Femoral interference screw divergence as a result of anteromedial portal insertion and outside-in FlipCutter femoral tunnel drilling: A cadaveric study.

Aims and objectives: To investigate whether interference screw fixation through an anteromedial portal into an outside-in drilled femoral tunnel via a flip cutter results in acceptable hardware position. Materials & methods: 10 cadaveric knees underwent ACL-reconstruction with patellar BTB autograft. Femoral tunnel drilling was performed utilizing an outside-in flip cutter drill and interference screws for femoral fixation. Lateral and anterior-posterior (AP) fluoroscopic images were taken to measure screw divergence within the femoral tunnel. The means of AP and lateral divergence angles were compared using two-tailed t-tests. Results: Using the flip cutter, the AP and lateral divergence angles were 7.3° ± 4.5° and 9.3° ± 9.3°, respectively, while the total divergence angles were 16.6° ± 11.8°. Divergence angles using a cannulated reamer were found to be 14.4° ± 2.5° and 6.8° ± 2.8° for AP and lateral, respectively and 21.1° ± 5.2° for the total divergence. The AP divergence angles using the flip cutter were significantly less than those reported using a cannulated reamer (p = 0.001). Conclusions: The flip cutter method resulted in significantly reduced divergence angle between the screw and graft when compared to previous cadaveric studies in the coronal plane. There was no significant difference in divergence angle in the sagittal plane. Both methods appear to result in divergence angles below the threshold which would be considered to significantly decrease pull-out strength. Large standard deviations also reflect limited sample size but may also suggest more variability in divergence when compared to historical control set. This study clearly establishes the outside-in technique using a retrograde reamer as a viable independent femoral drilling solution for ACL reconstruction when using a BTB autograft with a femoral interference screw.

Atraumatic intra-articular, extra-synovial ganglion cyst of the lateral knee deep to the iliotibial band: A case report and review of the literature.

Key Clinical Message: We highlight the rare case of an atraumatic, intra-articular ganglion cyst of the lateral knee deep to the iliotibial band that was successfully treated nonoperatively, a pathology yet to be reported in orthopedic literature. Abstract: Ganglion cysts are mucin-filled synovial cysts commonly found on the dorsal surface of the hands and feet. Intra-articular ganglion cysts of the knee are rare, and when they present clinically, are typically treated operatively through arthroscopic surgery. We present the first reported case of an atraumatic intraarticular, extra-synovial ganglion cyst of the lateral knee located deep to the iliotibial band that was successfully treated without operative intervention through repeated intra-articular aspirations of the knee.

Tommy John Ligament Repair with Ulnar Collateral Ligament Internal Brace.

Ulnar collateral ligament (UCL) injuries commonly occur in overhead athletes as a result of excess valgus stress on the elbow and can be functionally debilitating, requiring surgical intervention. Since the advent of the first initial UCL reconstruction technique pioneered by Dr. Frank Jobe performed on professional baseball player Tommy John, UCL, or Tommy John Ligament reconstruction has successfully returned athletes to sport following injury and shown enhanced clinical outcomes with minimal complication rates. Tommy John surgery continues to evolve with the development of various techniques over recent years. This technical note describes a UCL repair with an internal brace using knotless suture anchors and aims to contribute to the current literature a technique that is efficacious and reproducible and offers satisfactory stability, functionality, and return to play.

Online Patient Education Resources for Anterior Cruciate Ligament Reconstruction: An Assessment of the Accuracy and Reliability of Information on the Internet Over the Past Decade.

PURPOSE: The purpose of this study is to evaluate the quality of patient education materials accessible through popular online search engines regarding anterior cruciate ligament (ACL) injuries and anterior cruciate ligament reconstruction (ACLR).  Methods: Two search terms ("ACL surgery" and "ACL reconstruction") were entered into three search engines (Google, Yahoo, and Bing). The quality of information was scored using a novel scoring system developed and overseen by sports medicine orthopedic clinical research fellows and fellowship-trained orthopedic surgeons. Website quality, credibility, and readability were further assessed by the DISCERN score, Journal of the American Medical Association (JAMA) benchmark criteria, and Flesch-Kincaid Reading Grade Level (FKRGL), respectively. The Health On the Net Code of Conduct (HONcode) certification was also utilized to assess the transparency of health information for each website. RESULTS: We evaluated 39 websites. The average score for all websites was 11.2±5.6 out of 28 total points. Six out of the 39 websites (41%) were HONcode certified. The websites that contained HONcode certification had a higher average JAMA benchmark score (3.5±0.7) and DISCERN score (44.6±14.7) when compared to the websites without the certification, 2.2±1.2 and 37.6 ± 15.9 for JAMA and DISCERN, respectively. The mean JAMA benchmark score was 2.7±1.2 (67.5%) for all websites out of a possible four points. The average FKRGL for all 39 websites was 10.0±2.0 (range: 5.4-13). CONCLUSION: The quality of patient education materials accessible on the internet regarding ACL injuries and ACLR can be misleading and directly impact the patient's decision-making process essential to the patient-physician relationship over the past decade. CLINICAL RELEVANCE: The internet can be a helpful online resource, however, surgeon clarification and consultation with qualified healthcare professionals are strongly recommended prior to clinical decision-making regarding potential treatment options.

Biceps femoris accessory tendon tenodesis: A case report.

Key Clinical Message: We present a case of lateral knee pain from snapping of an accessory tendinous insertion of the biceps femoris. After failure of conservative treatment options, tenodesis of the accessory band to the direct arm insertion at the posterolateral edge of the fibular head effectively resolved symptoms. Abstract: There are several distinct causes of lateral knee pain including IT band syndrome, meniscus tears, or other soft tissue pathologies; however, a few case reports have shown the biceps femoris as a cause of lateral knee pain and snapping. Conservative treatment is of modest benefit to the patient in these scenarios, and an MRI is not always able to identify the accessory band, as in our case. Intraoperatively, we discovered an accessory band of the biceps femoris attaching to the anterolateral tibia, causing pain and snapping during knee flexion as the band passed over the fibular head. There have been various surgical attempts to address this pathology; however, we report a successful outcome after tenodesis of the accessory band to the direct insertion at the posterolateral fibular head.

Income and Insurance Status Impact Access to Health Care for Hip Osteoarthritis.

Purpose: To explore differences in the affordability of and accessibility to health care among adults with hip osteoarthritis with respect to race/ethnicity, income, and insurance status. Methods: This cross-sectional retrospective study was conducted using 2016 National Health Interview Survey (NHIS) data. NHIS data collection occurred continuously from January to December 2016. Individuals belonging to households and noninstitutionalized groups were included in the study. Because NHIS randomized surveys are conducted face-to-face on an annual basis, follow-up data are not collected. Results: Answers from 38,158,634 weighted respondents with a mean age of 58.33 ± 0.33 years were assessed. Among adults with hip osteoarthritis, those with public insurance had increased odds of delaying care owing to lack of transportation and had decreased odds of delaying care and follow-up care owing to cost. Individuals who were uninsured or who belonged to lower income brackets were associated with increased odds of being unable to afford or utilize health care. Conclusions: In this study, we found that income bracket and insurance status affect the accessibility to health care among adults with hip osteoarthritis in the United States. Level of Evidence: Level IV, prognostic case series.

Arthroscopic repair of traumatic rotator cuff tear following total shoulder arthroplasty: A case report and review of literature.

Key Clinical Message: We highlight the rare case of arthroscopic repair of a traumatic tear following total shoulder arthroplasty. Moreover, there is no reported literature describing the arthroscopic repair of a rotator cuff tear after total shoulder arthroplasty. Abstract: This case report highlights an arthroscopic rotator cuff repair involving full-thickness tears of the supraspinatus and infraspinatus after a total shoulder arthroplasty performed 7 years prior. To our best knowledge, no published literature exists highlighting the arthroscopic repair of a traumatic rotator cuff tear following total shoulder arthroplasty.

Glenoid Avulsion of the Glenohumeral Ligament Repair Through a Single Working Portal.

Glenoid avulsion of the glenohumeral ligament (GAGL) is a traumatic cause of shoulder instability. GAGL lesions are a rare shoulder pathology most commonly reported as a source of anterior shoulder instability, with no current reports implicating this pathology as a cause of posterior instability. Satisfactory surgical repairs of GAGL lesions with anterior shoulder instability have been well documented; however, this Technical Note highlights the successful repair of a posterior GAGL lesion through a single working portal with suture anchor fixation of the posterior capsule.

Open Acromioclavicular Repair With a Suture Cerclage Tensioning System: A Case Series.

Introduction Numerous surgical techniques to address a type III and type V acromioclavicular (AC) joint separation have been described in the literature, but a preferred standard approach is still in debate. Current approaches include anatomic reduction, coracoclavicular (CC) ligament reconstruction, and anatomic reconstruction of the joint. In this case series, subjects received a surgical approach that avoids metal anchors and utilizes a suture cerclage tensioning system to achieve adequate reduction. Surgical technique An AC joint repair was achieved with a suture cerclage tensioning system, which allows the surgeon to apply a specific amount of force on the clavicle to achieve adequate reduction. This technique repairs the AC and CC ligaments, restoring the anatomy of the AC joint while avoiding some of the common risks and disadvantages associated with metal anchors. Methods From June 2019 to August 2022, 16 patients underwent repair of the AC joint with a suture cerclage tension system. Inclusion criteria included the diagnosis of type III or type V AC joint separation with another concomitant injury, acute and chronic injury, and patients who attended all their postoperative visits. Exclusion criteria included patients who lost to follow-up or patients who missed any of their postoperative visits. Radiographic images were taken during each subject's preoperative and postoperative visits, and the CC distance was measured to determine the integrity of the all-suture cerclage repair. Results Of the 16 patients included in this case series, radiographic images taken during each subject's postoperative visit showed a stable construct with little changes in the CC distance. The average change in CC distance when comparing the two-week and one-month postoperative follow-up is 0.2mm. The average change in CC distance when comparing the two-week and two-month postoperative follow-up is 1.45mm. The average change in CC distance when comparing the two-week and four-month postoperative follow-up is 2.6mm. Conclusion Overall, an AC joint repair with the suture cerclage tension system can be a viable, cost-effective technique for restoring vertical and horizontal stability. Although follow-up, larger-scale studies are required to determine the biomechanical integrity of the construct with an all-suture approach, this case series presents 16 subjects whose postoperative radiographic images showed only a small change in CC distance at two to four months after surgery.

Single-Portal Arthroscopic Posterior Capsulorrhaphy for Recurrent Shoulder Capsule Laxity and Instability.

Arthroscopic stabilization for posterior shoulder instability is well documented in the literature, offering good to excellent clinical outcomes after injury with favorable return-to-sport and patient satisfaction rates. Posterior capsulorrhaphy addresses recurrent laxity by decreasing the size of the posterior capsule through arthroscopic placement of sutures, in addition to addressing posterior labral tears and any intra-articular pathology within the joint. This technical note describes an arthroscopic posterior capsulorrhaphy for recurrent posterior shoulder capsule laxity and instability in an active patient. This technique uses a single posterior working portal and 2 suture anchors to tighten the posterior capsule onto the intact labrum.

Arthroscopic Reduction of Bicruciate Tibial Avulsion Fractures: Lever Push Technique.

Combined anterior cruciate ligament and posterior cruciate ligament tibial avulsion fractures are rare knee injuries that are primarily seen in adults. Prompt surgical intervention is indicated for displaced fractures to restore knee stability. Arthroscopic techniques are now the preferred method for treating anterior tibial spine avulsion fractures with posterior cruciate ligament tibial avulsion fractures being treated arthroscopically or with open reduction and internal fixation methods. This Technical Note and accompanying video demonstrate an arthroscopically assisted repair of bicruciate tibial avulsion fractures using an arthroscopic lever push technique. Two sutures are passed through the anterior cruciate ligament and pulled down through two bone tunnels placed within the tibial fracture bed, and one suture is passed around the posterior cruciate ligament and pulled down through one bone tunnel passing from the anterior tibia to the tibial fracture bed. Our technique is simple and effective in reducing bicruciate tibial avulsion fractures to anatomic position.

Surgical repair of acute on chronic seven-year pectoralis major rupture near the distal myotendinous junction: A case report.

The surgical fixation of an acute on chronic pectoralis major rupture with inciting injury 7 years prior has never been reported in the literature. Thus, we report the first case of an acute on chronic pectoralis major rupture repair in an active male patient who underwent successful surgical intervention and review the pathophysiology and treatment of pectoralis major tears.

Subpectoral Biceps Tenodesis Using an All-Suture Anchor.

Long head biceps tendon pathology is a substantial contributor to anterior shoulder pain and often requires surgical intervention to offer a return to normal functionality. Surgical treatment options consist of both open and arthroscopic tenodesis or tenotomy of the long head biceps brachii. Several techniques exist for tenodesis and tenotomy of the biceps, although current debate continues regarding which surgical approach is the optimal intervention for symptomatic bicep pathology. In this technical note, we describe a subpectoral biceps tenodesis of the long head bicep tendon using an all-suture anchor. Our technique offers the advantages of using an all-suture anchor that incorporates a self-tensioning mechanism with direct visualization of the tendon during biceps tenodesis and anchor insertion.

Rehabilitation After Anterior Cruciate Ligament Injury: Review of Current Literature and Recommendations.

PURPOSE OF REVIEW: Anterior cruciate ligament reconstruction (ACLR) is a common surgical procedure with an estimated 120,000 cases performed in the USA each year. Physical therapy plays a critical role in the successful recovery of both surgically and non-surgically managed patients. Interestingly, ACL rehabilitation protocols vary greatly with little consensus among practitioners. Nonetheless, there has been agreement over the last decade to shift from conservative, standardized length protocols to more accelerated, individualized protocols that vary in length and modalities based on patient-specific findings and preferences. This review summarizes the most recent trends, opinions, and modalities in ACL rehabilitation research, with a specific focus on novel methods to treat the specific psychosocial needs of ACL deficient patients. RECENT FINDINGS: We found that new protocols emphasize early weight bearing, open kinetic chain (OKC) exercises, and other alternative modalities such as neuromuscular electrical stimulation and blood flow restriction. We also found a recent trend toward the use of clinical milestones to determine when a patient is ready for the next phase of a "step-up" rehabilitation program. One particularly nascent topic of research is the inclusion of methods to treat the psychosocial impacts of ACL injury, recovery, and the anxiety around return to sport. Rehabilitation strategy has become increasingly patient-dependent, and the new modalities being utilized are accelerating patient recovery. Return to sport is a particularly important factor for many ACLR patients, and recovery has an important psychological component that has only recently been addressed in the literature, with positive preliminary findings.

Open Peroneal Tendon Stabilization With Fibular Groove Deepening.

Peroneal tendon subluxation often occurs because of sudden dorsiflexion of the ankle, leading to a traumatic rupture of the superior peroneal retinaculum. Currently, there are several surgical techniques to deepen the fibular groove, but there is no universally accepted gold standard. This technique article describes a fibular groove deepening with preservation of the fibrocartilage in conjunction with repair of the superior peroneal retinaculum. Addressing the main pathologies that may be leading to subluxation of the peroneal tendons, we offer an approach that avoids many of the common pitfalls from previously proposed techniques while preserving the natural fibrocartilage within the malleolar groove and repairing the retinaculum.

Combined Double-Pulley Remplissage and Bankart Repair.

The use of arthroscopic Bankart repair to treat anterior shoulder instability has become increasingly widespread. However, high rates of recurrent instability within the presence of glenohumeral bony defects, specifically Hill-Sachs lesions, have well documented a key concern regarding the arthroscopic Bankart repair process. Our technique describes the pairing of a remplissage to fill the Hill-Sachs lesion with the Bankart repair, preventing loss in shoulder stiffness and stability. This technique involves a double-pulley-combined remplissage and Bankart repair to maintain a low-failure, minimally invasive procedure.

Single Knotless Suture Anchor Repair of Anterior Talofibular Ligament Following Distal Fibula Nonunion Excision.

Anterior talofibular ligament (ATFL) tear is the most common ankle ligament injury. This can lead to recurrent ankle instability, which is detrimental to ankle function and the patient's quality of life. Currently, several techniques have shown successful outcomes for ATFL repair. In this technical note, we describe an open ATFL repair using a single knotless suture anchor at the distal fibula location. This approach is rapid, equipment-efficient, and reproducible, while promising excellent results and high patient satisfaction by restoring ATFL anatomy.

Anchorless Acromioclavicular and Coracoclavicular Ligament Repair Using a Graft-Passing Instrument to Pass Suture Under the Coracoid.

Acromioclavicular joint separation is a common shoulder injury. Grade I and II separation may be treated nonoperatively, whereas higher grades tend to require surgical intervention. Various repair techniques have been described in the literature, with no consensus on the gold standard. This Technical Note describes our use of a graft-passing instrument to pass suture under the coracoid during an anatomic reconstruction of both the acromioclavicular and coracoclavicular ligaments. Although this approach is technically challenging, it avoids coracoid drilling and requires smaller-diameter clavicle and acromion drilling. Furthermore, using suture instead of graft material increases the cost-effectiveness of the procedure.

Evaluation of Osteochondral Allograft Transplant Using In-Office Needle Arthroscopy.

In-office needle arthroscopy (IONA) has been available in various iterations for decades. Studies have described it as comparable if not superior to magnetic resonance imaging for identifying intra-articular pathology with associated cost savings per patient. A new IONA system has been brought to market with a modernized user interface and disposable handpieces offering the opportunity to address intra-articular pathology. This article outlines the use of this IONA system for the postoperative evaluation of an osteochondral allograft transplant.

Double-Row Rotator Cuff Repair Technique With Dermal Allograft Augmentation.

Rotator cuff tears are common and debilitating injuries in the orthopaedic patient population. Although arthroscopic repair of the rotator cuff generally leads to satisfactory outcomes, some tears would benefit from augmentation with allograft to supplement the native tissue. This biological augmentation has been shown to decrease retear rates and can be beneficial in certain cases based on the size of the tear, amount of retraction, age of the patient, and chronicity. In this technical note, we describe a simple and effective technique for arthroscopic rotator cuff repair with biological augmentation.