Biomechanical Comparison Between Double-Row Repair and Soft Tissue Tenodesis for Treatment of Proximal Rectus Femoris Avulsions.

Background: Some patients with proximal rectus femoris (PRF) avulsions require surgical treatment after failed nonoperative treatment. There is no consensus on the superiority of suture anchor repair with the suture-bridge repair (SBR) technique versus tenodesis repair (TR) for PRF avulsions. Purpose: To compare the failure load and elongation at failure between SBR and TR and to compare the stiffness of these 2 repair techniques versus the native state. Study Design: Controlled laboratory study. Methods: Seven pairs of human cadaveric hemipelvises were dissected to the PRF and sartorius origins. Each specimen underwent preconditioning followed by a distraction test to determine the stiffness of the native specimen. One specimen of each pair received one of the repair methods (SBR or TR), while the other specimen in the pair received the other repair technique. After repair, each specimen underwent preconditioning followed by a pull to failure. The failure load, elongation at failure, stiffness, mode of failure, and stiffness as a percentage of the native state were determined for each repair. Results: The SBR group exhibited a stronger failure load (223 ± 51 N vs 153 ± 32 N for the TR group; P = .0116) and significantly higher stiffness as a percentage from the native state (70.4% ± 19% vs 33.8% ± 15.5% for the TR group; P = .0085). While the stiffness of the repair state in the SBR group (41.5 ± 9.4 N/mm) was not significantly different from that of the native state (66.2 ± 36 N/mm), the stiffness of the repair state in the TR group (20.3 ± 7.5 N/mm) was significantly lower compared with that of the native state (65.4 ± 22.1 N/mm; P < .001) and repair state in the SBR group (41.5 ± 9.4 N/mm; P = .02). The SBR group primarily failed at the repair site (71%), and the TR group primarily failed at the suture-sartorius interface (43%) and at the muscle (29%). Conclusion: SBR and TR specimens were significantly weaker than the native tendon. The stiffness of the SBR was equivalent to that of the native tendon, while TR was significantly less stiff than the native tendon. The SBR was superior to TR in terms of failure load, stiffness, and percentage stiffness from the native state. Clinical Relevance: SBR may be a better surgical option than TR to optimize failure load and stiffness for PRF avulsions.

Biomechanical Comparison of Proximal Hamstring Reconstruction Using Distal Hamstring Graft Versus Fascia Lata Graft for Treatment of Chronic Hamstring Injury.

BACKGROUND: Surgical reconstruction using autografts is often required in treating chronic proximal hamstring injuries where the hamstring has retracted >5 cm. There is a paucity of evidence that evaluates reconstructive procedures using the 2 most popular autografts, distal hamstring and fascia lata. PURPOSE: To (1) compare failure load and elongation at failure between the proximal hamstring tendon reconstruction with distal hamstring and fascia lata grafts and (2) compare the stiffness between these reconstructions and the native state. STUDY DESIGN: Controlled laboratory study. METHODS: Seven pairs of human cadaveric hemipelvises (mean age, 60.4 ± 5.0 years; 6 male, 1 female) with no evidence of previous injury or abnormality were dissected to the proximal hamstring origin. Through use of a dynamic tensile testing system, each specimen underwent preconditioning followed by a distraction test to determine the native specimen stiffness. Each pair of specimens was assigned to undergo proximal hamstring reconstruction with distal hamstring and reconstruction with fascia lata. Each specimen then underwent preconditioning followed by pull to failure. The failure load, elongation at failure, mode of failure, and stiffness were determined for each repair. RESULTS: The distal hamstring group exhibited a greater failure load (mean, 334 ± 108 N; P = .031) and higher stiffness (mean, 47.6 ± 16.0 N/mm; P = .009) compared with the fascia lata group (mean, 179 ± 78 N and 23.0 ± 11.2 N/mm, respectively). Although the stiffness of the repair state in the distal hamstring group (mean, 61.4 ± 13.4 N/mm) was not significantly different from that of the native state (mean, 47.6 ± 16.0 N/mm), the stiffness of the repair state in the fascia lata group (mean, 23.0 ± 11.2 N/mm) was significantly lower than that of the native state (mean, 60.1 ± 17.7 N/mm) (P < .0001). The elongation at failure of the distal hamstring graft group (mean, 33.0 ± 6.6 mm) was not significantly different from that of the fascia lata graft group (mean, 29.2 ± 14.9 mm) (P = .58). The most common modes of failure for the distal hamstring group (29% each) were at the repair site, at the graft-muscle interface, and at the muscle, while the most common modes of failure for the fascia lata graft were at the tendon-graft interface. CONCLUSION: The distal hamstring group achieved higher failure load and stiffness than the fascia lata group, and stiffness of the distal hamstring group was not significantly different from that of the native tendon. Elongation at failure was not different between repair techniques. Although distal hamstring graft failure predominantly occurred in 3 distinct locations, failure of the fascia lata repair occurred predominantly at the tendon-graft interface. These cadaveric results suggest that it may be more clinically appropriate to use distal hamstring versus fascia lata for proximal hamstring reconstruction. CLINICAL RELEVANCE: Our time-zero study suggests that the proximal hamstring reconstruction with distal hamstring could be the preferred surgical treatment for chronic hamstring injury over reconstruction with fascia lata. The failure load of reconstruction with distal hamstring was inferior to that of primary suture anchor, suggesting that rehabilitation after reconstruction should not be more aggressive than the standard postoperative rehabilitation protocol for acute repair.

Combined Arthroscopic Scapulothoracic Bursectomy, Partial Scapulectomy, and Pectoralis Minor Release for the Treatment of Snapping Scapular Syndrome.

Snapping scapula syndrome (SSS) is a source of pain and discomfort in patients. It is not uncommon for patients who present with SSS to have some degree of scapular dysfunction, especially with the tightness of the pectoralis minor (PM) muscle. In this Technical Note, we demonstrate our preferred technique for arthroscopic scapulothoracic bursectomy and partial scapulectomy with concomitant pectoralis minor release for the treatment of symptomatic SSS and PM tightness. In the treatment of these patients, PM release is beneficial because arthroscopic scapulothoracic bursectomy or partial scapulectomy alone may result in residual scapular dyskinesis.

Patient-Specific Instrumentation for Medial Closing Wedge Distal Femoral Osteotomy With Patellar Osteochondral Allograft.

The primary indications for performing a medial closing wedge distal femoral osteotomy are valgus knee malalignment, lateral knee compartment overload, lateral meniscus insufficiency, and/or lateral compartment osteoarthritis or cartilage damage. Without correction of this malalignment, there is an increased risk for chondral damage in the lateral and patellofemoral compartment of the knee. The optimal candidates for this procedure are young, active individuals with moderate to severe arthritis in the lateral compartment. Recently, preoperative planning for high tibial and distal femoral osteotomies (HTOs and DFOs) using 3-dimensional (3D) patient-specific instrumentation (PSI) has increased in popularity. Successful patient outcomes have been reported using this technique. This Technical Note illustrates our preferred technique that uses 3D PSI in addition to a patellar OCA transplant when treating a symptomatic cartilage lesion associated with genu valgum.

Efficacy of a 6-week Novel Exergaming Intervention Guided by Heart Rate Zones on Aerobic Performance in Children with Fetal Alcohol Spectrum Disorder and Attention-deficit/Hyperactivity Disorder: A Feasibility Study.

The purpose of this study was to determine the feasibility of a novel exergaming intervention guided by heart rate zones for children and adolescents with fetal alcohol spectrum disorder (FASD) and attention-deficit/hyperactivity disorder (ADHD). Eight study participants (6 females, 2 males, mean age= 11.4±1.4 years old) participated twice weekly over six weeks to complete twelve multimodal exergaming sessions. Participants significantly improved 6MWT from baseline to week 6 (575.4±55.0 m to 732.8±58.9 m; P<0.01), which conferred a 31% improvement in estimated VO2max (31.5±5.5 ml/kg/min to 40.9±5.9 ml/kg/min), respectively. There was an upward trend of the mean percentage of time spent in the intermediate HR zones over the course of the 6-week intervention. These findings may provide value to the field as they support the clinical utility and promising effects of cardiovascular improvement in children who engage in a compelling exergaming intervention. In doing so, this establishes a preliminary understanding of how to augment routine physical exercise through exergaming using visually targeted heart rate zones.

Anterior Closing-Wedge High Tibial Slope-Correcting Osteotomy Using Patient-Specific Preoperative Planning Software for Failed Anterior Cruciate Ligament Reconstruction.

Failure of anterior cruciate ligament reconstruction (ACLR) remains a challenging problem. Recently, the effect of increased posterior tibial slope has been identified as a risk factor for ACLR failure. In cases with increased posterior tibial slope, an anterior closing wedge, slope-correcting high tibial osteotomy can be used as a robust adjunct to revision ACLR. In this Technical Note, we demonstrate our preferred method for isolated sagittal plane correction following multiple failed ACLRs with an anterior closing-wedge high tibial osteotomy technique using 3-dimensional patient-specific instrumentation. Through correction of the angular deformity and restoration of the defined sagittal slope via the use of advanced 3-dimensional patient-specific instrumentation, this technique fosters an accurate, favorable mechanical environment to prevent recurrent instability of the knee joint.

Impact of prior anterior instability on shoulder arthroplasty outcomes: a systematic review.

Background: Anterior shoulder instability (ASI) is a frequently encountered pathology. Patients with a history of ASI have an increased rate of developing glenohumeral osteoarthritis and becoming candidates for shoulder arthroplasty. This systematic review aims to synthesize outcomes for patients undergoing shoulder arthroplasty with a history of ASI. Methods: A comprehensive literature review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) using PubMed, Embase, OVID Medline, Scopus, CINAHL, Web of Science, and Cochrane databases for studies evaluating the impact of prior ASI on total shoulder arthroplasty (TSA), reverse TSA, and/or hemiarthroplasty outcomes, with a minimum follow-up of 12 months. Studies were graded by level of evidence and data concerning patient demographics and outcomes were extracted. Results: Sixteen articles met the inclusion criteria, including 596 patients (413 male, 181 female). The average age of the control and prior ASI groups were 57.5 and 57.0 years, respectively. Overall, 251 patients were treated operatively, 132 nonoperatively, and 213 were controls without a history of prior ASI. Shoulder arthroplasty techniques included TSA (436 shoulders), reverse TSA (130 shoulders), and hemiarthroplasty (14 shoulders). Prior anterior stabilization management included soft tissue repair, bony augmentation, and nonoperative treatment. Almost all studies reported no significant difference in subjective and functional arthroplasty outcomes between control and prior ASI groups, or between patients with prior ASI treated nonoperatively vs. surgically. Conclusion: Shoulder arthroplasty in the setting of prior ASI results in improved subjective and functional outcome scores that are comparable to patients without a history of instability.

Talar Allograft Preparation for Treatment of Reverse Hill-Sachs Defect in Recurrent Posterior Shoulder Instability.

Reverse Hill-Sachs lesions (rHSLs) after chronic posterior shoulder instability are important to recognize and treat appropriately. Treatment options for posterior instability with rHSL in the current literature are primarily based on percentage of humeral bone loss. In cases of moderate (25% to 50%) anterolateral humeral head bone loss, fresh osteochondral allografts are preferred. Recent literature has indicated that the talus serves as a robust grafting alternative site for the humeral head, as the talar dome shows high congruency and offers variable sizes. The purpose of this Technical Note is, therefore, to describe our technique for talus allograft preparation for the treatment of a large rHSL that highlights precise cutting anatomy, sizing options, and use of orthobiologics to ensure excellent talus union to the native humeral head surface.

Treatment of Failed Coracoclavicular Ligament Reconstructions: Primary Acromioclavicular Ligament and Capsular Reconstruction and Revision Coracoclavicular Ligament Reconstruction.

Acromioclavicular (AC) joint dislocations are a common injury affecting 2 of every 10,000 people in the general population and comprise 9% to 12% of all injuries to the shoulder. Most injuries occur through contact activity, which drives the acromion inferiorly with the clavicle remaining in its anatomic position, initiating a cascade of injury propagating from the AC ligament followed by failure of the coracoclavicular ligaments. Many techniques have been described for AC joint injuries, without a consensus gold standard. The revision setting offers even less consensus on treatment options and countless difficulties for surgeons. There have been more than 60 described procedures regarding AC and coracoclavicular ligament reconstructions, with significant controversy regarding the optimal intervention for each injury. When these techniques fail, it is important to pinpoint the mechanism of failure to construct a successful plan for revision. The purpose of this Technical Note is to describe our preferred method of primary AC and revision coracoclavicular reconstruction using a combination of autograft and allograft semitendinosus as well as TightRope fixation.

How to Fashion the Bone Block for Reconstruction of the Glenoid in Anterior and Posterior Instability.

BACKGROUND: Glenoid restoration techniques to address glenohumeral instability-induced anterior and posterior glenoid bone loss (AGBL and PGBL) often require reconstruction, but best-fit bone block (BFBB) modeling has not been developed. PURPOSE: To provide glenoid bony reconstruction models for anterior and posterior instability of the shoulder using a bone loss instability cohort with high-fidelity 3-dimensional (3D) imaging. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: We reviewed consecutive patients indicated for operative stabilization who had posterior glenohumeral instability and suspected GBL who underwent 2-dimensional (2D) computed tomography (CT). Patients were matched by sex, laterality, and age to patients who underwent operative stabilization of anterior glenohumeral instability. Mimics software was used to convert all 2D CT scans into 3D models of the scapula. A BFBB model was designed to digitally reconstruct GBL and was used to predict the amount, anatomic configuration, and fixation configuration of bony reconstruction required in AGBL and PGBL. RESULTS: The study included 30 patients with posterior instability and 30 patients with anterior instability; the participants' mean ± SD age was 28.8 ± 8.15 years (range, 16.0-51.0 years). Mean surface area of AGBL was 24.9% ± 7.7% (range, 14.7%-39.1%). Mean BFBB dimensions to reconstruct the anterior glenoid were determined to be a superior-inferior length of 23.9 ± 4.2 mm, anterior-posterior width of 6.4 ± 2.4 mm, and height of 1 cm. Mean angle of AGBL bone block interface relative to glenoid to reconstruct the native concavity was 79.4°± 5.9°. For PGBL, the mean surface area was 9.2% ± 5.6% (range, 3.0%-26.3%). Mean BFBB dimensions to reconstruct the posterior glenoid were a superior-inferior length of 21.9 ± 3.4 mm, width of 4.5 ± 2.3 mm, and height of 1 cm. The mean angle of PGBL bone block interface relative to the glenoid to reconstruct the native concavity was 38.6°± 14.3°. Orientation relative to the vertical glenoid axis was 77.2°± 13.8° in anterior reconstructions versus 105.9°± 10.9° in posterior reconstructions. CONCLUSION: Patients with anterior instability required a more rectangular BFBB with a bone block-glenoid interface angle of 79°, whereas patients with posterior instability required a more trapezoidal, obtusely oriented BFBB with a bone block-glenoid interface angle of 39°. BFBBs for either AGBL or PGBL can be effectively designed, and their size and/or shape can be predicted based on approximate percentage of GBL.

Fresh Distal Tibial Allograft: An Updated Graft Preparation Technique for Anterior Shoulder Instability.

Fresh distal tibia allograft (DTA) has been gaining popularity among surgeons as an anatomic reconstruction option for the treatment of significant glenoid bone loss. Fresh DTA results in a clinically stable joint with excellent clinical outcomes and minimal graft resorption, and it has similar outcomes as the Latarjet procedure. Proper graft preparation and fixation are critical to ensuring optimal outcomes. The purpose of this Technical Note is, therefore, to describe our updated technique for DTA preparation that highlights precise cutting anatomy, sizing options, and use of orthobiologics to optimize distal tibia graft union to the native glenoid surface.

Reverse Total Shoulder Arthroplasty for Treatment of Massive, Irreparable Rotator Cuff Tear.

Massive tears of the rotator cuff can result in severe functional deficits due to loss of the axial force couple and effective fulcrum that the intact cuff normally provides. For massive, irreparable rotator cuff tears, especially in the setting of early to moderate degenerative changes, reverse total shoulder arthroplasty functions to modify the center of joint rotation, allowing the deltoid and intact components of the cuff to carry out shoulder function more effectively. Our preferred technique uses a standard open deltopectoral shoulder approach with a 3-dimensional glenoid baseplate model and a 135° prosthesis in an onlay configuration to reduce the risk of scapular notching and increase lateralization of the humerus.

Primary Distal Tibia Allograft for Restoration of Glenohumeral Stability with Anterior Glenoid Bone Loss.

Recurrent shoulder instability with glenoid bone deficiency remains an increasing risk for failed shoulder stabilization surgery. Numerous free bone block procedures for primary treatment of anterior shoulder stability have been introduced as an alternative for the Latarjet procedure, including both autografts and allografts. Among such options is the fresh distal tibial allograft (DTA), a dense weightbearing bone without donor site morbidity and excellent conformity to the native glenoid. The aim of this Technical Note is therefore to describe our surgical technique for use of fresh DTA as a free bone block choice in the setting of primary anterior glenoid reconstruction in a patient with recurrent shoulder instability.

The Efficacy of an Immersive Virtual Reality Exergame Incorporating an Adaptive Cable Resistance System on Fitness and Cardiometabolic Measures: A 12-Week Randomized Controlled Trial.

Exergaming, combining elements of video game into the realm of exercise, has recently incorporated immersive virtual reality (IVR) with resistance training. Thirty-two participants (14 females, mean age = 24.3) were randomized to IVR or self-directed control group (SELF) and worked out thrice weekly for 12 weeks (for 36 sessions). The IVR group spent 14 fewer minutes per session (p < 0.001) while reporting the sessions "enjoyable'. Compared to SELF, the IVR group had significantly greater improvement in changes from baseline to post-training in upper-and-lower muscular strength (1-RM) and muscular endurance (85% 1-RM) (14.3 kg vs. 10.0 kg for 1-RM upper, 28.6 kg vs. 22.5 kg for 1-RM lower, 2.6 reps vs. 1.9 reps for 85% 1-RM of upper, 2.7 vs. 2.0 reps for 85% 1-RM of lower, all p < 0.001), peak leg power (1424 vs. 865 W, p < 0.001), body fat% (−3.7% vs. −1.9%, p < 0.001), heart rate variability (4.3 vs. 1.8 ms, p < 0.001), rVO2max (3.28 vs. 0.89 mL/min/kg, p < 0.001) with decreased systolic BP (−0.4 vs. −2.3 mmHg, p < 0.001), and level of perceived exertion during workouts (RPE 14 vs. 16, p < 0.001). With its high-paced and action-filled gaming coupled with superior fitness and cardiometabolic outcomes, this IVR exergaming platform should be considered as another exercise modality for performance and health-related training.

Full-Thickness Radial Medial Meniscal Tear: Fixation With Inside-Out Technique With Tibial Knotless Suture Anchors.

Complete radial tears of the meniscus render the entirety of the meniscus functionally incompetent (known as an ameniscal state); therefore, attempts at repair are essential. Although various techniques have been described, repair failures continue to frequently occur, especially with the medial meniscus. Inside-out repair and anchoring of the preserved meniscus to both the capsule and tibia may offer the advantage of a more robust repair. The objective of this Technical Note is to describe a method of repair for complete radial tears of the medial meniscus using a combination of inside-out sutures and secondary reinforcement to the tibia using all-suture knotless anchors.