Indirect Head of the Rectus Femoris Tendon as a Graft for Segmental Hip Labral Reconstruction: An Anatomic, Radiographical, and Biomechanical Study in Comparison With Iliotibial Labral Reconstruction.

BACKGROUND: The indirect head of the rectus femoris (IHRF) tendon has been used as an autograft for segmental labral reconstruction. However, the biomechanical properties and anatomic characteristics of the IHRF, as they relate to surgical applications, have yet to be investigated. PURPOSE: To (1) quantitatively and qualitatively describe the anatomy of IHRF and its relationship with surrounding arthroscopically relevant landmarks; (2) detail radiographic findings pertinent to IHRF; (3) biomechanically assess segmental labral reconstruction with IHRF, including restoration of the suction seal and contact pressures in comparison with iliotibial band (ITB) reconstruction; and (4) assess potential donor-site morbidity caused by graft harvesting. STUDY DESIGN: Descriptive laboratory study. METHODS: A cadaveric study was performed using 8 fresh-frozen human cadaveric full pelvises and 7 hemipelvises. Three-dimensional anatomic measurements were collected using a 3-dimensional coordinate digitizer. Radiographic analysis was accomplished by securing radiopaque markers of different sizes to the evaluated anatomic structures of the assigned hip.Suction seal and contact pressure testing were performed over 3 trials on 6 pelvises under 4 different testing conditions for each specimen: intact, labral tear, segmental labral reconstruction with ITB, and segmental labral reconstruction with IHRF. After IHRF tendon harvest, each full pelvis had both the intact and contralateral hip tested under tension along its anatomic direction to assess potential site morbidity, such as tendon failure or bony avulsion. RESULTS: The centroid and posterior apex of the indirect rectus femoris attachment are respectively located 10.3 ± 2.6 mm and 21.0 ± 6.5 mm posteriorly, 2.5 ± 7.8 mm and 0.7 ± 8.0 mm superiorly, and 5.0 ± 2.8 mm and 22.2 ± 4.4 mm laterally to the 12:30 labral position. Radiographically, the mean distance of the IHRF to the following landmarks was determined as follows: anterior inferior iliac spine (8.8 ± 2.5 mm), direct head of the rectus femoris (8.0 ± 3.9 mm), 12-o'clock labral position (14.1 ± 2.8 mm), and 3-o'clock labral position (36.5 ± 4.4 mm). During suction seal testing, both the ITB and the IHRF reconstruction groups had significantly lower peak loads and lower energy to peak loads compared with both intact and tear groups (P = .01 to .02 for all comparisons). There were no significant differences between the reconstruction groups for peak loads, energy, and displacement at peak load. In 60° of flexion, there were no differences in normalized contact pressure and contact area between ITB or IHRF reconstruction groups (P > .99). There were no significant differences between intact and harvested specimen groups in donor-site morbidity testing. CONCLUSION: The IHRF tendon is within close anatomic proximity to arthroscopic acetabular landmarks. In the cadaveric model, harvesting of the IHRF tendon as an autograft does not lead to significant donor-site morbidity in the remaining tendon. Segmental labral reconstruction performed with the IHRF tendon exhibits similar biomechanical outcomes compared with that performed with ITB. CLINICAL RELEVANCE: This study demonstrates the viability of segmental labral reconstruction with an IHRF tendon and provides a detailed anatomic description of the tendon in the context of an arthroscopic labral reconstruction. Clinicians can use this information during the selection of a graft and as a guide during an arthroscopic graft harvest.

Managing the Severe Cavus Foot Deformity in Global Humanitarian Programs.

The cavus foot represents a complex spectrum of deformity ranging from the subtle idiopathic to the severe sensorimotor neuropathy and other neuromuscular deformities. The successful surgical treatment of the cavus foot depends on a fundamental understanding of the underlying multiplanar deformity, inherent muscle balance, and the rigidity of the hindfoot. The location of the deformity is described and understood according to its multiple apices. These deformities are addressed with osteotomies or arthrodesis directed at the apices of deformity. Simultaneously, correction of muscular imbalances with appropriate tendon transfers must also be performed to prevent recurrent deformity. With these principles in mind, the surgical correction of the cavus foot becomes simplified and algorithmically driven.

A Radiostereometric Analysis of Tendon Migration After Arthroscopic and Mini-Open Biceps Tenodesis: Interference Screw Versus Single Suture Anchor Fixation.

BACKGROUND: Studies suggest that similar clinical results are achieved via arthroscopic and open biceps tenodesis (BT) techniques. PURPOSE: To quantify the postoperative migration of the BT construct between arthroscopic suprapectoral BT (ASPBT) and open subpectoral BT (OSPBT) techniques via interference screw (IS) or single-suture suture anchor (SSSA) fixation using radiostereometric analysis. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Distal migration of the biceps tendon after OSPBT with a polyetheretherketone IS, OSPBT with 1 SSSA, ASPBT with polyetheretherketone IS, and ASPBT with 2 SSSAs was measured prospectively. Patients with symptomatic biceps tendinopathy and preoperative patient-reported outcome measures (PROMs) including Constant-Murley subjective, Single Assessment Numeric Evaluation, or Patient-Reported Outcomes Measurement Information System-Upper Extremity scores were included. A tantalum bead was sutured on the proximal end of the long head of the biceps tendon before fixation of tendon tissue. Anteroposterior radiographs were performed immediately postoperatively, at 1 week, and at 3 months. Bead migration was measured, and preoperative PROMs were compared with those at latest follow-up. RESULTS: Of 115 patients, 94 (82%) were available for final follow-up. IS fixation yielded the least tendon migration with no difference between the open and arthroscopic approaches (4.31 vs 5.04 mm; P = .70). Fixation with 1 suture anchor demonstrated significantly greater migration than that achieved with an IS at both 1 week (6.47 vs 0.1 mm, 6.47 vs 1.75 mm, P < .001;) and 3 months (14.76 vs 4.31 mm, 14.76 vs 5.04 mm, P < .001) postoperatively. Two-suture anchor fixation yielded significantly greater migration than IS fixation at 1 week (7.02 vs 0.1 mm, P < .001; 7.02 vs 1.75 mm, P = .003) but not 3 months postoperatively (8.06 vs 4.31 mm, P = .10; 8.06 vs 5.04 mm, P = .07). Four patients with suture anchor fixation (3 patients in the OSPBT 1 SSSA group, 9.4%, and 1 patient in the ASPBT 2 SSSAs group, 3.8%) developed a Popeye deformity, whereas no Popeye deformities occurred in the IS groups. Mean 3-month bead migration in patients with and without a Popeye deformity was 60.8 and 11.2 mm, respectively (P < .0001). PROMs did not differ among groups at final follow-up. CONCLUSION: Interference screw fixation yielded the least tendon migration whether achieved arthroscopically or open. The available data indicated that fixation with 1 SSSA but not 2 SSSAs resulted in significantly greater migration than that achieved with an IS. Despite variations in tendon migration, PROMs were similar among all groups. When SSSAs are used, tendon migration may be minimized by using ≥2 anchors.

The Large Focal Isolated Chondral Lesion.

Focal chondral defects (FCDs) of the knee can be a debilitating condition that can clinically translate into pain and dysfunction in young patients with high activity demands. Both the understanding of the etiology of FCDs and the surgical management of these chondral defects has exponentially grown in recent years. This is reflected by the number of surgical procedures performed for FCDs, which is now approximately 200,000 annually. This fact is also apparent in the wide variety of available surgical approaches to FCDs. Although simple arthroscopic debridement or microfracture are usually the first line of treatment for smaller lesions, chondral lesions that involve a larger area or depth require restorative procedures such as osteochondral allograft transplantation or other cell-based techniques. Given the prevalence of FCDs and the increased attention on treating these lesions, a comprehensive understanding of management from diagnosis to rehabilitation is imperative for the treating surgeon. This narrative review aims to describe current concepts in the treatment of large FCDs through providing an algorithmic approach to selecting interventions to address these lesions as well as the reported outcomes in the literature.

Two-Stage Revision Total Knee Arthroplasty for Chronic Histoplasma Capsulatum Prosthetic Joint Infection: A Case Report.

CASE: This report describes a histoplasma capsulatum total knee prosthetic joint infection (PJI) in an immunosuppressed patient treated with a 2-stage revision. The diagnosis of PJI was made based on minor criteria, and the causative organism was identified from cultures obtained at the time of explantation. The patient underwent induction with amphotericin B, followed by oral antifungal therapy and a successful 2-stage revision with a hinged prosthesis with an interval of ∼7 months between stage 1 and stage 2. At the most recent follow-up (18 months), she remained clear from infection with planned lifetime antifungal suppression. CONCLUSION: This case report highlights the importance of consideration of atypical organisms when treating immunocompromised patients. Furthermore, this case report documents one of the few cases of histoplasma PJI and provides a successful treatment algorithm to potentially be applied to future cases.

Preoperative symptom duration does not affect clinical outcomes after high tibial osteotomy at a minimum of 2-year follow-up.

OBJECTIVES: To determine if patients with preoperative symptom durations greater than two-years' experience inferior patient-reported and clinical outcomes at a minimum of two years after high tibial osteotomy. METHODS: An institutional registry was retrospectively queried for patients treated with high tibial osteotomy for symptomatic medial knee overload/arthritis and varus malalignment between February 2006 and March 2018. Demographic characteristics, clinical outcomes, patient-reported outcomes (PROs), including the International Knee Documentation Committee â€‹score, Knee Injury and Osteoarthritis Outcome Score for Joint Replacement â€‹and Patient-Reported Outcome Measurement Information System Pain Interference â€‹and Physical Function â€‹scores, were assessed at a minimum of two-years postoperatively. Patients were compared based on preoperative symptom duration greater than or less than two years. Correlation coefficients were used to analyse the association between patient demographics and postoperative outcomes for the overall patient sample. RESULTS: A total of 41 patients were included in the analysis with a mean age (± standard deviation) of 37.0 â€‹± â€‹8.2 years and body mass index of 27.6 â€‹± â€‹4.2 â€‹kg/m2. The median (interquartile range) follow-up time for the entire study sample was 48.5 (24-100.5) months. There were no significant differences in delta (pre-to-post improvement) or postoperative PRO scores, number or time-to-reoperation â€‹or conversion to TKA (all P â€‹> â€‹0.05) based on the preoperative duration of symptoms. A statistically significant but weak correlation was observed between greater age (r â€‹= â€‹0.344, P â€‹= â€‹0.027) and BMI (r â€‹= â€‹0.320, P â€‹= â€‹0.044) with conversion to TKA. CONCLUSION: Patients with a preoperative duration of symptomatic medial knee overload/arthritis of two years or greater do not experience inferior PRO or clinical outcomes than patients with a symptom duration of less than 2 years at mid-term follow-up. Greater age and BMI were weakly correlated with conversion to TKA. Greater age was negatively correlated with undergoing at least one reoperation. LEVEL OF EVIDENCE: IV; Retrospective case series.

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.

Does native glenoid anatomy predispose to shoulder instability? An MRI analysis.

BACKGROUND: It is unclear if native glenohumeral anatomic features predispose young patients to instability and if such anatomic risk factors differ between males and females. The purpose of this study was to compare glenoid and humeral head dimensions between patients with a documented instability event without bone loss to matched controls and to evaluate for sex-based differences across measurements. The authors hypothesized that a smaller glenoid width and glenoid surface area would be significant risk factors for instability, whereas humeral head width would not. METHODS: A prospectively maintained database was queried for patients aged <21 years who underwent magnetic resonance imaging (MRI) for shoulder instability. Patients with prior shoulder surgery, bony Bankart, or glenoid or humeral bone loss were excluded. Patients were matched by sex and age to control patients who had no history of shoulder instability. Two blinded independent raters measured glenoid height, glenoid width, and humeral head width on sagittal MRI. Glenoid surface area, glenoid index (ratio of glenoid height to width), and glenohumeral mismatch ratio (ratio of humeral head width to glenoid width) were calculated. RESULTS: A total of 107 instability patients and 107 controls were included (150 males and 64 females). Among the entire cohort, there were no differences in glenoid height, glenoid width, glenoid surface area, humeral head width, or glenoid index between patients with instability and controls. Overall, those with instability had a greater glenohumeral mismatch ratio (P = .029) compared with controls. When stratified by sex, female controls and instability patients showed no differences in any of the glenoid or humerus dimensions. However, males with instability had a smaller glenoid width by 3.5% (P = .017), smaller glenoid surface area by 5.2% (P = .015), and a greater glenohumeral mismatch ratio (P = .027) compared with controls. CONCLUSION: Compared with controls, males with instability were found to have smaller glenoid width and surface area, and a glenoid width that was proportionally smaller relative to humeral width. In contrast, bony glenohumeral morphology did not appear to be a significant risk factor for instability among females. These sex-based differences suggest that anatomic factors may influence risk of instability for male and female patients differently.

A Comprehensive Description of the Lateral Patellofemoral Complex: Anatomy and Anisometry.

BACKGROUND: The lateral patellofemoral complex (LPFC) is an important stabilizer of the patella composed of the lateral retinacular structures including the lateral patellofemoral ligament (LPFL), the lateral patellomeniscal ligament (LPML), and the lateral patellotibial ligament (LPTL). While the isolated anatomy of the LPFL has been previously described, no previous study has investigated the entirety of the LPFC structure, length changes, and radiographic landmarks. An understanding of LPFC anatomy is important in the setting of LPFL injury or previous lateral release resulting in iatrogenic medial instability requiring LPFC reconstruction. PURPOSE: To both qualitatively and quantitatively describe the anatomy and length changes of the LPFC on gross anatomic dissections and standard radiographic views. STUDY DESIGN: Descriptive laboratory study. METHODS: Ten nonpaired cadaveric specimens were utilized in this study. Specimens were dissected to identify distinct attachments of the LPFL, LPML, and LPTL. Ligament lengths, footprints, and centers of each attachment were described with respect to osseous landmarks using a 3-dimensional coordinate measuring device. Ligament length changes were also assessed from 0° to 90° of flexion. Radiopaque markers were subsequently utilized to describe attachments on standard anteroposterior and lateral radiographic views. RESULTS: The individual elements of the LPFC were identified in all specimens. The LPFL patellar attachment had an average total length of 22.5 mm (range, 18.3-27.5 mm), involving a mean of 59% (range, 50%-75%) of the sagittal patella. Based on the average patellar size, a mean of 63% of the LPFL attached to the patella, and the remainder (11.1 ± 1.4 mm) inserted into the patellar tendon. The femoral attachment of the LPFL had a mean maximum length of 24.4 ± 4.3 mm. The center of the LPFL femoral attachment was a mean distance of 13.5 ± 3.2 mm anterior and distal to the lateral epicondyle. The LPFL demonstrated significant shortening, especially in the first 45° of flexion (7.5 ± 5.1 mm). In contrast, the LPTL (5.5 ± 3.0 mm) and LPML (10.0 ± 3.3 mm) demonstrated significant shortening from 45° to 90°. On lateral radiographs, the center of the femoral attachment of the LPFL was a mean total distance of 19.2 ± 7.2 mm from the lateral epicondyle. CONCLUSION: The most important findings of this study were the correlative anatomy of 3 distinct lateral patellar ligaments (LPFL, LPML, and LPTL) and their anisometry through flexion. All 3 components demonstrated significant shortening during flexion. The quantitative and radiographic measurements detailed the LPFL osseous attachment on the patella; soft tissue attachment on the patellar tendon; and finally, the osseous insertion on the femur distal and anterior to the lateral epicondyle. Similarly, the authors documented the meniscal insertion of the LPML and defined a patellar insertion of the LPTL and LPML as a single attachment. These data allow for reproducible landmarks to aid in the understanding and reconstruction of the lateral patellar restraints. CLINICAL RELEVANCE: The data produced from this investigation provide a comprehensive description of these 3 lateral patellar stabilizers (LPFL, LPML, LPTL). These data can be used intraoperatively to facilitate anatomic reconstructions of the lateral patellar stabilizers.

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.

Higher Incidence of Radiographic Posttraumatic Osteoarthritis With Transtibial Femoral Tunnel Positioning Compared With Anteromedial Femoral Tunnel Positioning During Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis.

BACKGROUND: Anteromedial (AM) femoral tunnel positioning in anterior cruciate ligament reconstruction (ACLR) has been reported by some authors to yield superior clinical and functional outcomes compared with the transtibial (TT) approach; however, differences in the subsequent rates of posttraumatic osteoarthritis (PTOA) are not clear. PURPOSE: To perform a systematic review and meta-analysis of the literature to evaluate the influence of femoral tunnel positioning during primary ACLR on the development of radiographic PTOA. STUDY DESIGN: Systematic review and Meta-analysis. METHODS: The Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed (1980-2019), and MEDLINE (1980-2019) were queried for all studies describing the development of PTOA after TT or AM ACLR. Data pertaining to patient demographics, ACLR technique, and radiographic PTOA were extracted. A meta-analysis utilizing the DerSimonian-Laird method for random effects was used to compare the weighted proportion of PTOA after ACLR between the TT and AM approaches. RESULTS: There were 16 studies identified for inclusion with a total of 1546 patients. The mean follow-up across all studies was 10.9 years (range, 5.4-17.8 years). The mean follow-up in the AM and TT groups was 10.8 years (range, 5.4-17 years) and 11.4 years (range, 6-17.8 years), respectively. A total of 783 (50.6%) patients underwent TT ACLR. Of these patients, 401 (weighted mean, 49.3%) developed radiographic PTOA. A total of 763 (49.4%) patients underwent AM ACLR. Of these patients, 166 (mean, 21.8%) went on to develop radiographic PTOA. The meta-analysis demonstrated a significantly greater rate of PTOA after ACLR using a TT technique compared with an AM technique overall (49.3% vs 25.4%, respectively; P < .001) and when studies were stratified by 5- to 10-year (53.7% vs 14.2%, respectively; P < .001) and greater than 10-year (45.6% vs 31.2%, respectively; P < .0001) follow-up. CONCLUSION: TT ACLR was associated with higher overall rates of radiographic PTOA compared with the AM ACLR approach. The rates of radiographic PTOA after ACLR with a TT approach were also significantly higher than using an AM approach when stratified by length of follow-up (5- to 10-year and >10-year follow-up).

Complication rates and outcomes after outpatient shoulder arthroplasty: a systematic review.

BACKGROUND: As the number of total shoulder arthroplasties (TSAs) performed annually increases, some surgeons have begun to shift toward performing TSAs in the outpatient setting. However, it is imperative to establish the safety of outpatient TSA. The purpose of this systematic review was to define complication, readmission, and reoperation rates and patient-reported outcomes after outpatient TSA. METHODS: A systematic review of the literature was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using three databases (PubMed, Ovid, and Embase). English-language publications describing results on complication rates in patients who underwent TSA in an outpatient or ambulatory setting were included. All nonclinical and deidentified database studies were excluded. Bias assessment was conducted with the methodologic index for nonrandomized studies criteria. RESULTS: Seven studies describing outcomes in outpatient TSA were identified for inclusion. The included studies used varying criteria for selecting patients for an outpatient procedure. The total outpatient 90-day complication rate (commonly including hematomas, wound issues, and nerve palsies) ranged from 7.1%-11.5%. Readmission rates ranged from 0%-3.7%, and emergency and urgent care visits ranged from 2.4%-16.1%. Patient-reported outcomes improved significantly after outpatient TSA in all studies. Two studies found a higher complication rate in the comparative inpatient cohort (P = .023-.027). Methodologic index for nonrandomized studies scores ranged from 9 to 11 (of 16) for noncomparative studies (n = 3), while all comparative studies received a score of a 16 (of 24). CONCLUSION: Outpatient TSA in properly selected patients results in a similar complication rate to inpatient TSA. Further studies are needed to aid in determining proper risk stratification to direct patients to inpatient or outpatient shoulder arthroplasty.

Incidence of Intraoperative and Postoperative Complications After Posterolateral Corner Reconstruction or Repair: A Systematic Review of the Current Literature.

BACKGROUND: Posterolateral corner (PLC) injuries of the knee are being increasingly recognized and treated in current orthopaedic practice. While there are numerous systematic reviews evaluating the management and outcomes after PLC injuries, there are limited data investigating complications after PLC reconstruction or repair. PURPOSE: To systematically review the literature to determine the incidence of postoperative complications after the surgical treatment of PLC injury. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: The Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed (2008-2019), Embase (2008-2019), and MEDLINE (2008-2019) were queried for literature reporting on PLC reconstruction or repair, with or without concomitant ligamentous or meniscal surgery. Data including type of surgery performed, concomitant procedures, and follow-up time were extracted. Complications recorded included intra- and postoperative complications. RESULTS: After the intra- and postoperative complication data of 60 studies (1747 cases) were combined, surgical management of PLC injuries was associated with an intraoperative complication rate of 0.34% (range, 0%-2.8%) and a postoperative complication rate of 20% (range, 0%-51.2%). The most common postoperative complication was arthrofibrosis (range, 0%-20%). The overall infection rate was 1.3% (range, 0%-10%). Four cases of postoperative common peroneal nerve palsy were reported. Failure of reconstruction or repair was reported in 164 (9.4%) of all cases examined (range, 0%-37.1%). CONCLUSION: Although the intraoperative rate of complications during PLC reconstructions is low, postoperative complications rates of 20% can be expected, including arthrofibrosis, infection, and neurovascular injury. PLC structures repaired or reconstructed failed in 9.4% of the cases.

Transtibial Anterior Cruciate Ligament Reconstruction: Tips for a Successful Anatomic Reconstruction.

Anterior cruciate ligament (ACL) reconstruction is one of the most commonly performed orthopaedic sports procedures. Two main techniques are used for accomplishing an ACL reconstruction: transtibial and anteromedial portal techniques. The transtibial technique has been criticized for its inability to create an anatomic femoral tunnel given the intrinsic constraint of the tibial tunnel during drilling. However, technical modifications of the transtibial technique can result in anatomic tunnel entrance positioning and a properly oriented graft. This Technical Note presents our technique for anatomic transtibial ACL reconstruction.

Diagnostic Performance of Artificial Intelligence for Detection of Anterior Cruciate Ligament and Meniscus Tears: A Systematic Review.

PURPOSE: To (1) determine the diagnostic efficacy of artificial intelligence (AI) methods for detecting anterior cruciate ligament (ACL) and meniscus tears and to (2) compare the efficacy to human clinical experts. METHODS: PubMed, OVID/Medline, and Cochrane libraries were queried in November 2019 for research articles pertaining to AI use for detection of ACL and meniscus tears. Information regarding AI model, prediction accuracy/area under the curve (AUC), sample sizes of testing/training sets, and imaging modalities were recorded. RESULTS: A total of 11 AI studies were identified: 5 investigated ACL tears, 5 investigated meniscal tears, and 1 investigated both. The AUC of AI models for detecting ACL tears ranged from 0.895 to 0.980, and the prediction accuracy ranged from 86.7% to 100%. Of these studies, 3 compared AI models to clinical experts. Two found no significant differences in diagnostic capability, whereas one found that radiologists had a significantly greater sensitivity for detecting ACL tears (P = .002) and statistically similar specificity and accuracy. Of the 5 studies investigating the meniscus, the AUC for AI models ranged from 0.847 to 0.910 and prediction accuracy ranged from 75.0% to 90.0%. Of these studies, 2 compared AI models with clinical experts. One found no significant differences in diagnostic accuracy, whereas one found that the AI model had a significantly lower specificity (P = .003) and accuracy (P = .015) than radiologists. Two studies reported that the addition of AI models significantly increased the diagnostic performance of clinicians compared to their efforts without these models. CONCLUSIONS: AI prediction capabilities were excellent and may enhance the diagnosis of ACL and meniscal pathology; however, AI did not outperform clinical experts. CLINICAL RELEVANCE: AI models promise to improve diagnosing certain pathologies as well as or better than human experts, are excellent for detecting ACL and meniscus tears, and may enhance the diagnostic capabilities of human experts; however, when compared with these experts, they may not offer any significant advantage.

Regenerative Potential of Mesenchymal Stem Cells for the Treatment of Knee Osteoarthritis and Chondral Defects: A Systematic Review and Meta-analysis.

PURPOSE: To perform a systematic review and meta-analysis evaluating the effects of mesenchymal stem cells (MSCs) on cartilage regeneration and patient-reported pain and function. METHODS: A systematic review was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using a PRISMA checklist. The Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed (2008-2019), EMBASE (2008-2019), and MEDLINE (2008-2019) were queried in July 2019 for literature reporting use of stem cells to treat knee osteoarthritis or chondral defects. Data describing administered treatment, subject population, injection type, duration of follow-up, pain and functional outcomes, and radiographic and magnetic resonance imaging findings were extracted. Risk of bias was assessed using the Downs and Black scale. Meta-analyses adjusted for random effects were performed, calculating pooled effect sizes in terms of patient-reported pain and function, cartilage quality, and cartilage volume. RESULTS: Twenty-five studies with 439 subjects were identified. There was no significant difference in pain improvement between MSC treatment and controls (pooled standardized mean difference [SMD] = 0.23, P = .30). However, MSC treatment was significantly favored for functional improvement (SMD = 0.66, P < .001). There was improvement in cartilage volume after MSC treatment (SMD = 0.84, P < .001). Regarding cartilage quality, meta-analysis resulted in a small, nonsignificant effect size of 0.37 (95%, -0.03 to 0.77, P = .07). There was risk for potential bias among included studies, with 17 (68%) receiving either a grade of "poor" or "fair." CONCLUSIONS: The pooled SMD from meta-analyses showed statistically significant effects of MSC on self-reported physical function but not self-reported pain. MSCs provided functional benefit only in patients who underwent concomitant surgery. However, this must be interpreted with caution, as there was substantial variability in MSC composition and mode of delivery. MSC treatment provided significant improvement in cartilage volume but not cartilage quality. Preliminary data regarding therapeutic properties of MSC treatment suggest significant heterogeneity in the current literature, and risk of bias is not negligible. LEVEL OF EVIDENCE: II, Systematic Review and Meta-analysis.

Patient Factors Associated With Clinical Failure Following Arthroscopic Superior Capsular Reconstruction.

PURPOSE: To identify demographic, clinical, and radiographic factors associated with failure after superior capsular reconstruction (SCR). METHODS: Prospectively collected data were analyzed from patients who underwent SCR using a decellularized dermal allograft for an irreparable rotator cuff tear. Demographic characteristics, radiographic findings, concomitant procedures, and patient-reported outcomes (PROs) were recorded. Failure was defined by ≥1 of the following criteria: (1) conversion to reverse total shoulder arthroplasty (RTSA), (2) a decrease in 1-year postoperative shoulder-specific PROs compared with preoperative scores, or (3) patient reports at final follow-up that the shoulder was in a worse condition than before surgery. Preoperative variables were compared between patients meeting the criteria for clinical failure and those who did not. RESULTS: Fifty-four patients (mean age 56.3 ± 5.8 years, range 45 to 70) who underwent SCR, with minimum 1-year follow-up, were included in the analysis. Mean follow-up after surgery was 24 months (range 12 to 53). Eleven patients (20.4%) met criteria for clinical failure. Of the 11, 8 reported decreased American Shoulder and Elbow Surgeons (ASES) or Constant scores or indicated that the operative shoulder was in a worse condition than before surgery. Three patients underwent RTSA in the 6 to 12 months after SCR. Female sex and the presence of a subscapularis tear were associated with failure (P = .023 and P = .029, respectively). A trend toward greater body mass index (BMI), lower preoperative forward flexion, and lower preoperative acromiohumeral distance (AHD) was found in patients with clinical failure (P = .075, P = .088, and P = .081, respectively). No other variable included in the analysis was significantly associated with failure. CONCLUSION: The proportions of female patients and those with subscapularis tear were greater among patients with clinical failure after SCR. Greater BMI, lower preoperative forward flexion, and lower preoperative AHD trended toward association with clinical failure of SCR. LEVEL OF EVIDENCE: 4, case series.

Indications and Outcomes for Arthroscopic Hip Labral Reconstruction With Autografts: A Systematic Review.

Background: The acetabular labrum plays a major role in hip function and stability. The gold standard treatment for labral tears is labral repair, but in cases where tissue is not amenable to repair, reconstruction has been demonstrated to provide superior outcomes compared to debridement. Many types of grafts have been used for reconstruction with good to excellent outcomes. Autograft options include iliotibial band (ITB), semitendinosus, and indirect head of the rectus femoris tendon, while allografts have included fascia lata and gracilis tendon allografts. Questions/Purposes: As allografts are not always readily available and have some inherent disadvantages, the aims of this systematic review were to assess (1) indications for labral reconstruction and (2) summarize outcomes, complications, and reoperation rates after arthroscopic labral reconstruction with autografts. Methods: A systematic review of the literature was performed using six databases (PubMed, CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Scopus, and Google Scholar) to identify studies reporting outcomes for arthroscopic labral reconstruction utilizing autografts, with a minimum follow-up of 1 year. Study design, patient demographics, autograft choice, complications, donor site morbidity, reoperation rates, conversion to arthroplasty, and patient reported outcomes were extracted and reported. Results: Seven studies were identified for inclusion with a total of 402 patients (173 females, age range 16-72, follow-up range 12-120 months). The most commonly reported functional outcome score was the modified Harris Hip Score (mHHS), which was reported in six of seven studies. Preoperative mHHS ranged from 56 to 67.3 and improved postoperatively to a range of 81.4-97.8. Conversion to total hip arthroplasty and reoperation rates ranged from 0 to 13.2% and 0 to 11%, respectively. The most common indication for labral reconstruction was an irreparable labrum. Autografts utilized included ITB, hamstring tendons, indirect head of rectus femoris, and capsular tissue. Conclusions: Arthroscopic autograft reconstruction of the acetabular labrum results in significant improvement in the short- and mid-term patient reported outcomes, for properly selected patients presenting with pain and functional limitation in the hip due to an irreparable labral injury.

First-time Glenohumeral Dislocations: Current Evidence and Considerations in Clinical Decision Making.

The decision to manage first-time shoulder dislocations conservatively or operatively has become increasingly complex because of conflicting literature. Although shoulder dislocations have traditionally been managed with reduction and immobilization, recent evidence has suggested high rates of subsequent recurrence. Surgical intervention is thought to better restore stability and decrease recurrence rates; however, it also has the potential for additional morbidity and financial cost. As such, recent literature has sought to better define patient risk profiles to identify optimal candidates for both conservative and operative management. The purpose of the current review is to provide a comprehensive and evidence-based assessment of the most recent literature to better delineate an appropriate treatment algorithm for this challenging clinical scenario.

Is There a Role for Ultrasound in Hip Arthroscopy? A Systematic Review.

PURPOSE: The purpose of this study is to identify and summarize the current utility of intraoperative ultrasound (US) during hip arthroscopy. METHODS: A systematic database query of the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, EMBASE, PubMed (1980 to 2019), and Ovid MEDLINE (1980 to 2019) was performed. After article identification, descriptions of the surgical procedure, use of intraoperative US, procedural complications, and conclusions from each article were recorded and summarized. RESULTS: Five studies met inclusion criteria, all of which were surgical techniques or technical notes. Four of the 5 studies described US used for placement of arthroscopic portals, and 1 described the use of an intraarticular US catheter for the assessment of an osteochondritis dissecans (OCD) lesion. Of the 4 studies using US for portal placement, 3 were performed supine and 1 was performed in the lateral decubitus position. All studies recognized the need for additional US training or the required assistance of a radiologist to incorporate US into a surgical practice. CONCLUSION: Descriptions of intraoperative US during hip arthroscopy are limited in the literature. However, existing technique reports demonstrate the feasibility of US for both portal placement with superficial probes and limited evaluation of cartilage using intraarticular US catheters. LEVEL OF EVIDENCE: V, systematic review.