Anterior Cruciate Ligament Repair Using a Re-tensionable All-Suture Construct.

Anterior cruciate ligament (ACL) tears are among the most common injuries to the knee. With recent improvements in imaging that allow for more precise identification of ACL tear patterns, improved techniques for repair, and advancements in biological augmentation, there has been a re-emerging interest in primary ACL repair, especially for acute proximal ACL tears. This article aims to describe a surgical technique for primary ACL repair using a re-tensionable all-suture-based construct.

Micro-Fragmented Adipose Tissue Demonstrates Comparable Clinical Efficacy to Other Orthobiologic Injections in Treating Symptomatic Knee Osteoarthritis: A Systematic Review of Level I to IV Clinical Studies.

PURPOSE: To perform a systematic review of clinical outcomes in patients who underwent treatment with micro-fragmented aspirated tissue for symptoms of knee osteoarthritis. METHODS: Medline, Embase, Scopus, and Google Scholar were screened for studies from 2000 to 2023. Risk of bias (ROB) was assessed using the Cochrane Collaboration's tools and the Risk Of Bias In Non-randomised Studies-of Interventions tool. Study quality was assessed with the modified Coleman Methodology Score and Methodological Index for Non-Randomized Studies score. Heterogeneity was assessed using χ2 and I2 statistics. RESULTS: Twenty-one studies were included. One study had a high ROB, 1 had a critical ROB, 3 had serious ROB, and 16 had a moderate ROB. The mean Coleman score was 58, demonstrating fair study quality; the Methodological Index for Non-Randomized Studies score had a mean value of 13, indicating overall fair quality. Best evidence synthesis revealed moderate evidence. The visual analog scale score improved from 5.2 to 3.2 at 6 and 12 months. Knee injury and Osteoarthritis Outcome Score (KOOS) activities of daily living subscore improved from 58.8 to 70.2 at 6 months and 67.5 at 12 months. KOOS pain subscore improved from 54.3 to 70.2 at 6 months and 72.4 at 12 months. KOOS quality of life subscore improved from 33.1 to 43.6 at 6 months and 42.9 at 12 months. KOOS sports subscore improved from 23.7 to 43.6 at 6 months and 57.4 at 12 months. KOOS symptoms subscore improved from 55.3 to 70.1 at 6 months and 67.9 at 12 months. The Western Ontario and McMaster Universities Osteoarthritis Index score steadily increased from 61.8 at baseline to 78.4 at 12 months. CONCLUSIONS: micro-fragmented aspirated tissue injection therapy for the treatment of symptomatic knee osteoarthritis is effective and improves pain and functional outcomes. Moderate study quality combined with a moderate risk of bias, moderate certainty of evidence, and moderate best synthesis evidence reduces external validity. Therefore, the results should be interpreted with a degree of caution. LEVEL OF EVIDENCE: Level IV, systematic review of Level I-IV studies.

Most Orthopaedic Platelet-Rich Plasma Investigations Don't Report Protocols and Composition: An Updated Systematic Review.

PURPOSE: To systematically review the literature to assess the heterogeneity of platelet-rich plasma (PRP) preparation and composition reporting for the treatment of musculoskeletal/orthopaedic pathologies. METHODS: A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify Level I and Level II studies from 2016 to 2022 that evaluated the use of PRP therapy for musculoskeletal pathologies. The search phrase used was "platelet-rich plasma clinical studies." Studies were assessed based on their reporting of the PRP preparation methods and reporting of PRP composition. RESULTS: One hundred twenty-four studies (in 120 articles) met inclusion criteria for analysis. Of these studies, 15 (12.1%) provided comprehensive reporting, including a clear, well-described, and reproducible preparation protocol that future investigators can follow. Thirty-three studies (26.6%) quantitatively reported the final PRP product composition. CONCLUSIONS: Among the studies using PRP for the treatment of musculoskeletal/orthopaedic pathologies, less than 20% provided a clear, well-described, and reproducible PRP preparation protocol, and only one-fourth of studies reported on the final PRP product composition. CLINICAL RELEVANCE: A diverse current reporting of PRP composition between studies provides a high heterogeneity of the term "PRP," which becomes a limitation for a comparison of studies using PRP.

Meniscus Repair Technique Must be Determined on a Tear-by-Tear Basis: Hybrid Techniques Plus Biologics are Optimal.

Bucket-handle meniscus tears alter knee biomechanics and significantly elevate the risk of osteoarthritis when the tissue is not preserved. Consequentially, meniscus repair is preferred whenever possible to optimize load distribution and knee stability, with the overall goal of joint preservation. Bucket-handle meniscus tears have a higher rate of repair failure compared to many other tear patterns, and both the inside-out (IO) and all-inside (AI) techniques are acceptable options, each with distinct advantages and disadvantages. Both have demonstrated improved clinical outcomes with similar failure rates. IO is cost-effective and allows less meniscal trauma due to small diameter needles, while risks include increased surgical time, increased risk of infection, and need for 1 or more skilled assistants. AI avoids an extra-incisions and extra assistants and shows decreased surgical time, while complications can include hardware irritation, chondral and neurovascular injury (particularly for posterolateral repairs), and motion loss. Hybrid repair using AI for posterior tears, and IO for middle-third, and outside-in for the anterior meniscus is cost-effective and efficacious. Biologics to promote healing through mechanical stimulation of tear, notch marrow venting, trephination, and/or platelet-rich plasma is an essential adjunct.

Patient Perception of Social Media Use by Orthopaedic Surgeons: A Pilot Study.

Background: Social media (SM) use by orthopaedic surgeons is becoming increasingly common; nonetheless, it needs to be clarified how patients perceive the content posted by physicians. Purpose: To characterize SM content posted by orthopaedic surgeons while investigating patient perceptions of this content and how it may influence their health care decisions. Study Design: Cross-sectional study. Methods: Posts on SM outlets by orthopaedic surgeons were reviewed and categorized. A survey to assess patient perception of these categories was administered between December 2021 and February 2022 in the clinics of 3 orthopaedic surgeons. Survey results were analyzed for differences in patient SM use and perception of SM content types. Results: There were 250 completed surveys. SM use was high among all age groups; however, the 18 to 24 years (87.1%) and 25 to 34 years (86.4%) age groups were more likely than older age groups to report daily use (P = .002). Overall, 17% of patients reported using SM to see information about their health care at least once per month, 21% reported reviewing the SM account of a physician at least once per month, 19% reported that they were likely or very likely to view the SM account of their physician, and 23% reported that SM content was likely or very likely to influence which physician they see. Patients held the most consistently positive view of posts that educated patients, discussed sports team coverage, and provided patient testimonials. Patients had consistently neutral views of posts educating colleagues, discussing presentations at national meetings, displaying aspects of surgeons' personal lives, and supporting marginalized groups. Several post categories elicited highly polarized responses-including those discussing research publications and showing surgical techniques or pictures/videos taken during surgery. Respondents had a consistently negative response to posts making political statements. Conclusion: SM is likely a useful tool to help physicians interact with patients. Physicians who wish to interact with patients should consider posting content viewed most positively-including posts educating patients, discussing sports team coverage, and providing patient testimonials. Content that is viewed less favorably should be posted sparingly or with a sensitive tag.

Improved Network Integrity and Patient Follow-up After In-Office Needle Arthroscopy Compared to Outpatient Advanced Diagnostic Imaging for Intra-articular Pathology.

Purpose: To evaluate network integrity for diagnostic testing and patient follow-up comparing in-office needle arthroscopy and outpatient advanced diagnostic imaging for intra-articular pathology. Methods: A retrospective chart review was performed to identify patients who were indicated for either in-office needle arthroscopy (IONA) or outpatient advanced diagnostic imaging (OADI). Current Procedural Terminology (CPT) codes 29870 and 29805 with place of service modifier 11 were used to identify patients who underwent IONA of the knee and shoulder, respectively, between January 2020 and March 2023. CPT codes 73721-3 and 73221-3 were utilized to identify patients indicated for outpatient advanced magnetic resonance imaging of the knee or shoulder. All patients who were indicated for the procedure and denied by the insurance were identified and recorded. Inclusion criteria consisted of patients older than 18 years with suspected intra-articular pathology who had failed conservative treatment. Exclusion criteria included patients younger than 18 years, non-English speaking, or those who failed to follow up due to death. The location of where the imaging was performed was recorded (within the health system vs an unaffiliated center). Additionally, patient follow-up with the provider after the diagnostic testing was indicated was recorded. Results: Two separate groups of 100 consecutive patients who were indicated for IONA or OADI were identified and retrospectively chart reviewed. Ninety-four percent of the IONA patients underwent the procedure after it was indicated within the physician office. Sixty-eight percent underwent the procedure the day they were indicated for the procedure. All 94 patients were deemed to have a follow-up with a definitive plan of care after the procedure. Eighty-seven percent of the OADI patients completed their ordered testing. Sixty-two percent (54/87) of the patients had the study performed at one of the primary hospital-affiliated imaging centers. Thirty-eight percent of the studies (33/87) were deemed to have leaked from the system. Of the 87 patients who had the imaging performed, 79% (69/87) had a definitive treatment plan rendered with the lead author (S.M.) based on the imaging results. Twenty-one percent (18/87) of the patients who underwent imaging did not follow up with the treating provider or show for a scheduled follow-up appointment. Nineteen percent (13/69) of the patients who had a definite treatment plan rendered did not come into the office for their results but requested and received them over the phone from the provider. The IONA cohort demonstrated statistically significant (P < .001) network integrity in terms of location of service remaining within the system compared to the OADI group. Furthermore, patient follow-up for definitive treatment plans after IONA was also higher (P < .001) than in the OADI group. Conclusions: IONA results in greater network integrity and patient follow-up compared to conventional imaging. Clinical Relevance: In-office needle arthroscopy performed for the diagnosis of intra-articular pathology may offer a valuable clinical diagnostic tool while providing a meaningful avenue for network integrity and patient retention.

On-Field and Pitch-Side (Sideline) Assessment of Sports Concussion in Collision Sports: An Expert Consensus Statement Using the Modified Delphi Technique.

PURPOSE: To perform a Delphi consensus for on-field and pitch-side assessment of sports-related concussion (SRC). METHODS: Open-ended questions in rounds 1 and 2 were answered. The results of the first 2 rounds were used to develop a Likert-style questionnaire for round 3. If agreement at round 3 was ≤80% for an item, if panel members were outside consensus, or there were >30% neither agree/disagree responses, the results were carried forward into round 4. The level of agreement and consensus was defined as 90%. RESULTS: Loss of consciousness (LOC) or suspected LOC, motor incoordination/ataxia, balance disturbance, confusion/disorientation, memory disturbance/amnesia, blurred vision/light sensitivity, irritability, slurred speech, slow reaction time, lying motionless, dizziness, headaches/pressure in the head, falling to the ground with no protective action, slow to get up after a hit, dazed look, and posturing/seizures were clinical signs of SRC and indicate removal from play. Video assessment is helpful but should not replace clinical judgment. LOC/unresponsiveness, signs of cervical spine injury, suspicion of other fractures (skull/maxillo-facial), seizures, Glasgow Coma Scale score <14 and abnormal neurologic examination findings are indications for hospitalization. Return to play should only be considered when no clinical signs of SRC are present. Every suspected concussion should be referred to an experienced physician. CONCLUSIONS: Consensus was achieved for 85% of the clinical signs indicating concussion. On-field and pitch-side assessment should include the observation of the mechanism, a clinical examination, and cervical spine assessment. Of the 19 signs and red flags requiring removal from play, consensus was reached for 74%. Normal clinical examination and HIA with no signs of concussion allow return to play. Video assessment should be mandatory for professional games but should not replace clinical decision-making. Sports Concussion Assessment Tool, Glasgow Coma Scale, vestibular/ocular motor screening, Head Injury Assessment Criteria 1, and Maddocks questions are useful tools. Guidelines are helpful for non-health professionals. LEVEL OF EVIDENCE: Level V, expert opinion.

Experts Achieve Consensus on a Majority of Statements Regarding Platelet-Rich Plasma Treatments for Treatment of Musculoskeletal Pathology.

PURPOSE: To establish consensus statements on platelet-rich plasma (PRP) for the treatment of musculoskeletal pathologies. METHODS: A consensus process on the treatment of PRP using a modified Delphi technique was conducted. Thirty-five orthopaedic surgeons and sports medicine physicians participated in these consensus statements on PRP. The participants were composed of representatives of the Biologic Association, representing 9 international orthopaedic and musculoskeletal professional societies invited due to their active interest in the study of orthobiologics. Consensus was defined as achieving 80% to 89% agreement, strong consensus was defined as 90% to 99% agreement, and unanimous consensus was indicated by 100% agreement with a proposed statement. RESULTS: There was consensus on 62% of statements about PRP. CONCLUSIONS: (1) PRP should be classified based on platelet count, leukocyte count, red blood count, activation method, and pure-plasma versus fibrin matrix; (2) PRP characteristics for reporting in research studies are platelet count, leukocyte count, neutrophil count, red blood cell count, total volume, the volume of injection, delivery method, and the number of injections; (3) the prognostic factors for those undergoing PRP injections are age, body mass index, severity/grade of pathology, chronicity of pathology, prior injections and response, primary diagnosis (primary vs postsurgery vs post-trauma vs psoriatic), comorbidities, and smoking; (4) regarding age and body mass index, there is no minimum or maximum, but clinical judgment should be used at extremes of either; (5) the ideal dose of PRP is undetermined; and (6) the minimal volume required is unclear and may depend on the pathology. LEVEL OF EVIDENCE: Level V, expert opinion.

Autograft Demonstrates Superior Outcomes for Revision Anterior Cruciate Ligament Reconstruction When Compared With Allograft: A Systematic Review.

BACKGROUND: Multiple studies have compared outcomes among patients undergoing revision anterior cruciate ligament reconstruction (ACLR) with autograft versus allograft, but these data are inconsistently reported and long-term outcomes depending on graft type are yet to be determined. PURPOSE: To perform a systematic review of clinical outcomes after revision ACLR (rACLR) with autograft versus allograft. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: A systematic review of the literature was performed by searching PubMed, the Cochrane Library, and Embase to identify studies that compared the outcomes of patients undergoing rACLR with autograft versus allograft. The search phrase used was autograft allograft revision anterior cruciate ligament reconstruction. Graft rerupture rates, return-to-sports rates, anteroposterior laxity, and patient-reported outcome scores (subjective International Knee Documentation Committee, Tegner, Lysholm, and Knee injury and Osteoarthritis Outcome Score) were evaluated. RESULTS: Eleven studies met inclusion criteria, including 3011 patients undergoing rACLR with autograft (mean age, 28.9 years) and 1238 patients undergoing rACLR with allograft (mean age, 28.0 years). Mean follow-up was 57.3 months. The most common autograft and allograft types were bone-patellar tendon-bone grafts. Overall, 6.2% of patients undergoing rACLR experienced graft retear, including 4.7% in the autograft group and 10.2% in the allograft group (P < .0001). Among studies that reported return-to-sports rates, 66.2% of patients with an autograft returned to sports as opposed to 45.3% of patients with an allograft (P = .01). Two studies found significantly greater postoperative knee laxity in the allograft group as compared with the autograft group (P < .05). Among all patient-reported outcomes, 1 study found 1 significant difference between groups: patients with an autograft had a significantly higher postoperative Lysholm score when compared with patients with an allograft. CONCLUSION: Patients undergoing revision ACLR with an autograft can be expected to experience lower rates of graft retear, higher rates of return to sports, and less postoperative anteroposterior knee laxity when compared with patients undergoing revision ACLR with an allograft.

Immobilization in External Rotation Versus Arthroscopic Stabilization After Primary Anterior Shoulder Dislocation: A Systematic Review of Level 1 and 2 Studies.

BACKGROUND: Arthroscopic stabilization has been established as a superior treatment option for primary glenohumeral instability when compared with immobilization in internal rotation. However, immobilization in external rotation (ER) has recently gained interest as a viable nonoperative treatment option for patients with shoulder instability. PURPOSE: To compare the rates of recurrent instability and subsequent surgery in patients undergoing treatment for primary anterior shoulder dislocation with arthroscopic stabilization versus immobilization in ER. STUDY DESIGN: Systematic review; Level of evidence, 2. METHODS: A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify studies that'evaluated patients being treated for primary anterior glenohumeral dislocation with either arthroscopic stabilization or immobilization in ER. The search phrase used various combinations of the keywords/phrases "primary closed reduction,""anterior shoulder dislocation,""traumatic,""primary,""treatment,""management,""immobilization,""external rotation,""surgical,""operative,""nonoperative," and "conservative." Inclusion criteria included patients undergoing treatment for primary anterior glenohumeral joint dislocation with either immobilization in ER or arthroscopic stabilization. Rates of recurrent instability, subsequent stabilization surgery, return to sports, positive postintervention apprehension tests, and patient-reported outcomes were evaluated. RESULTS: The 30 studies that met inclusion criteria included 760 patients undergoing arthroscopic stabilization (mean age, 23.1 years; mean follow-up time, 55.1 months) and 409 patients undergoing immobilization in ER (mean age, 29.8 years; mean follow-up time, 28.8 months). Overall, 8.8% of operative patients experienced recurrent instability at latest follow-up compared with 21.3% of patients who had undergone ER immobilization (P < .0001). Similarly, 5.7% of operative patients had undergone a subsequent stabilization procedure at latest follow-up compared with 11.3% of patients who had undergone ER immobilization (P = .0015). A higher rate of return to sports was found in the operative group (P < .05), but no other differences were found between groups. CONCLUSION: Patients undergoing arthroscopic treatment for primary anterior glenohumeral dislocation with arthroscopic stabilization can be expected to experience significantly lower rates of recurrent instability and subsequent stabilization procedures compared with patients undergoing ER immobilization.

Return to Sports Following Sports-Related Concussion in Collision Sports: An Expert Consensus Statement Using the Modified Delphi Technique.

PURPOSE: To perform a Delphi consensus for return to sports (RTS) following sports-related concussion (SRC). METHODS: Open-ended questions in rounds 1 and 2 were answered. The results of the first 2 rounds were used to develop a Likert-style questionnaire for round 3. If agreement at round 3 was ≤80% for an item, if panel members were outside consensus or there were >30% neither agree/disagree responses, the results were carried forward into round 4. The level of agreement and consensus was defined as 90%. RESULTS: Individualized graduated RTS protocols should be used. A normal clinical, ocular and balance examination with no more headaches, and asymptomatic exertional test allows RTS. Earlier RTS can be considered if athletes are symptom free. The Sports Concussion Assessment Tool 5 and vestibular and ocular motor screening are recognized as useful tools to assist in decision-making. Ultimately RTS is a clinical decision. Baseline assessments should be performed at both collegiate and professional level and a combination of neurocognitive and clinical tests should be used. A specific number of recurrent concussions for season-or career-ending decisions could not be determined but will affect decision making for RTS. CONCLUSIONS: Consensus was achieved for 10 of the 25 RTS criteria: early RTS can be considered earlier than 48 to 72 hours if athletes are completely symptom-free with no headaches, a normal clinical, ocular and balance examination. A graduated RTS should be used but should be individualized. Only 2 of the 9 assessment tools were considered to be useful: Sports Concussion Assessment Tool 5 and vestibular and ocular motor screening. RTS is mainly a clinical decision. Only 31% of the baseline assessment items achieved consensus: baseline assessments should be performed at collegiate and professional levels using a combination of neurocognitive and clinical tests. The panel disagreed on the number of recurrent concussions that should be season- or career-ending. LEVEL OF EVIDENCE: Level V, expert Opinion.

Arthroscopic Simulation-Based Training of Orthopaedic Surgery Residents: Past, Present, and Future.

Simulation-based training is required by many medical specialties. Barriers, however, have prevented widespread implementation of simulators for arthroscopic training. The advantages of arthroscopic simulator-based training of residents include decreased errors, decreased cost of training, and improved patient care. Before an educational program can focus on the type of simulator, it is essential to have a validated curriculum and framework for how to use those simulators. One of the most validated systems is called proficiency-based progression training. Proficiency-based progression is essentially a paradigm in which basic skills must be mastered and demonstrated via objective evaluation, before moving on to more advanced skills. There are a variety of different validation methods and tools that have been described, with the Arthroscopic Surgical Skill Evaluation Tool being the most widely used tool. It is essential that any simulator has evidence and validation that it will ultimately improve surgical skills in the operating room. In the future, emerging technologies such as virtual reality, augmented reality, and three-dimensional printing will likely play a major role in the creation of newer simulators and may improve access to residents throughout the world.

Preparing for and Executing the Ideal Posterior Labral Repair.

Posterior labral tears are a source of pain and instability of the shoulder. Despite being relatively uncommon (reported in approximately 10% of instability cases), the incidence of posterior labral tear is increasingly recognized as underestimated in highly active populations. Posterior labral tears can result from a traumatic posterior dislocation or repetitive microtrauma, leading to posterior chondral/labral attrition. Patients often present with vague, deep-seated shoulder discomfort rather than the sensation of instability. Unfavorable results with nonsurgical management will indicate which patients will most benefit from surgery. Arthroscopic stabilization has proven to be an effective and reliable treatment, and many techniques for posterior labral repair have been described. It is important to highlight the evaluation, preparation, and execution of arthroscopic stabilization of an isolated posterior labral repair using high-strength knotless all-suture anchors to allow for a stable, efficient, reproducible, and reliable repair while maintaining a low-profile construct that minimizes damage to the surrounding tissue.

Reclassification of Adolescent Ambulatory Prehypertension and Unclassified Blood Pressures by 2022 American Heart Association Pediatric Ambulatory Blood Pressure Monitoring Guidelines.

OBJECTIVE: To describe the epidemiology of reclassification of prehypertensive and unclassified adolescents by 2022 American Heart Association pediatric ambulatory blood pressure monitoring (ABPM) guidelines, and to evaluate the association of the new diagnostic categories with left ventricular hypertrophy (LVH). STUDY DESIGN: A single-center, retrospective review of ABPM reports from adolescents 13-21 years old, from 2015 through 2022, was performed. Adolescents with prehypertension or unclassified by 2014 guidelines were reclassified by 2022 definitions. Logistic regression models evaluated the association of reclassification phenotypes with LVH. RESULTS: A majority of prehypertensive adolescents reclassified to hypertension (70%, n = 49/70). More than one-half (57%, n = 28/49) of the hypertension was isolated nocturnal hypertension, and 80% was systolic hypertension. Reclassification to hypertension was more common in males. The majority (55.6%) of unclassified adolescents were reclassified to normotension. No demographic or clinical variables were associated with reclassification categories. LVH was not associated with hypertension in the reclassified prehypertensive or unclassified groups. CONCLUSIONS: The 2022 ABPM guidelines clearly define blood pressure phenotypes. However, reclassification to hypertension was not associated with an increased odds of LVH. Because most prehypertensive adolescents reclassified as hypertensive by nighttime BPs alone, this study highlights the lowered threshold for nocturnal hypertension. Prospective studies in larger, well-defined cohorts are needed to describe better the predictive value of 2022 BP phenotypes for target organ damage.

A modified Delphi consensus statement on patellar instability: part I.

Aims: The aim of this study was to establish consensus statements on the diagnosis, nonoperative management, and indications, if any, for medial patellofemoral complex (MPFC) repair in patients with patellar instability, using the modified Delphi approach. Methods: A total of 60 surgeons from 11 countries were invited to develop consensus statements based on their expertise in this area. They were assigned to one of seven working groups defined by subtopics of interest within patellar instability. Consensus was defined as achieving between 80% and 89% agreement, strong consensus was defined as between 90% and 99% agreement, and 100% agreement was considered to be unanimous. Results: Of 27 questions and statements on patellar instability, three achieved unanimous consensus, 14 achieved strong consensus, five achieved consensus, and five did not achieve consensus. Conclusion: The statements that reached unanimous consensus were that an assessment of physeal status is critical for paediatric patients with patellar instability. There was also unanimous consensus on early mobilization and resistance training following nonoperative management once there is no apprehension. The statements that did not achieve consensus were on the importance of immobilization of the knee, the use of orthobiologics in nonoperative management, the indications for MPFC repair, and whether a vastus medialis oblique advancement should be performed.

A modified Delphi consensus statement on patellar instability: part II.

Aims: The aim of this study was to establish consensus statements on medial patellofemoral ligament (MPFL) reconstruction, anteromedialization tibial tubercle osteotomy, trochleoplasty, and rehabilitation and return to sporting activity in patients with patellar instability, using the modified Delphi process. Methods: This was the second part of a study dealing with these aspects of management in these patients. As in part I, a total of 60 surgeons from 11 countries contributed to the development of consensus statements based on their expertise in this area. They were assigned to one of seven working groups defined by subtopics of interest. Consensus was defined as achieving between 80% and 89% agreement, strong consensus was defined as between 90% and 99% agreement, and 100% agreement was considered unanimous. Results: Of 41 questions and statements on patellar instability, none achieved unanimous consensus, 19 achieved strong consensus, 15 achieved consensus, and seven did not achieve consensus. Conclusion: Most statements reached some degree of consensus, without any achieving unanimous consensus. There was no consensus on the use of anchors in MPFL reconstruction, and the order of fixation of the graft (patella first versus femur first). There was also no consensus on the indications for trochleoplasty or its effect on the viability of the cartilage after elevation of the osteochondral flap. There was also no consensus on postoperative immobilization or weightbearing, or whether paediatric patients should avoid an early return to sport.

Factors Associated With Humeral Avulsion of Glenohumeral Ligament Lesions in Patients With Anterior Shoulder Instability: An Analysis of the MOON Shoulder Instability Cohort.

Background: Humeral avulsion of the glenohumeral ligament (HAGL) lesions are an uncommon cause of anterior glenohumeral instability and may occur in isolation or combination with other pathologies. As HAGL lesions are difficult to detect via magnetic resonance imaging (MRI) and arthroscopy, they can remain unrecognized and result in continued glenohumeral instability. Purpose: To compare patients with anterior shoulder instability from a large multicenter cohort with and without a diagnosis of a HAGL lesion and identify preoperative physical examination findings, patient-reported outcomes, imaging findings, and surgical management trends associated with HAGL lesions. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Patients with anterior glenohumeral instability who underwent surgical management between 2012 and 2020 at 11 orthopaedic centers were enrolled. Patients with HAGL lesions identified intraoperatively were compared with patients without HAGL lesions. Preoperative characteristics, physical examinations, imaging findings, intraoperative findings, and surgical procedures were collected. The Student t test, Kruskal-Wallis H test, Fisher exact test, and chi-square test were used to compare groups. Results: A total of 21 HAGL lesions were identified in 915 (2.3%) patients; approximately one-third (28.6%) of all lesions were visualized intraoperatively but not identified on preoperative MRI. Baseline characteristics did not differ between study cohorts. Compared with non-HAGL patients, HAGL patients were less likely to have a Hill-Sachs lesion (54.7% vs 28.6%; P = .03) or an anterior labral tear (87.2% vs 66.7%; P = .01) on preoperative MRI and demonstrated increased external rotation when their affected arm was positioned at 90° of abduction (85° vs 90°; P = .03). Additionally, HAGL lesions were independently associated with an increased risk of undergoing an open stabilization surgery (odds ratio, 74.6 [95% CI, 25.2-221.1]; P < .001). Conclusion: Approximately one-third of HAGL lesions were missed on preoperative MRI. HAGL patients were less likely to exhibit preoperative imaging findings associated with anterior shoulder instability, such as Hill-Sachs lesions or anterior labral pathology. These patients underwent open procedures more frequently than patients without HAGL lesions.

Biomechanical Comparison of 3 Adjustable-Loop Suspensory Devices for All-Inside ACL Reconstruction: A Time-Zero Full-Construct Model.

Background: Little is known about the stability of adjustable-loop devices (ALDs) for anterior cruciate ligament (ACL) reconstruction (ACLR). Purpose: To evaluate the stabilization behavior of 3 different types of ALDs for all-inside ACLR in a full-construct surgical technique-based manner. Study Design: Controlled laboratory study. Methods: The femoral and tibial devices of Ultrabutton (Smith & Nephew), Infinity (Conmed), and TightRope II (Arthrex) were applied to quadrupled bovine tendon grafts (n = 8 each) with tibial-sided traction applied (350 N) for graft tensioning in a simulated fully extended knee. Knotless femoral graft fixation was based on either a suture-locking device (SLD; Ultrabutton), button-locking device (BLD; Infinity), or dual-locking device (DLD; TightRope II). All constructs were progressively loaded (50 N/500 cycles) from 50 to 300 N for 3000 cycles (0.75 Hz), including complete unloading situations and pull to failure (50 mm/min). Construct elongation, stiffness, and ultimate load were analyzed. Results: BLD showed significantly greater initial elongation (-2.69 ± 0.15 mm) than DLD (-3.19 ± 0.21 mm; P < .001) but behaved similarly to SLD (-2.93 ± 0.23 mm). While DLD and SLD had the smallest initial elongation at the same significance level, they behaved opposite to each other with gradually increasing peak loading. At the end of testing, DLD had the lowest (-0.64 ± 0.32 mm) and SLD the highest (3.41 ± 1.01 mm) total elongation (P < .003 for both). SLD displayed significantly higher dynamic elongation (6.34 ± 0.23 mm) than BLD (3.21 ± 0.61 mm) and DLD (2.56 ± 0.31 mm) (P < .001 for both). The failure load of BLD (865.0 ± 183.8 N) was significantly lower (P < .026) compared with SLD and DLD (>1000 N). The predominant failure mode was suture rupture and tibial bone breakage with button subsidence (SLD, n = 4). No significant difference in stiffness between constructs was found. Conclusion: While DLD successfully restricted critical construct elongation, BLD partially and SLD completely exceeded the clinical failure threshold (>3 mm) of plastic elongation with loop lengthening during increasing cyclic peak loading with complete unloading. Higher failure loads of SLD and DLD implants (>1000 N) were achieved at similar construct stiffness to BLD. Clinical Relevance: A detailed biomechanical understanding of the stabilization potential is pertinent to the continued evolution of ALDs to improve clinical outcomes.

Arthroscopic Repair and Reconstruction of Coracoclavicular Ligament.

Acromioclavicular joint separations are common shoulder injuries that require prompt recognition, diagnosis, and treatment. Deciding on a treatment algorithm relies on a detailed knowledge of anatomy and a thorough understanding of the specific functional demands of the patient in question. When a repair or reconstruction is indicated, arthroscopic assistance can be a helpful tool to ensure a safe, anatomic reconstruction that minimizes morbidity and maximizes the potential return to high-level function.