptomatic glenohumeral instability, as diagnosed by the operative surgeon, that restricted patients from carrying out their military duties. Of those, 82% (443 of 543) could be evaluated in this retrospective study, while 18% (100 of 543) were excluded due to either incomplete data or because the procedure performed was not to address instability. No patient underwent an open stabilization procedure during this period. Of the 443 patients investigated, the mean age was 22 ± 4 years, and 88% (392 of 443 patients) were men. Instability type was characterized as isolated anterior, isolated posterior, or combined (anterior and posterior) according to the physician's diagnosis as listed in the patient's clinical records and operative reports after the particular capsulolabral pathology was identified and addressed. RESULTS: Isolated anterior instability occurred in 47% of patients (210 of 443). Isolated posterior instability happened in 18% of patients (80 of 443), while combined anteroposterior instability occurred in 35% of patients (153 of 443). CONCLUSION: Shoulder instability is common in the military population. Although anterior instability occurred most frequently, these findings demonstrate higher proportions of posterior and combined instability than have been previously reported. Surgeons should have a heightened suspicion for posterior and combined anteroposterior labral pathology when performing arthroscopic stabilization procedures to ensure that these instability patterns are recognized and treated appropriately. The current investigation examines a unique cohort of young and active individuals who are at particularly high risk for instability and whose findings may represent a good surrogate for other active populations that a surgeon may encounter.Level of Evidence Level III; therapeutic study.

Pectoralis Major Rupture in Military Academy Athletes.

BACKGROUND: Pectoralis major ruptures are rare injuries that can occur at several parts of the muscle. Little is known of the pathoanatomic process and performance following pectoralis major ruptures in young athletes. PURPOSE/HYPOTHESIS: The objective of this study was to describe a series of pectoralis major ruptures in military academy athletes at the US Military Academy and US Naval Academy. We hypothesized that military academy athletes will demonstrate a different rupture location than previously reported in older patients. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective case series was performed by analyzing all electronic medical records and imaging software for consecutive pectoralis major ruptures undergoing surgical repair within the student population at 2 military academies. The primary outcome of interest was rupture pattern and location. We also assessed functional recovery following surgery by analyzing push-up performance on the biannual Army Physical Fitness Test and Navy Physical Readiness Test. RESULTS: From 2005 to 2017, a total of 19 cases of pectoralis major ruptures occurred in military academy cadets. Patients ranged in age from 19 to 23 years, with a mean age of 20 years. All injuries occurred during sports activity, with bench press as the most common mechanism of injury (n = 10; 53%). The most common rupture location was the musculotendinous junction (n = 10; 53%), followed by pectoralis major tendon insertion (n = 8; 42%), and only 1 bony avulsion was noted. Physical activity performance following the rupture was negatively affected. The mean ± SD number of push-ups preinjury was 73.20 ± 12.10, which decreased following injury and surgery (66.50 ± 11.98; P = .037). CONCLUSION: Military academy athletes in our study cohort demonstrated a different type of rupture location than has been reported in older cohorts, with the majority experiencing tearing at a location other than the tendon itself. Performance was also negatively affected immediately following repair, but moderate improvement was observed as time from surgery increased.

Incidence and Risk Factors for Reoperation Following Meniscal Repair in a Military Population.

The purpose of this study is to determine the reoperation rate following meniscal repair and the associated risk factors. The Military Health System Data Repository was queried for active duty patients between January 2009 and December 2012 undergoing meniscal repair by Current Procedural Terminology code (29882, 29883, and 27403). This cohort was then screened for subsequent procedures following the index procedure. Risk factors for reoperation were calculated using a Cox proportional hazard analysis. A total of 3259 primary meniscal repairs were identified over the study period, of which 1423 (43.7%) were performed in conjunction with anterior cruciate ligament (ACL) reconstruction. The reoperation rate was 13.6%, occurring at a median of 1.1 years following the index procedure. Marine Corps service, younger age (>35), enlisted or cadet rank, and junior rank status were identified as significant risk factors for requiring reoperation. Isolated repairs were significantly more likely to require a secondary procedure than those with concomitant ACL reconstruction. Meniscal repairs performed in the military demonstrate similar reoperation rates as published literature despite increased occupational demands. (Journal of Surgical Orthopaedic Advances 27(1):47-51, 2018).

Return to Play Following Meniscus Surgery.

Meniscus tears are commonly encountered in the athletic population and can result in significant loss of playing time. Current treatment methods for acute tears consist of meniscectomy and meniscal repair, whereas meniscal allograft transplant is reserved as a salvage procedure for symptomatic meniscectomized patients who desire a more functional knee. This review describes the postoperative rehabilitation protocol for each procedure and evaluates the outcomes in existing literature as it pertains to the athlete.

Incidence Rate and Results of the Surgical Treatment of Pectoralis Major Tendon Ruptures in Active-Duty Military Personnel.

BACKGROUND: Pectoralis major tendon ruptures are commonly described as rare injuries affecting men between 20 and 40 years of age, with generally excellent results after surgical repair. However, this perception is based on a relatively small number of case series and prospective studies in the orthopaedic literature. PURPOSE: To determine the incidence of pectoralis major tendon ruptures in the active-duty military population and the demographic risk factors for a rupture and to describe the outcomes of surgical treatment. STUDY DESIGN: Case control study; Level of evidence, 3. METHODS: We utilized the Military Health System Data Repository (MDR) to identify all active-duty military personnel surgically treated for a pectoralis major tendon rupture between January 2012 and December 2014. Electronic medical records were searched for patients' demographic information, injury characteristics, and postoperative complications and outcomes. Risk factors for a rupture were calculated using Poisson regression, based on population counts obtained from the MDR. Risk factors for a postoperative complication, the need for revision surgery, and the inability to continue with active duty were determined using univariate analysis and multivariate logistic regression. RESULTS: A total of 291 patients met inclusion criteria. The mean patient age was 30.5 years, all patients were male, and the median follow-up period was 18 months. The incidence of injuries was 60 per 100,000 person-years over the study period. Risk factors for a rupture included service in the Army, junior officer or junior enlisted rank, and age between 25 and 34 years. White race and surgery occurring >6 weeks after injury were significant risk factors for a postoperative complication. Among the 214 patients with a minimum of 12 months' clinical follow-up, 95.3% were able to return to military duty. Junior officer/enlisted status was a significant risk factor for failure to return to military duty. CONCLUSION: Among military personnel, Army soldiers and junior officer/enlisted rank were at highest risk of pectoralis major tendon ruptures, and junior personnel were at highest risk of being unable to return to duty after surgical treatment. Although increasing time from injury to surgery was not a risk factor for treatment failure or inability to return to duty, it did significantly increase the risk of a postoperative complication.

Hybrid Tibia Fixation of Soft Tissue Grafts in Anterior Cruciate Ligament Reconstruction: A Systematic Review.

BACKGROUND: Optimal fixation of soft tissue grafts in anterior cruciate ligament (ACL) reconstruction remains a controversial topic, and tibial-sided fixation is frequently cited as the "weak point" of the femur-graft-tibia construct. Some studies have recommended the use of hybrid fixation (combining intratunnel aperture fixation and extracortical suspensory fixation) on the tibial side to increase the strength of the reconstructed ACL and decrease the risk of graft slippage and subsequent failure. However, no consensus has emerged on the necessity or suitability of this technique, relative to single modes of fixation. PURPOSE: This study sought answers to the following questions: (1) Does hybrid fixation result in stronger, stiffer initial fixation of soft tissue grafts? (2) Does hybrid fixation reduce side-to-side laxity differences in clinical practice? (3) Does hybrid fixation increase complication rates when compared with a single mode of tibial fixation? STUDY DESIGN: Systematic review. METHODS: A systematic keyword search of PubMed, EMBASE, the Cochrane Library of Systematic Reviews, and the PROSPERO International Prospective Register of Systematic Reviews was performed. Candidate articles were included if they compared biomechanical or clinical characteristics of tibial-sided hybrid fixation (defined as a combination of aperture and suspensory fixation methods) with single-mode fixation of soft tissue grafts in ACL reconstruction. RESULTS: A total of 21 studies (15 biomechanical, 6 clinical) met criteria for inclusion. Most biomechanical studies reported significantly increased strength and stiffness with hybrid fixation versus single modes of fixation. Among clinical studies, 66% reported significantly decreased anterior-posterior laxity when hybrid fixation methods were employed, with the remainder showing no difference. CONCLUSION: Hybrid methods of tibial-sided graft fixation in ACL reconstruction result in stronger initial fixation and less side-to-side laxity after healing but do not change patient-reported outcomes at 1- to 3-year follow-up. REGISTRATION: PROSPERO International Prospective Register of Systematic Reviews No. 42014015464.

Analysis of Orthopaedic Research Produced During the Wars in Iraq and Afghanistan.

BACKGROUND: Military orthopaedic surgeons have published a substantial amount of original research based on our care of combat-wounded service members and related studies during the wars in Iraq and Afghanistan. However, to our knowledge, the influence of this body of work has not been evaluated bibliometrically, and doing so is important to determine the modern impact of combat casualty research in the wider medical community. QUESTIONS/PURPOSES: We sought to identify the 20 most commonly cited works from military surgeons published during the Iraq and Afghanistan conflicts and analyze them to answer the following questions: (1) What were the subject areas of these 20 articles and what was the 2013 Impact Factor of each journal that published them? (2) How many citations did they receive and what were the characteristics of the journals that cited them? (3) Do the citation analysis results obtained from Google Scholar mirror the results obtained from Thompson-Reuters' Web of Science? METHODS: We searched the Web of Science Citation Index Expanded for relevant original research performed by US military orthopaedic surgeons related to Operation Iraqi Freedom and Operation Enduring Freedom between 2001 and 2014. Articles citing these studies were reviewed using both Web of Science and Google Scholar data. The 20 most cited articles meeting inclusion criteria were identified and analyzed by content domain, frequency of citation, and sources in which they were cited. RESULTS: Nine of these studies examined the epidemiology and outcome of combat injury. Six studies dealt with wound management, wound dehiscence, and formation of heterotopic ossification. Five studies examined infectious complications of combat trauma. The median number of citations garnered by these 20 articles was 41 (range, 28-264) in Web of Science. Other research citing these studies has appeared in 279 different journals, covering 26 different medical and surgical subspecialties, from authors in 31 different countries. Google Scholar contained 97% of the Web of Science citations, but also had 31 duplicate entries and 29 citations with defective links. CONCLUSIONS: Modern combat casualty research by military orthopaedic surgeons is widely cited by researchers in a diverse range of subspecialties and geographic locales. This suggests that the military continues to be a source of innovation that is broadly applicable to civilian medical and surgical practice and should encourage expansion of military-civilian collaboration to maximize the utility of the knowledge gained in the treatment of war trauma. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Risk of Anterior Cruciate Ligament Injury in Athletes on Synthetic Playing Surfaces: A Systematic Review.

BACKGROUND: The effect of synthetic playing surfaces on the risk of injury in athletes is frequently debated in the orthopaedic literature. Biomechanical studies have identified increased frictional force at the shoe-surface interface, theoretically increasing the risk of injury relative to natural grass. This increase in frictional force is potentially relevant for the risk of anterior cruciate ligament (ACL) rupture, where noncontact mechanisms are frequent. However, clinical studies examining this issue have shown mixed results. HYPOTHESIS/PURPOSE: The purpose of this study was to systematically review the available literature on risk of ACL rupture on natural grass versus artificial turf. We hypothesized that the risk of ACL rupture on synthetic playing surfaces would not be higher than that of natural grass playing surfaces. STUDY DESIGN: Systematic review. METHODS: A systematic keyword search was performed of OVID, EMBASE, the Cochrane Library of Systematic Reviews, and the PROSPERO International Prospective Register of Systematic Reviews. Candidate articles were included if they reported the risk ratio of ACL rupture on natural grass versus synthetic playing surfaces, were of level 3 evidence or better, and included only ACL injuries sustained during organized athletic events. Exclusion criteria included a study with non-field-related sports and the use of historical cohorts for calculating risk ratios. RESULTS: A total of 10 studies with 963 ACL injuries met criteria for inclusion, all of which reported on soccer and football cohorts. Among these, 4 studies (753 ACL injuries) found an increased risk of ACL injury on artificial playing surfaces. All 4 of these articles were conducted using American football cohorts, and they included both earlier-generation surfaces (AstroTurf) and modern, 3rd-generation surfaces. Only 1 study in football players found a reduced risk of ACL injury on synthetic playing surfaces. No soccer cohort found an increased risk of ACL injury on synthetic surfaces. CONCLUSION: High-quality studies support an increased rate of ACL injury on synthetic playing surfaces in football, but there is no apparent increased risk in soccer. Further study is needed to clarify the reason for this apparent discrepancy.

Management of mid-season traumatic anterior shoulder instability in athletes.

Shoulder dislocation and subluxation injuries are common in young athletes and most frequently occur during the competitive season. Controversy exists regarding optimal treatment of an athlete with an in-season shoulder dislocation, and limited data are available to guide treatment. Rehabilitation may facilitate return to sport within 3 weeks, but return is complicated by a moderate risk of recurrence. Bracing may reduce the risk of recurrence, but it restricts motion and may not be tolerated in patients who must complete certain sport-specific tasks such as throwing. Surgical management of shoulder dislocation or subluxation with arthroscopic or open Bankart repair reduces the rate of recurrence; however, the athlete is unable to participate in sport for the remainder of the competitive season. When selecting a management option, the clinician must consider the natural history of shoulder instability, pathologic changes noted on examination and imaging, sport- and position-specific demands, duration of treatment, and the athlete's motivation.

Anterior cruciate ligament anatomy: a review of the anteromedial and posterolateral bundles.

Critical evaluations of anterior cruciate ligament (ACL) reconstruction failure modes have shown that the most common cause for failure is aberrant femoral tunnel placement. Regardless of the surgical reconstruction technique, it is imperative to have a thorough understanding of the anatomy and function of the anteromedial (AM) and posterolateral (PL) bundles of the native ACL to successfully restore the stability and motion of the injured knee. Similar to the observation that anatomic reduction is critical to successful fracture management, ACL reconstruction techniques must focus on restoring the normal anatomy of the ACL. This article reviews the anatomy of the AM and PL bundles of the ACL, including landmarks for identifying their femoral and tibial footprints.

Trochlear contact pressures after straight anteriorization of the tibial tuberosity.

BACKGROUND: Anteromedialization of the tibial tuberosity has been shown to decrease mean total contact pressures of the lateral trochlea and to shift contact pressures to the medial trochlea. HYPOTHESIS: Modifying the anteromedialization osteotomy to a straight anteriorization osteotomy of the tibial tuberosity can decrease trochlear contact pressures without a resultant medial shift of forces to the medial trochlear contact area. STUDY DESIGN: Controlled laboratory study. METHODS: Ten cadavers were tested before and after straight anteriorization tibial tuberosity osteotomy by loading the extensor mechanism with 89.1 and 178.2 N at 0 degrees , 30 degrees , 60 degrees , and 90 degrees of flexion following a validated patellofemoral joint loading protocol. Contact pressures were measured with electroresistive pressure sensors placed directly on the trochlea. RESULTS: The mean trochlear contact pressures after osteotomy decreased significantly (P < .05) for loads of 89.1 and 178.2 N at both 30 degrees (23% and 20%, respectively) and 60 degrees (18.7% and 31.9%, respectively) of knee flexion. The peak contact pressures decreased significantly (P < .05) for loads of 89.1 and 178.2 N at 30 degrees (24.3% and 27.0%, respectively) and 60 degrees (31.9% and 24.5%, respectively) and for loads of 89.1 N at 90 degrees (13.4%) of knee flexion. CONCLUSION: The authors demonstrated significantly decreased trochlear contact forces after straight anteriorization osteotomy of the tibial tuberosity, without a significant resultant medial shift of the center of force. CLINICAL RELEVANCE: Straight anteriorization of the tibial tuberosity may be a useful adjunct for patients with medial articular defects of the patellar or trochlea in whom anteromedialization would be otherwise contraindicated.

Systematic review of single-bundle anterior cruciate ligament reconstruction outcomes: a baseline assessment for consideration of double-bundle techniques.

BACKGROUND: There is increasing interest in comparing the efficacy of single-bundle versus double-bundle anterior cruciate ligament reconstruction. Challenging this comparison, however, has been the lack of an established consensus on the success of single-bundle reconstruction. HYPOTHESIS: The current outcomes of single-bundle reconstruction can be clarified from a large unbiased body of evidence for future comparisons with double-bundle reconstructions. STUDY DESIGN: Systematic review. METHODS: A systematic review of 11 randomized, controlled trials comparing patellar tendon and hamstring tendon grafting is reported. The respective outcomes of each group were combined to assist the orthopaedic surgeon in assessing the current success of single-bundle reconstruction. The primary factors assessed were tibial subluxation and side-to-side differences in laxity. Secondary outcomes included concomitant injuries and treatments, complications, graft failure, range of motion, and radiographic evidence of degenerative changes. RESULTS: In this review of 1024 single-bundle anterior cruciate ligament reconstructions, 495 concomitant meniscal tears, 95 chondral injuries, and 2 posterior cruciate ligament tears were noted. The complication rate was 6%, and graft failure 4%. Reported pivot-shift test results were negative in 81% of cases; reported Lachman tests were negative in 59% cases; and KT-1000 arthrometer side-to-side differences were

Posterior wall blowout in anterior cruciate ligament reconstruction: avoidance, recognition, and salvage.

Posterior wall blowout is an important potential source of anterior cruciate ligament reconstruction failures that can be avoided if surgeons adhere to proper technique and are vigilant in confirming appropriate femoral tunnel placement. This article reviews techniques for avoidance, recognition, and salvage of posterior wall blowouts in anterior cruciate ligament reconstruction surgery.