The effect of intravenous tranexamic acid on visual clarity in arthroscopic shoulder surgery compared to epinephrine and a placebo: a double-blinded, randomized controlled trial.

BACKGROUND: The addition of epinephrine in irrigation fluid and the intravenous or local administration of tranexamic acid have independently been reported to decrease bleeding, thereby improving surgeons' visualization during arthroscopic shoulder procedures. No study has compared the effect of intravenous tranexamic acid, epinephrine in the irrigation fluid, or the combination of both tranexamic acid and epinephrine on visual clarity during shoulder arthroscopy with a placebo group. We hypothesized that intravenous tranexamic acid is more effective than epinephrine mixed in the irrigation fluid in improving visualization during shoulder arthroscopy, with no additive effect when both are used. METHODS: Patients aged ≥18 years undergoing shoulder arthroscopy were randomized into one of 4 study arms: (1) saline irrigation fluid (placebo); (2) epinephrine (0.33 mL of 1:1000 per liter) mixed in irrigation fluid (EPI); (3) 1 g intravenous tranexamic acid (TXA); and (4) epinephrine and tranexamic acid combined (TXA + EPI). Visualization was rated intraoperatively on a scale from 0, indicating poor clarity, to 3, indicating excellent clarity, every 15 minutes and overall. The primary outcome measure was the overall rating of visualization. A stepwise linear regression was performed using visualization as the dependent variable and independent variables including presence or absence of epinephrine and tranexamic acid, surgery duration, complexity, mean arterial pressure, increase in pump pressure, and volume of irrigation fluid. RESULTS: One hundred twenty-eight patients (mean age 56 years) were randomized. Mean visual clarity for the placebo, TXA, EPI, and TXA + EPI groups were 2.0 (±0.6), 2.0 (±0.6), 2.6 (±0.5), and 2.7 (±0.5), respectively (P < .001). The presence or absence of epinephrine was the most significant predictor of visual clarity (P < .001). Tranexamic acid presence or absence had no effect. No adverse events were recorded in any of the groups. CONCLUSION: Intravenous tranexamic acid is not an effective alternative to epinephrine in irrigation fluid to improve visualization during routine arthroscopic shoulder surgeries, and there is no additive effect when both are used.

Rate of Total Hip Replacement after Legg Calve Perthes Disease in a Canadian Province.

Legg Calve Perthes disease is a pediatric hip condition that leads to early hip degeneration. The efficacy of operative and nonoperative treatment is not well defined in the literature. Using the rate of total hip arthroplasty as a surrogate measure for symptomatic hip degeneration, the rate of total hip arthroplasty was compared in Legg Calve Perthes disease patients with and without previous surgical intervention in the province of Manitoba, Canada. A retrospective review was conducted using de-identified, individual-level administrative records of health services for the entire population of Manitoba. Codes for Legg Calve Perthes disease, femoral osteotomies, pelvic osteotomies, adductor tenotomies, and total hip arthroplasty were searched from 1984 to 2018. The rate of total hip arthroplasty in patients with Legg Calve Perthes disease was determined for two groups: (1) patients with earlier surgical intervention and (2) patients with no previous surgical intervention. Of the 202 patients included in the study, 180 had no prior surgery and 22 had prior surgery. The rate of total hip arthroplasty between the previous operative and nonoperative groups was found to be 32% and 40%, respectively (p = 0.458). There was no significant difference in rates of total hip arthroplasty in the operative and nonoperative groups. Further prospective studies are required to elucidate the differences in outcomes between operative and nonoperative treatment groups in patients with Legg Calve Perthes disease.

Characterizing the Practices of Canadian Orthopedic Surgeons in the Management of patients With Anterior Glenohumeral Instability.

OBJECTIVE: To determine the practice patterns of Canadian orthopedic surgeons in the management of patients with anterior glenohumeral instability (AGHI). DESIGN: Cross-sectional survey. SETTING: Canada. PATIENTS OR OTHER PARTICIPANTS: Canadian orthopedic surgeons with membership in the Canadian Orthopedic Association or Canadian Shoulder and Elbow Surgeon group who had managed at least 1 patient with AGHI in the previous year. INTERVENTIONS: A survey including demographics and questions on the management of patients with AGHI was completed. Statistical comparisons (χ 2 ) were completed with responses stratified using the instability severity index score (ISIS) in practice, years of practice, and surgical volumes. MAIN OUTCOME MEASURES: Summary statistics were compiled, and response frequencies were considered for consensus (75%). Case series responses were stratified on use of the ISIS in practice, years of experience, and annual procedure volumes (χ 2 , P < 0.05). RESULTS: Eighty orthopedic surgeons responded, with consensus on areas of diagnostic workup of AGHI, nonoperative management, and operative techniques. There was no consensus on indications for soft tissue and bony augmentation or postoperative management. There was no difference in practices based on the use of ISIS, years in practice, or surgical volumes. CONCLUSIONS: Canadian orthopedic surgeons manage AGHI consistently with consensus achieved in preoperative diagnostics and operative techniques, although debate remains as to the indications for soft tissue and bony augmentation procedures.

Intraoperative Channeling in Arthroscopic Rotator Cuff Repair: A Multicenter Randomized Controlled Trial.

BACKGROUND: Despite recent advances in arthroscopic rotator cuff repair, the retear rate remains high. New methods to optimize healing rates must be sought. Bone channeling may create a quicker and more vigorous healing response by attracting autologous mesenchymal stem cells, cytokines, and growth factors to the repair site. HYPOTHESIS: Arthroscopic rotator cuff repair with bone channeling would result in a higher healing rate compared with arthroscopic rotator cuff repair without adjuvant channeling. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: Our primary objective was to compare healing rates in patients undergoing arthroscopic rotator cuff repair for degenerative tears, with and without bone channeling. Secondary objectives included comparisons of the Western Ontario Rotator Cuff Index (WORC) score, American Shoulder and Elbow Surgeons (ASES) score, Constant score, Constant strength subscore, and visual analog scale (VAS) for pain score between groups. Patients undergoing arthroscopic rotator cuff repair were recruited at 3 sites and were randomized to receive either bone channeling augmentation or standard repair. Healing was determined via ultrasound at 24 months postoperatively. WORC, ASES, and Constant scores were compared between groups at baseline and at 3, 6, 12, and 24 months postoperatively. RESULTS: A total of 168 patients were enrolled between 2013 and 2018. Intention-to-treat analysis revealed no statistical differences in healing rates between the 2 interventions at 24 months postoperatively. Statistically significant improvements occurred in both groups from preoperatively to all time points for the WORC, the ASES score, the Constant score or Constant strength subscore, and the VAS for pain (P < .0001). No differences were observed between the bone channeling and control groups in WORC, ASES, Constant, and VAS pain scores at any time point. CONCLUSION: This trial did not demonstrate the superiority of intraoperative bone channeling in rotator cuff repair over standard rotator cuff repair at 24 months postoperatively. Healing rates, patient-reported function, and quality-of-life outcomes were similar between groups. REGISTRATION: NCT01877772 (ClinicalTrials.gov identifier).

Knee flexor strength and symmetry vary by device, body position and angle of assessment following ACL reconstruction with hamstring grafts at long-term follow-up.

PURPOSE: Persistent deficits in knee flexor strength following harvest of semitendinosus and gracilis for anterior cruciate ligament reconstruction are inconsistent in the literature. Variation in methodology, including measuring torque at higher knee flexion angles may partially explain these discrepant findings. The objective of this study was to determine whether positioning (seated vs supine), consideration of peak or joint-angle-specific torque or device (Isokinetic Dynamometer vs NordBord Hamstring Dynamometer) impact the magnitude of knee flexor strength differences between limbs. METHODS: Participants (n = 31, 44.2 ± 10.7 years,) who were at 14 ± 4.4 years follow-up for unilateral ACL reconstruction with semitendinosus/gracilis grafts completed the ACL Quality of Life outcome and an assessment including isokinetic concentric knee extensor and flexor strength in seated and supine with peak torque and torque at 60° (T60) and 75° (T75) knee flexion measured, followed by an eccentric Nordic Hamstring Curl. RESULTS: Isokinetic concentric knee flexor torque was reduced in supine relative to seated, on the reconstructed limb against the unaffected, and at higher degrees of knee flexion relative to peak torque (T60 and T75 against peak torque). Limb symmetry varied by methodology (F(6,204) = 8.506, p = 0.001) with reduced symmetry in supine T75 against all measures (71.1 ± 16.5%, p < 0.05), supine T60 against seated peak torque (82.7 ± 14.2%, p < 0.05), and the NordBord was lower than seated peak torque that was not statistically significant (83.9 ± 12.8%, n.s.). Knee extensor peak (r2 = 0.167 (F(1,27) = 5.3, p = 0.03) and Nordic curl eccentric torque (r2 = 0.267, F(2,26) = 4.736, p = 0.02) were predictors of ACL-QoL score, although a combined model did not improve over Nordic torque alone. CONCLUSION: Limb symmetry cannot be assumed in clinical practice across differing assessment methods for knee flexor strength as deficits are greatest in the supine position with torque measured at 75° knee flexion. Isokinetic knee extensor and eccentric knee flexor torque during the Nordic hamstring curl were predictors of ACL-QoL scoring and should be considered alongside patient-reported outcomes for patients following ACL reconstruction with hamstring grafts. LEVEL OF EVIDENCE: Level IV.

Biomechanics of hamstring tendon, quadriceps tendon, and bone-patellar tendon-bone grafts for anterior cruciate ligament reconstruction: a cadaveric study.

PURPOSE: The three most commonly used autografts for anterior cruciate ligament reconstruction (ACL) are: bone-patellar tendon-bone (BTB), hamstring tendons (HT), and quadriceps tendon (QT). A cadaveric study was performed to determine if there were any differences in mechanical and structural properties under biomechanical testing. METHODS: Twenty-seven graft specimens were harvested from 9 human cadaveric legs. Mean donor age was 75.2 years (range 53-85 years). Twenty-two specimens (8 HT, 7 QT, and 7 BTB) completed cyclic preconditioning from 50 to 800 N for 200 cycles and a load to failure test at an extension rate of 1 mm/s. Structural and mechanical properties of BTB, HT, and QT grafts were compared using a one-way ANOVA and Tukey's honest significant difference. RESULTS: There was no difference in the ultimate load to failure (N) across all 3 graft types (p = 0.951). Quadriceps tendon demonstrated greater cross-sectional area (mm2) when compared to both HT and BTB (p = 0.001) and was significantly stiffer (N/mm) than HT but not BTB (p = 0.004). Stress (N/mm2) of the HT at ultimate load was greater than QT but not BTB (p = 0.036). Elastic modulus (MPa) of HT was greater than both QT and BTB (p = 0.016). CONCLUSION: There was no difference in the ultimate load to failure of BTB, HT, and QT grafts harvested from the same specimens. All 3 grafts had similar loads to failure with a significant increase in stiffness when compared to the native ACL. Furthermore, QT demonstrated more favourable structural properties compared to HT and BTB with greater cross-sectional area to both HT and BTB and greater stiffness compared to HT.

Arthroscopic Rotator Cuff Repair with and without Acromioplasty in the Treatment of Full-Thickness Rotator Cuff Tears: Long-Term Outcomes of a Multicenter, Randomized Controlled Trial.

BACKGROUND: The aim of this study was to reevaluate patients from a previous randomized controlled trial at a long-term follow-up to determine the long-term efficacy of subacromial decompression in patients with full-thickness rotator cuff tears. METHODS: This is a secondary study based on a previous, multicenter, randomized controlled trial with patients allocated to arthroscopic rotator cuff repair with or without acromioplasty. The original study was conducted between 2003 and 2011, and the secondary study was conducted between 2015 and 2021. Patients were invited by a blinded assessor to return to complete the Western Ontario Rotator Cuff (WORC) index and a questionnaire about reoperation and to undergo a clinical assessment. If participants were unable to return, they were asked to complete the questionnaires by mail. A chart review on all participants in the original study was conducted. RESULTS: Eighty-six patients were randomized in the original trial, with 31 of 45 from the group without acromioplasty and 25 of 41 from the acromioplasty group returning for long-term follow-up. The mean duration (and standard deviation) of follow-up was 11.2 ± 2.4 years for the group without acromioplasty and 11.5 ± 2.6 years for the acromioplasty group. There was no significant difference in WORC scores between the groups with and without acromioplasty at the time of the long-term follow-up (p = 0.30). Seven (16%) of the 45 patients in the group without acromioplasty underwent reoperation. One (2%) of the initial 41 patients allocated to acromioplasty underwent reoperation. All patients who underwent a reoperation had a Type-2 or 3 acromion. CONCLUSIONS: Patients who underwent rotator cuff repair with or without acromioplasty experienced improvement of outcomes from their preoperative level at a long-term follow-up (mean, 11 years), and there were no differences in patient-reported outcomes, specifically WORC scores, between these groups. However, a significantly higher reoperation rate was observed in patients who had rotator cuff repair without acromioplasty, specifically in those with a Type-2 or 3 acromion. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Performance of 5-Strand Hamstring Autograft Anterior Cruciate Ligament Reconstruction in the STABILITY Study: A Subgroup Analysis.

BACKGROUND: Anterior cruciate ligament (ACL) reconstructions (ACLRs) with graft diameters <8mm have been shown to have higher revision rates. The 5-strand (5S) hamstring autograft configuration is a proposed option to increase graft diameter. PURPOSE: To investigate the differences in clinical outcomes between 4-strand (4S) and 5S hamstring autografts for ACLR in patients who underwent ACLR alone or concomitantly with a lateral extra-articular tenodesis (LET) procedure. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Data from the STABILITY study were analyzed to compare a subgroup of patients undergoing ACLR alone or with a concomitant LET procedure (ACLR + LET) with a minimum graft diameter of 8mm that had either a 4S or 5S hamstring autograft configuration. The primary outcome was clinical failure, a composite of rotatory laxity and/or graft failure. The secondary outcome measures consisted of 2 patient-reported outcome scores (PROs)-namely, the ACL Quality of Life Questionnaire (ACL-QoL) and the International Knee Documentation Committee (IKDC) score at 24 months postoperatively. RESULTS: Of the 618 patients randomized in the STABILITY study, 399 (228 male; 57%) fit the inclusion criteria for this study. Of these, 191 and 208 patients underwent 4S and 5S configurations of hamstring ACLR, respectively, with a minimum graft diameter of 8mm. Both groups had similar characteristics other than differences in anthropometric factors-namely, sex, height, and weight, and Beighton scores. The primary outcomes revealed no difference between the 2 groups in rotatory stability (odds ratio [OR], 1.19; 95% CI, 0.77-1.84; P = .42) or graft failure (OR, 1.13; 95% CI, 0.51-2.50; P = .76). There was no significant difference between the groups in Lachman (P = .46) and pivot-shift (P = .53) test results at 24 months postoperatively. The secondary outcomes revealed no differences in the ACL-QoL (P = .67) and IKDC (P = .83) scores between the 2 subgroups. CONCLUSION: At the 24-month follow-up, there were no significant differences in clinical failure rates and PROs in an analysis of patients with 4S and 5S hamstring autografts of ≥8mm diameter for ACLR or ACLR + LET. The 5S hamstring graft configuration is a viable option to produce larger-diameter ACL grafts.

No differences found in long-term outcomes of a randomized controlled trial comparing ipsilateral versus contralateral hamstring graft in ACL reconstruction.

PURPOSE: Contralateral graft harvest in primary ACL reconstruction is relatively uncommon and the long-term comparative of this approach relative to ipsilateral harvest has not been described. The purpose of this study was to evaluate ACL graft and contralateral rupture following ipsilateral or contralateral semitendinosus and gracilis (STG) graft harvest at follow-up of a minimum 10 years post-reconstruction in the treatment of a complete ACL tear. METHODS: Patients from a previous randomized trial were evaluated. The primary outcome measures were ipsilateral and contralateral reinjury as well as the International Knee Documentation Committee (IKDC) knee assessment form, the ACL Quality of Life questionnaire (ACL-QoL) and the Tegner activity scale. Participants completed four different single-leg hop tests and concentric knee flexion and extension strength were assessed on an isokinetic dynamometer. RESULTS: Of the original 100 patients, 50 patients (41.3 ± 9.5 years of age, 31 males, 19 females) reported on re-injury at 12.6 ± 1.4 years post-operative. Thirty-eight patients returned for full assessment and 12 responded by mail or phone survey. There were no differences between groups for graft rupture, contralateral injury, ACL-QoL score, IKDC categorization, or anterior tibial translation, though both groups experienced a reduction in the Tegner Activity Scale from their preinjury scores. There was no difference in knee flexor and extensor isokinetic concentric strength, or single leg hop test performance. Knee flexor strength limb symmetry index was reduced when measured in the supine relative to the seated position in both groups, indicating persistent deficits in knee flexor strength when measured in the supine position. CONCLUSION: Contralateral hamstring harvest does not put patients at an increased risk of a contralateral ACL tear and long-term outcomes of ACL reconstruction do not differ based on the side of graft harvest. Contralateral STG harvest may provide a safe alternative surgical option for select patients. LEVEL OF EVIDENCE: Level II.

Quality of life during the wait for ruptured anterior cruciate ligament reconstruction: a randomized controlled trial.

BACKGROUND: There is a lack of prospective evidence to guide surgeons when making recommendations about the appropriate timing of surgical intervention for ruptured anterior cruciate ligament (ACL), activity modifications to reduce the risk of secondary injury before surgery, and the short- and long-term risks associated with delayed ACL reconstruction. This study aimed to determine whether longer wait times are associated with a prolonged decrease in quality of life and an increased incidence of secondary joint injury after ACL rupture. METHODS: We recruited 53 patients who presented between 2013 and 2017 at a single sports medicine minor injury clinic with a suspected acute ACL rupture, based on clinical examination; ACL rupture was confirmed on magnetic resonance imaging. Patients were randomly allocated to undergo early reconstruction (< 12 wk after injury) or reconstruction after a regular wait time (≥ 12 wk). We compared scores on the ACL quality of life measure (ACL-QOL) and the incidence of secondary knee injury at baseline and at surgery between the 2 groups. Participants also completed the Tegner scale (level of activity) at the time of consent and within 7 days before surgery. RESULTS: Twenty-eight patients were randomly assigned to the early surgery group and 25 patients to the regular wait time group. There was no difference in mean age between the 2 groups. There were no between-group differences in mean ACL-QOL score at the time of injury (28.5 [standard deviation (SD) 12.5] v. 28.5 [SD 12.6]) or at surgery (34.9 [SD 17.5] v. 38.0 [SD 17.5]). The mean wait time was significantly longer in the regular wait time group than in the early surgery group (29.6 wk [SD 13.2 wk] v. 10.6 wk [SD 5.1 wk], p = 0.001). In both groups, Tegner scale scores were significantly lower after than before ACL rupture (p < 0.001) and remained low while patients waited for surgery. There were no between-group differences in the incidence of chondral or meniscal injury at surgery, although the study was not adequately powered to draw any statistical conclusions. CONCLUSION: Wait time for ACL reconstruction may affect patients' quality of life, as it remained diminished for a longer period when surgery was delayed. A low activity level during the waiting period was observed in both groups; this low activity level may be one reason why no between-group differences in the incidence of secondary injury were observed. The findings suggest that patients with a limited activity level during the waiting period have a low risk of secondary injuries.

Does the Nice Knot Offer Less Elongation Than the Modified Prusik Knot? An In Vitro Study in Cadaver Quadriceps Tendons.

BACKGROUND: ACL graft-suture fixation can be constructed with needle or needleless techniques. Needleless techniques have the advantage of decreased injury, preparation time, and cost. The Nice knot is common among upper extremity procedures, and has been shown to have higher load to failure and less elongation compared with other double loop knots; however, there are no studies that have looked at its use for ACL graft-suture construct to determine whether it offers less elongation relative to other needleless techniques. QUESTIONS/PURPOSES: In a cadaver quadriceps tendon model, we asked: (1) Does the Nice knot have less elongation than the Prusik knot? (2) Does the Nice knot have increased peak load and stiffness compared with the Prusik knot? (3) What were the modes of failure of each knot? METHODS: Sixteen quadriceps tendon grafts were harvested from 16 cadaver knee specimens. The median (range) age of the donors was 80 years (70 to 96) and included three male and five female donors. Eight grafts were prepared with the Prusik knot and eight with the Nice knot using a braided polyblend suture. The graft-suture constructs were mounted in a materials testing machine and subjected to a tensile loading protocol beginning with pretensioning of three cycles from 0 to 100 N at 1 Hz followed by a constant load of 50 N for 1 minute then cyclic loading of 200 cycles from 50 to 200 N at 1 Hz. The constructs were loaded to failure as the final step of the loading protocol. Elongations of the construct after each loading step, peak load, stiffness, and graft cross-sectional area were compared. RESULTS: Construct elongations (median [IQR]) for the Nice knot were lower than that of the Prusik knot after pretensioning (4.4 mm [0.8] versus 5.7 mm [1.4]; p = 0.02), preloading (0.6 mm [0.3] versus 1.0 mm [0.3]; p = 0.005), and cyclic loading (7.4 mm [1.4] versus 10.9 mm [2.1]; p = 0.005). Peak load was not different for the Prusik knot construct compared with the Nice knot (334 N [43] versus 312 N [13]; p = 0.08). Stiffness of the Prusik knot construct (103 N/mm [17]) was no different than the Nice knot construct (110 N/mm [13]; p = 0.13). Graft cross-sectional area of the Prusik knot constructs (85 mm2 [35]) were similar to the grafts of the Nice knot constructs (97 mm2 [31]; p = 0.28). Failure mode of the constructs did not differ between groups; it was caused by suture rupture near the knots that secured the free suture ends to the machine and was seen in all 16 tests. CONCLUSIONS: The results of this biomechanical study show that the Nice knot construct has similar or greater biomechanical properties compared with the Prusik knot in the graft suture construct, although the magnitude of the differences are not likely to the level of clinical importance. CLINICAL RELEVANCE: The Nice knot offers an attractive alternative option for needleless ACL graft preparation technique. Future studies should consider comparison to established needle techniques such as Krackow or whipstitch and testing in an intraarticular component in an in vivo model.

Predictors of Graft Failure in Young Active Patients Undergoing Hamstring Autograft Anterior Cruciate Ligament Reconstruction With or Without a Lateral Extra-articular Tenodesis: The Stability Experience.

BACKGROUND: Anterior cruciate ligament (ACL) reconstruction (ACLR) has higher failure rates in young active patients returning to sports as compared with older, less active individuals. Augmentation of ACLR with an anterolateral procedure has been shown to reduce failure rates; however, indications for this procedure have yet to be clearly defined. PURPOSE/HYPOTHESIS: The purpose of this study was to identify predictors of ACL graft failure in high-risk patients and determine key indications for when hamstring ACLR should be augmented by a lateral extra-articular tenodesis (LET). We hypothesized that different preoperative characteristics and surgical variables may be associated with graft failure characterized by asymmetric pivot shift and graft rupture. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Data were obtained from the Stability 1 Study, a multicenter randomized controlled trial of young active patients undergoing autologous hamstring ACLR with or without a LET. We performed 2 multivariable logistic regression analyses, with asymmetric pivot shift and graft rupture as the dependent variables. The following were included as predictors: LET, age, sex, graft diameter, tear chronicity, preoperative high-grade knee laxity, preoperative hyperextension on the contralateral side, medial meniscal repair/excision, lateral meniscal repair/excision, posterior tibial slope angle, and return-to-sports exposure time and level. RESULTS: Of the 618 patients in the Stability 1 Study, 568 with a mean age of 18.8 years (292 female; 51.4%) were included in this analysis. Asymmetric pivot shift occurred in 152 (26.8%) and graft rupture in 43 (7.6%). The addition of a LET (odds ratio [OR], 0.56; 95% CI, 0.37-0.83) and increased graft diameter (OR, 0.62; 95% CI, 0.44-0.87) were significantly associated with lower odds of asymmetric pivot shift. The addition of a LET (OR, 0.40; 95% CI, 0.18-0.91) and older age (OR, 0.83; 95% CI, 0.72-0.96) significantly reduced the odds of graft rupture, while greater tibial slope (OR, 1.15; 95% CI, 1.01-1.32), preoperative high-grade knee laxity (OR, 3.27; 95% CI, 1.45-7.41), and greater exposure time to sport (ie, earlier return to sport) (OR, 1.18; 95% CI, 1.08-1.29) were significantly associated with greater odds of rupture. CONCLUSION: The addition of a LET and larger graft diameter were significantly associated with reduced odds of asymmetric pivot shift. Adding a LET was protective of graft rupture, while younger age, greater posterior tibial slope, high-grade knee laxity, and earlier return to sport were associated with increased odds of graft rupture. Orthopaedic surgeons should consider supplementing hamstring autograft ACLR with a LET in young active patients with morphological characteristics that make them at high risk of reinjury.

A Multicenter Randomized Controlled Trial Comparing Single-Row With Double-Row Fixation in Arthroscopic Rotator Cuff Repair: Long-Term Follow-up.

BACKGROUND: The long-term outcomes of single- versus double-row fixation in arthroscopic rotator cuff repair are not currently known. PURPOSE: To compare the treatment effects of the single- versus double-row suture technique in arthroscopic rotator cuff repair of full-thickness tears at 10-year follow-up. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: Patients were evaluated at 10 years postoperatively. The primary outcome measure was the Western Ontario Rotator Cuff Index (WORC). Secondary outcome measures included the American Shoulder and Elbow Surgeons (ASES) score, Constant score, strength, and incidence of revision surgery. Ultrasound was used to evaluate the rotator cuff to determine repair integrity. Statistical analyses consistent with those of the main trial were conducted. RESULTS: Of the original 90 participants, 77 (85%) returned at a mean follow-up of 10 years. At ten year follow-up, the WORC score was higher in the double row group (79.9 [95% CI, 16.2 to 99.1]) compared with the single row group (72.9, [95% CI, 4.3 to 100]), P = .020. From baseline to 2 years, the mean change in WORC scores for the single-row group was -48.5 compared with -40.6 for the double-row group, with a between-group difference of -7.8 (95% CI, -20.4 to 4.7). From 2 to 10 years, the change in WORC scores for the single-row group was 11.5 compared with -0.2 for the double-row group, with a between-group difference of 11.7 (95% CI, -0.7 to 24.3). From baseline to 10 years, the mean between-group difference was 3.9 (95% CI, -7.8 to 15.6). Similarly, a decrease in ASES scores was observed between 2 and 10 years for the single-row group (9.2 [95% CI, 0.9 to 17.5]; P = .029), with a nonsignificant decrease in ASES scores for the double-row group (6.2 [95% CI, -3.2 to 15.6]; P = .195) as well as a decrease in Constant scores for both the single- (9.5 [95% CI, 1.4 to 17.5]; P = .020) and double-row (14.4 [95% CI, 5.6 to 23.3]; P = .001) groups. Overall, 3 participants developed a full-thickness tear after 2 years: 2 from the double-row group and 1 from the single-row group. One participant from each study group underwent revision surgery after the 2-year time point. CONCLUSION: A statistically significant (but likely not clinically important) difference in WORC scores was seen at 10-year follow-up in favor of double-row fixation. Between baseline and 10-year follow-up, a decrease in most outcome scores was observed in both the single- and the double-row groups. REGISTRATION: NCT00508183 (ClinicalTrials.gov identifier).

Module-Based Arthroscopic Knee Simulator Training Improves Technical Skills in Naive Learners: A Randomized Trial.

PURPOSE: To compare the effectiveness, in comparison to a control group (C), of module-based training (MBT) and traditional learning (TL) as a means of acquiring arthroscopic skills on an arthroscopic surgery simulator. METHODS: Thirty health sciences students with no previous arthroscopy experience were recruited and randomized into 1 of 3 groups: MBT, TL, or C (1:1:1 ratio). Participants in MBT were required to independently practice on a VirtaMed ArthroS simulator (VirtaMed AG, Zurich, Switzerland) for a minimum of 2 hours per week, whereas TL received one-on-one coaching by a senior orthopaedic resident for 15 minutes per week. The control group received no training. All groups were assessed at baseline and at 4 weeks based on objective measures generated by the surgical simulator (procedure time, camera path length, meniscus cutting score, detailed visualization, safety score and total score), and subjective ratings scales (Objective Assessment of Arthroscopic Skill [OAAS] global assessment form, and Competency-Based Assessment form). RESULTS: Participants in the MBT group trained on average 113 min/week whereas the TL group trained on average 24 min/week. Three-way repeated-measures analysis of variance showed significant group by time interactions for procedure time (P = .006), camera path length (P = .008), safety score (P = .013), total score (P = .003), OAAS form (P < .001), and Competency-Based Assessment form (P < .001). MBT group was superior to C group for procedure time (P = .02), camera path length (P = .003), total score (P = .004), and OAAS form (P = .021), but there were no significant post-hoc differences between MBT and TL groups, or TL and C groups after Bonferroni correction. Total practice time explained 37.5% of the final simulator total score variance. CONCLUSIONS: Knee arthroscopy simulation training with self-learning modules can improve skills in areas such as procedure time, camera path length, and total score in untrained participants compared with a control group. CLINICAL RELEVANCE: Module-based simulation training provides additional training time and improves technical skills in naive health science students. It is hoped that this effect can be preserved and applied to junior resident developing in a busy residency program.

Uncommon Bilateral Absence of Long Heads of the Biceps Tendons in Twin Sisters: A Report of 2 Cases.

We present 2 cases, 45-year-old identical twin sisters, with bilateral congenital absence of the long head of the biceps tendon (LHBT); 1 twin was symptomatic, while the other was not. Variations of the intra-articular portion of this tendon are widely reported, but there are few reports of cases with absent LHBT. These cases may be of particular interest to radiologists and surgeons because they demonstrate that absent biceps when congenital in nature may not always coincide with symptoms.

Effect of age, gender, and body mass index on incidence and satisfaction of a Popeye deformity following biceps tenotomy or tenodesis: secondary analysis of a randomized clinical trial.

BACKGROUND: The purpose of this study was to determine the incidence of Popeye deformity following biceps tenotomy vs. tenodesis and evaluate risk factors and subjective and objective outcomes. METHODS: Data for this study were collected as part of a randomized clinical trial in which patients aged ≥18 years undergoing arthroscopic shoulder surgery for a long head of the biceps tendon lesion were allocated to undergo tenotomy or tenodesis. The primary outcome measure for this secondary analysis was rate of Popeye deformity at 24 months postoperation as determined by an evaluator blinded to group allocation. Those with a deformity indicated their satisfaction with the appearance of their arm on a 10-cm visual analog scale, rated their pain and cramping, and completed the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form and the Western Ontario Rotator Cuff index. Isometric elbow flexion and supination strength were also measured. Cohen kappa was calculated to measure inter-rater reliability between patient and evaluator on the presence of a deformity. Logistic regression was performed to identify predictors of presence or absence of a Popeye deformity. RESULTS: One hundred fourteen patients were randomly assigned to 2 groups, of which 42 to the tenodesis group and 45 to the tenotomy group completed a 24-month follow-up. Based on clinical observation, the odds of a Popeye in the tenotomy group were 4.3 times greater than in the tenodesis group (P = .018) with incidence of 33% (15/45) and 9.5% (4/42), respectively. Surgical technique was the only significant predictor of perceived deformity, with male gender trending toward significance (odds ratio 7.33, 95% confidence interval 0.867-61.906, P = .067). Mean (standard deviation) satisfaction score of those with a deformity regarding appearance of their arm was 7.3 (2.6). Increasing satisfaction was correlated with increasing age (r = 0.640, P = .025), but there was no association with gender (r = -0.155, P = .527) or body mass index (r = -0.221, P = .057). Differences in subjective outcomes were dependent on whether the Popeye was clinician- or self-assessed. CONCLUSION: The odds of developing a perceived Popeye deformity was 4.3 higher after tenotomy compared to tenodesis based on clinician observation. Male gender was trending toward being predictive of having a deformity. Pain and cramping were increased in those with a self-reported Popeye. Younger patients were significantly less satisfied with a deformity despite no difference in functional outcomes at 24 months. Thus, biceps tenodesis may be favored in younger male patients to minimize the risk of Popeye and the risk of dissatisfaction in the appearance of their arm following surgery.

Comparison of Common Methodologies for the Determination of Knee Flexor Muscle Strength.

BACKGROUND: Knee flexion strength may hold important clinical implications for the determination of injury risk and readiness to return to sport following injury and orthopedic surgery. A wide array of testing methodologies and positioning options are available that require validation prior to clinical integration. The purpose of this study was to 1) investigate the validity and test-retest reliability of isometric knee flexion strength measured by a fixed handheld dynamometer (HHD) apparatus compared to a Biodex Dynamometer (BD), 2) determine the impact of body position (seated versus supine) and foot position (plantar- vs dorsiflexed) on knee flexion peak torque and 3) establish the validity and test-retest reliability of the NordBord Hamstring Dynamometer. STUDY DESIGN: Validity and reliability study, test-retest design. METHODS: Forty-four healthy participants (aged 27 ± 4.8 years) were assessed by two raters over two testing sessions separated by three to seven days. Maximal isometric knee flexion in the seated and supine position at 90o knee flexion was measured with both a BD and an externally fixed HHD with the foot held in maximal dorsiflexion or in plantar flexion. The validity and test-retest reliability of eccentric knee flexor strength on the NordBord hamstring dynamometer was assessed and compared with isometric strength on the BD. RESULTS: Level of agreement between HHD and BD torque demonstrated low bias (bias -0.33 Nm, SD of bias 13.5 Nm; 95% LOA 26.13 Nm, -26.79 Nm). Interrater reliability of the HHD was high, varying slightly with body position (ICC range 0.9-0.97, n=44). Isometric knee flexion torque was higher in the seated versus supine position and with the foot dorsiflexed versus plantarflexed. Eccentric knee flexion torque had a high degree of correlation with isometric knee flexion torque as measured via the BD (r=0.61-0.86). The NordBord had high test-retest reliability (0.993 (95%CI 0.983-0.997, n=19) for eccentric knee flexor strength, with an MDC95 of 26.88 N and 28.76 N for the left and right limbs respectively. CONCLUSION: Common measures of maximal isometric knee flexion display high levels of correlation and test-retest reliability. However, values obtained by an externally fixed HHD are not interchangeable with values obtained via the BD. Foot and body position should be considered and controlled during testing. LEVEL OF EVIDENCE: 2b.

Association of Ligamentous Laxity, Male Sex, Chronicity, Meniscal Injury, and Posterior Tibial Slope With a High-Grade Preoperative Pivot Shift: A Post Hoc Analysis of the STABILITY Study.

BACKGROUND: A spectrum of anterolateral rotatory laxity exists in anterior cruciate ligament (ACL)-injured knees. Understanding of the factors contributing to a high-grade pivot shift continues to be refined. PURPOSE: To investigate factors associated with a high-grade preoperative pivot shift and to evaluate the relationship between this condition and baseline patient-reported outcome measures (PROMs). STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: A post hoc analysis was performed of 618 patients with ACL deficiency deemed high risk for reinjury. A binary logistic regression model was developed, with high-grade pivot shift as the dependent variable. Age, sex, Beighton score, chronicity of the ACL injury, posterior third medial or lateral meniscal injury, and tibial slope were selected as independent variables. The importance of knee hyperextension as a component of the Beighton score was assessed using receiver operator characteristic curves. Baseline PROMs were compared between patients with and without a high-grade pivot. RESULTS: Six factors were associated with a high-grade pivot shift: Beighton score (each additional point; odds ratio [OR], 1.17; 95% CI, 1.06-1.30; P = .002), male sex (OR, 2.30; 95% CI, 1.28-4.13; P = .005), presence of a posterior third medial (OR, 2.55; 95% CI, 1.11-5.84; P = .03) or lateral (OR, 1.76; 95% CI, 1.01-3.08; P = .048) meniscal injury, tibial slope >9° (OR, 2.35; 95% CI, 1.09-5.07; P = .03), and chronicity >6 months (OR, 1.70; 95% CI, 1.00-2.88; P = .049). The presence of knee hyperextension improved the diagnostic utility of the Beighton score as a predictor of a high-grade pivot shift. Tibial slope <9° was associated with only a high-grade pivot in the presence of a posterior third medial meniscal injury. Patients with a high-grade pivot shift had higher baseline 4-Item Pain Intensity Measure scores than did those without a high-grade pivot shift (mean ± SD, 11 ± 13 vs 8 ± 14; P = .04); however, there was no difference between groups in baseline International Knee Documentation Committee, ACL Quality of Life, Knee injury and Osteoarthritis Outcome Score, or Knee injury and Osteoarthritis Outcome Score subscale scores. CONCLUSION: Ligamentous laxity, male sex, posterior third medial or lateral meniscal injury, increased posterior tibial slope, and chronicity were associated with a high-grade pivot shift in this population deemed high risk for repeat ACL injury. The effect of tibial slope may be accentuated by the presence of meniscal injury, supporting the need for meniscal preservation. Baseline PROMs were similar between patients with and without a high-grade pivot shift.

Complications of Superior Capsule Reconstruction for the Treatment of Functionally Irreparable Rotator Cuff Tears: A Systematic Review.

PURPOSE: The purpose of this systematic review is to characterize the complications associated with superior capsule reconstruction (SCR) for the treatment of functionally irreparable rotator cuff tears (FIRCTs). METHODS: This systematic review was completed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Two independent reviewers completed a search of PubMed, Embase, and Medline databases. Studies were deemed eligible for inclusion if they reported postoperative outcomes of arthroscopic SCR for FIRCTs and considered at least 1 postoperative complication. Statistical heterogeneity was quantified via the I2 statistic. Due to marked heterogeneity, pooled proportions were not reported. All complications and patient-reported outcomes were described qualitatively. RESULTS: Fourteen studies met the inclusion/exclusion criteria. The overall complication rate post-SCR ranged from 5.0% to 70.0% (I2 = 84.9%). Image-verified graft retear ranged from 8% to 70%, I2 = 79.4%), with higher rates reported when SCR was performed using allograft (19%-70%, I2 76.6%) compared to autograft (8%-29%, I2 = 66.1%). Reoperation (0%-36%, I2 = 73.4%), revision surgeries (0%-21%, I2 = 81.2%), medical complications (0%-5%, I2 = 0.0%), and infections (0%-5%, I2 = 0.0%) were also calculated. CONCLUSIONS: SCR carries a distinct complication profile when used for the treatment of FIRCTs. The overall rate of complications ranged from 5.0% to 70.0%. The most common complication is graft retear with higher ranges in allografts (19%-70%) compared to autografts (8%-29%). The majority of studies reported at least 1 reoperation (range, 0%-36%), most commonly for revision to reverse shoulder arthroplasty. LEVEL OF EVIDENCE: Level IV, systematic review of Level IV or better investigations.

Arthroscopic Bankart repair with and without arthroscopic infraspinatus remplissage in anterior shoulder instability with a Hill-Sachs defect: a randomized controlled trial.

BACKGROUND: The purpose of this study was to compare patient-reported and clinic outcomes between arthroscopic Bankart repair with (REMP) and without (NO REMP) arthroscopic infraspinatus remplissage in patients with recurrent anterior shoulder instability with a Hill-Sachs lesion and minimal glenoid bone loss. METHODS: Patients 14 years or older with a recurrent anterior shoulder instability with the presence of an engaging Hill-Sachs defect (of any size) confirmed on computed tomography or magnetic resonance imaging were eligible to participate. Consented patients were randomized intraoperatively to NO REMP or REMP. Study visits were conducted preoperatively and 3, 6, 12, and 24 months postoperatively. The primary outcome was the Western Ontario Shoulder Instability score. Secondary outcomes included incidence of postoperative recurrent shoulder instability, Simple Shoulder Test, American Shoulder and Elbow Surgeons score, range of motion, complications, and revision surgery. To compare groups, a mixed-effects linear model was used for continuous variables and a χ2 or Fisher's exact test for categorical data. A Kaplan-Meier survival analysis assessed survival distribution between groups. RESULTS: One hundred and eight patients were randomized to Bankart repair with (n = 54) or without (n = 54) remplissage. The mean follow-up was 26.5 months (21-53 months) and 24.3 months (23-64 months) for the REMP and NO REMP groups, respectively. Rates of postoperative recurrent instability were higher (P = .027) in the NO REMP group with 9 of 50 (18%) vs. 2 of 52 (4%) postoperative dislocations in the REMP group. There were no significant differences in patient-reported outcomes between groups at any time point. Survival curve distributions were also significantly different favoring REMP (χ2 = 5.255, P = .022). There was a significant difference in rate of revision surgery between groups with 6 in the NO REMP and none in the REMP groups (P = .029). Post hoc, patients were noted to have a higher risk for re-dislocation if their Hill-Sachs lesion was ≥20 mm in width or ≥15% of humeral head diameter. One intraoperative complication was reported in the REMP group. CONCLUSIONS: There is significantly greater risk of postoperative recurrent instability in patients who did not have a remplissage performed in conjunction with an arthroscopic Bankart repair for the treatment of traumatic recurrent anterior shoulder instability with Hill-Sachs lesions of any size and minimal glenoid bone loss (<15%) at 2 years postoperatively. Otherwise, there are no differences in patient-reported outcomes, complications, or shoulder function at 2 years postoperatively. In addition, the remplissage procedure has significantly lower rates of re-dislocation in high-risk patients with Hill-Sachs lesions ≥20 mm and/or ≥15% in size.