Classification of Distal Clavicle Fractures and Indications for Conservative Treatment.

Management of distal clavicle fractures depends on a clear understanding of the injury's proximity to the ligamentous attachments joining the clavicle and scapula. Various classification systems have been proposed to guide treatment. Despite this, controversy between operative and nonoperative management remains for certain fracture patterns. Patient-specific factors, concomitant injuries, fracture characteristics (displacement, shortening, and rotation) should all be considered when deciding on treatment. When nonoperative management is indicated, patients should be immobilized in a sling for 2 weeks, followed by gradual range of motion, and strengthening exercises.

Systematic Review of Injuries in the Men's and Women's National Basketball Association.

BACKGROUND: Numerous studies have reported the incidence and outcomes of injuries in the men's and women's National Basketball Association (NBA and WNBA, respectively). PURPOSE: To synthesize published data regarding the incidence and outcomes of all injuries in the NBA and WNBA in a comprehensive review. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we searched 3 electronic databases (PubMed, MEDLINE, Embase) for studies of all levels of evidence since 1990 pertaining to injuries sustained by active players in the NBA and WNBA. Studies were excluded if the cohort of interest included ≤3 active players. RESULTS: The initial search of the 3 databases yielded 1253 unique studies, of which 49 met final inclusion criteria for this review. Only 4 studies included athletes in the WNBA. Based on the mean annual incidence, the 5 most common orthopaedic sports injuries sustained in the NBA were concussions (9.5-14.9 per year), fractures of the hand (3.5-5.5 per year), lower extremity stress fractures (4.8 per year), meniscal tears (2.3-3.3 per year), and anterior cruciate ligament tears (1.5-2.6 per year). Cartilage defects treated using microfracture, Achilles tendon ruptures, and anterior cruciate ligament injuries were 3 injuries that led to significant reductions in performance measurements after injury. CONCLUSION: With advances in sports technology and statistical analysis, there is rapidly growing interest in injuries among professional basketball athletes. High-quality prospective studies are needed to understand the prevalence and effect of injuries on player performance and career length. This information can inform preventative and treatment measures taken by health care providers to protect players and guide safe return to play at a high level.

Racial Differences in Iliac Crest Cancellous Bone Composition: Implications for Preoperative Planning in Spinal Fusion Procedures.

STUDY DESIGN: This was a retrospective cohort study. OBJECTIVE: The objective of this study was to determine whether race, specifically American white and American black, correlates with the ratio of cancellous to total bone at the iliac crest. SUMMARY OF BACKGROUND DATA: Studies have demonstrated higher proximal femur bone density in American blacks than American whites. However, whether differences occur at the iliac crest, a common site for autologous graft material in spinal fusion surgery, is not well studied. Understanding such differences could aid orthopedic surgeon decision-making regarding graft options. MATERIALS AND METHODS: A retrospective review was performed on 133 sequential patients ages 18-75 who underwent computed tomography scan of the pelvis, at a single academic medical center from January 1, 2014, to January 1, 2016. The cohort included 46 American white (21 females, 25 males) and 87 American black participants (40 females, 37 males), an average age of 51.8 years. Groups were matched regarding age, sex, body mass index, and Charlson Comorbidity Score. Measurements of cortical and cancellous bone thickness in the right and left iliac crests were performed using bone window protocol on computed tomography scans. Statistical significance was determined using a 2-tailed t test. RESULTS: The interobserver interclass correlation coefficient reliability (N=2) for measurements at the right iliac crest is 0.895 (95% confidence interval, 0.852-0.925), and the interclass correlation coefficient for the left iliac crest is 0.912 (95% confidence interval, 0.877-0.938). A statistically significant difference in the mean cancellous bone ratio was found between American black (0.667±0.065) and American white (0.750±0.051) groups (P<0.001). CONCLUSIONS: At the iliac crest, American black patients had a lower mean ratio of cancellous to the total bone as compared with American white patients. This population may benefit from alternative graft options. While iliac crest autograft remains the first option for fusion surgeries, alternative options should be considered to ensure that each patient receives the best-personalized care.

Risk Factors Associated With Complications After Operative Treatment of Multiligament Knee Injury.

BACKGROUND: Many factors can affect clinical outcomes and complications after a complex multiligament knee injury (MLKI). Certain aspects of the treatment algorithm for MLKI, such as the timing of surgery, remain controversial. PURPOSE: To determine the risk factors for common complications after MLKI reconstruction. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: A retrospective review was conducted on 134 patients with MLKI who underwent reconstruction between 2011 and 2018 at a single academic center. Patients included in the review had a planned surgical reconstruction of >1 ligament based on clinical examination and magnetic resonance imaging. Complications were categorized as (1) wound infection requiring irrigation and debridement, (2) arthrofibrosis requiring manipulation under anesthesia and/or lysis of adhesions, (3) deep venous thrombosis, (4) need for removal of hardware, and (5) revision ligament surgery. The potential risk factors for complications included patient characteristics, injury pattern categorized according to Schenck classification (knee dislocation [KD] I-KD IV), and timing of surgery. Significant risk factors for complications were analyzed by t test, chi-square test, and Fisher exact test. RESULTS: A total of 108 patients met the inclusion criteria; of these, 29.6% experienced at least 1 complication. Smoking (odds ratio [OR], 3.20 [95% CI, 1.28-8.02]; P = .01) and planned staged surgery (OR, 2.71 [95% CI, 1.04-7.04]; P = .04) significantly increased the overall risk of complication, while increased time from injury to surgery (OR, 0.99 [95% CI, 0.98-0.998]; P < .01) significantly decreased the risk. Increasing time from injury to surgery (OR, 0.99 [95% CI, 0.97-0.998]; P = .02) also led to a slightly but significantly decreased risk for arthrofibrosis. CONCLUSION: The study findings suggest that smoking, decreased time from injury to initial surgery, and planned staged procedures may increase the rate of complications. Further studies are needed to determine which changes in the treatment algorithm are most effective to reduce the complication rate in patients.

Augmentation of Anatomic Anterior Cruciate Ligament Reconstruction With Lateral Extra-articular Tenodesis Does Not Significantly Affect Rotatory Knee Laxity: A Time Zero, In Vivo Kinematic Analysis.

BACKGROUND: The pivot-shift test is used to assess for rotatory knee laxity in the anterior cruciate ligament (ACL)-deficient knee and ACL-reconstructed knee; however, the pivot shift uses a subjective grading system that is limited by variability between examiners. Consequently, quantified pivot shift (QPS) test software (PIVOT iPad application) has been developed and validated to measure the magnitude of rotatory knee laxity during the positive pivot-shift test. PURPOSE: To employ intraoperative QPS (iQPS) to assess for differences in residual rotatory knee laxity after ACL reconstruction (ACLR) versus ACLR augmented with lateral extra-articular tenodesis (ACLR + LET), and to employ iQPS to determine if ACLR and/or ACLR + LET result in overconstrained knee kinematics when compared with the contralateral knee. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: iQPS was performed in 20 patients by a single surgeon on both the operative and contralateral knees before ACLR. ACLR was augmented with a LET if the lateral compartment tibial translation measured during QPS was greater than or equal to double the amount of lateral tibial compartment translation measured for the contralateral knee. After each reconstruction (ACLR or ACLR + LET), iQPS measurements were performed. iQPS data were compared with the preoperative QPS measurements of the operative and contralateral knees. Postoperative iQPS data were compared with both the preoperative QPS measurements of the operative and contralateral knees with paired samples t tests. Categorical variables were compared using the Fisher exact test. RESULTS: The mean age in the cohort was 17.3 years (range, 15-24 years). There were no significant differences between the groups in terms of the proportion of male patients (ACLR: 5 male, 5 female vs ACLR + LET: 4 male, 6 female) or age (ACLR: 17.7 ± 3.3 years; 95% CI, 15.4-24.0 vs ACLR + LET: 16.8 ± 2.8 years, 95% CI, 14.8-22.0; P = .999). There were no significant differences between the groups with respect to preoperative QPS performed during examination under anesthesia (ACLR: 4.7 ± 2.0 mm; 95% CI, 3.3-6.1 vs ACLR + LET: 3.6 ± 1.8 mm; 95% CI, 2.3-4.9; P = .2). Both ACLR and ACLR + LET resulted in significant decreases in rotatory knee laxity when compared with preoperative QPS measurements (ACLR: -3.4 ± 1.7 mm; 95% CI, -4.6 to -2.2; P < .001: ACLR + LET: -2.6 ± 1.9 mm; 95% CI, -3.9 to -1.3; P < .002). Moreover, when compared with isolated ACLR, ACLR + LET did not result in a significantly smaller magnitude of change in iQPS between the pre- and postoperative states (P = .3). CONCLUSION: Both ACLR and ACLR + LET resulted in significant decreases in rotatory knee laxity. The augmentation of ACLR with LET did not change the constraint of the knee with respect to lateral compartment translation as measured during iQPS.

Patient-Reported and Quantitative Outcomes of Anatomic Anterior Cruciate Ligament Reconstruction With Hamstring Tendon Autografts.

BACKGROUND: The pivot-shift test has become more consistent and reliable and is a meaningful outcome measurement after anterior cruciate ligament reconstruction (ACLR). PURPOSE/HYPOTHESIS: The purpose of this investigation was to assess patient-reported outcomes (PROs) and the quantitative pivot shift (QPS) preoperatively, at time zero immediately after anatomic ACLR, and after 24 months as well as the relationship between PROs and the QPS. It was hypothesized that anatomic ACLR would restore rotatory stability measured by the pivot-shift test and that QPS measurements would be positively correlated with PROs. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: The ACL-injured and contralateral uninjured knees from 89 of 107 (83.2%) enrolled patients at 4 international centers were evaluated using a standardized pivot-shift test. Tibial acceleration was assessed with an inertial sensor, and lateral compartment translation was measured using an image analysis system preoperatively, at time zero immediately postoperatively, and at follow-up after 2 years. PROs were assessed at 12 and 24 months postoperatively with the International Knee Documentation Committee (IKDC) subjective knee form, Cincinnati Knee Rating System (CKRS), Marx activity rating scale, and activity of daily living score (ADLS). RESULTS: The mean patient age at surgery was 27 years (range, 15-45 years). A positive pivot shift preoperatively (side-to-side difference in tibial acceleration, 2.6 ± 4.0 m/s2; side-to-side difference in anterior tibial translation, 2.0 ± 2.0 mm) was reduced at time zero postoperatively (side-to-side difference in tibial acceleration, -0.5 ± 1.3 m/s2; side-to-side difference in anterior tibial translation, -0.1 ± 1.0 mm). All PROs improved from preoperatively to final follow-up at 24 months: from 56.5 to 85.5 points for the IKDC (P = .0001), from 28.8 to 32.4 points for the CKRS (P = .04), from 11.2 to 7.9 points for the Marx (P < .0001), and from 75.7 to 91.6 points for the ADLS (P < .0001). Neither preoperative nor time zero postoperative rotatory laxity assessed by the pivot-shift test correlated with PROs at 24-month follow-up. A graft retear was observed in 4 patients (4.5%) within 2 years of follow-up. CONCLUSION: Anatomic ACLR resulted in significantly improved and acceptable PROs at 2-year follow-up and a low failure rate. Anatomic ACLR restored QPS measurements of anterior tibial translation and tibial acceleration to those of the contralateral knee immediately after surgery while still under anesthesia, but there was no correlation between the QPS preoperatively or at time zero after ACLR and PROs at 2-year follow-up.

Intercondylar Notch Size Can Be Predicted on Preoperative Magnetic Resonance Imaging.

PURPOSE: To develop a standardized method of intercondylar notch measurement on preoperative radiographs and magnetic resonance imaging (MRI) and validate that it could predict intraoperative notch measurements. METHODS: The charts and imaging of 50 patients undergoing anterior cruciate ligament reconstruction were reviewed. A standardized method of intercondylar notch measurement on radiographs and MRI was used by 3 blinded reviewers. Arthroscopic measurements were made by the surgeon who was blinded to the imaging measurements. Interrater reliability was determined between reviewers and between imaging and arthroscopic measurements using interclass correlation coefficients (r). RESULTS: The average notch base width was 16.5 (± 2.7) mm on MRI, 19.0 (± 3.4) mm on radiographs, and 15.8 (± 3.0) mm on arthroscopic measurement. The radiographic notch base width measurements were on average 1.2 times greater than the arthroscopic measurements. There was no significant difference between males and females in notch base width (16.7 mm vs 15.3 mm, P = .19) or area (312.5 mm2 vs 284.3 mm2, P = .17). Interrater reliability was excellent between the reviewers for notch base width measurement on both MRI (r = 0.91) and radiographs (r = 0.95). Good-to-excellent interrater reliability between notch base width measurements on MRI and arthroscopy (r = 0.78, 0.73, 0.7) and fair-to-good interrater reliability between notch base width measurements on radiographs and arthroscopy were found (r = 0.61, 0.58, 0.55). CONCLUSIONS: This study introduces a reliable method of using preoperative MRI to predict intercondylar notch width during arthroscopy. This data can be used to identify patients with narrow notches preoperatively. LEVEL OF EVIDENCE: Level III, diagnostic study.

Systematic Review of Outcomes Following 10-Year Mark of Spine Patient Outcomes Research Trial (SPORT) for Degenerative Spondylolisthesis.

STUDY DESIGN: We performed a comprehensive search of PubMed, MEDLINE, and EMBASE for all English language studies of all levels of evidence pertaining to Spine Patient Outcomes Research Trial (SPORT), in accordance with Preferred Reported Items for Systematic Reviews and Meta-analyses guidelines. OBJECTIVE: We aim to summarize the 10-year clinical outcomes of SPORT and its numerous follow-up studies for degenerative spondylolisthesis. SUMMARY OF BACKGROUND DATA: The SPORT was a landmark randomized control trial including approximately 2500 patients at 13 clinics across the country. SPORT compared surgical and nonoperative management of the three most common spinal pathologies. METHODS: Keywords used in the literature search included SPORT, spine patient outcomes research trial, degenerative spondylolisthesis, and surgical outcomes. RESULTS: The intent-to-treat analysis failed to show a significant difference between patients treated surgically as compared to those treated nonoperatively. However, as-treated analysis revealed statically greater improvements at 6 weeks, 2 years, and 4 years in patients treated surgically. Secondary outcomes such as low back pain, leg pain, stenosis bothersome scales, overall satisfaction with current symptoms, and self-rated progress were also significantly improved in surgical patients. Regardless of the initial grade of listhesis, disk height, or mobility, patients who had surgical treatment improved more in terms of Oswestry Disability Index, bodily pain, physical function, and low back pain bothersomeness scales. Risk of reoperation increased with age, having two or three moderate or severe stenotic levels, pain predominantly localized to the back, no physical therapy, the absence of neurogenic claudication, and greater leg pain scores. Risk of reoperation was not significantly affected by type of surgery performed, smoking, diabetes, obesity, longer duration of symptoms, or workman's compensation. CONCLUSION: Although intent-to-treat analysis failed to show significant differences in patients treated surgically, results of the as-treated analysis determined statically greater improvements in those patients with spondylolisthesis who were treated surgically as compared to those treated nonoperatively. LEVEL OF EVIDENCE: 2.

Systematic Review of Outcomes Following 10-Year Mark of Spine Patient Outcomes Research Trial for Intervertebral Disc Herniation.

MINI: We summarized the 10-year outcomes of Spine Patient Outcomes Research Trial for intervertebral disc herniation through a systematic review. The observational cohort 2-year analysis and the as-treated analysis of the randomized control trial at 4 and 8 years showed statistically greater improvements in those patients who were treated surgically. STUDY DESIGN: We performed a comprehensive search of Pubmed, MEDLINE, and EMBASE for English-language studies of all levels of evidence pertaining to SPORT, in accordance with Preferred Reported Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. OBJECTIVE: We aim to summarize the 10-year clinical outcomes of SPORT and its numerous follow-up studies for intervertebral disc herniation. SUMMARY OF BACKGROUND DATA: The Spine Patient Outcomes Research Trial (SPORT) was a landmark study. SPORT compared surgical and nonoperative management of the three most common spinal pathologies. METHODS: Keywords utilized included: SPORT, spine patient outcomes research trial, disc herniation, and surgical outcomes. RESULTS: The observational cohort analysis revealed statically greater improvement in primary outcomes at 3 months and 2 years in patients who had surgery, while analysis of the randomized control trial cohort failed to show a significant difference based on the intent-to-treat principle due to significant patient crossover. However, 4 year and 8 year as-treated analysis showed statistically greater improvements in those patients who were treated surgically. SPORT's subgroup analysis evaluated important factors when considering the treatment of IDH, including patient characteristics, level of herniation, duration of symptoms, recurrence of pain, presence of retrolistheiss, patient functional status, effects of previous treatment with epidural steroid injections and opioid medication, outcomes after incidental durotomy, MRI reader reliability, reoperation rates, and risk factors for reoperation. The clinical impact of SPORT was also investigated and included comparison of SPORT patients to NSQIP patients to determine generalizability, outcome differences in SPORT's surgical center sites, patient preferences, patient expectations, level of education, and effects of watching an evidence-based video. CONCLUSION: Ten years after its inception, SPORT has made strides in standardization and optimization of treatment for spinal pathologies. SPORT has provided clinicians with insight about outcomes of surgical and nonoperative treatment of IDH. Results showed significantly greater improvements in patients treated surgically. LEVEL OF EVIDENCE: 3.

We performed a comprehensive search of Pubmed, MEDLINE, and EMBASE for English-language studies of all levels of evidence pertaining to SPORT, in accordance with Preferred Reported Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. We aim to summarize the 10-year clinical outcomes of SPORT and its numerous follow-up studies for intervertebral disc herniation. The Spine Patient Outcomes Research Trial (SPORT) was a landmark study. SPORT compared surgical and nonoperative management of the three most common spinal pathologies. Keywords utilized included: SPORT, spine patient outcomes research trial, disc herniation, and surgical outcomes. The observational cohort analysis revealed statically greater improvement in primary outcomes at 3 months and 2 years in patients who had surgery, while analysis of the randomized control trial cohort failed to show a significant difference based on the intent-to-treat principle due to significant patient crossover. However, 4 year and 8 year as-treated analysis showed statistically greater improvements in those patients who were treated surgically. SPORT's subgroup analysis evaluated important factors when considering the treatment of IDH, including patient characteristics, level of herniation, duration of symptoms, recurrence of pain, presence of retrolistheiss, patient functional status, effects of previous treatment with epidural steroid injections and opioid medication, outcomes after incidental durotomy, MRI reader reliability, reoperation rates, and risk factors for reoperation. The clinical impact of SPORT was also investigated and included comparison of SPORT patients to NSQIP patients to determine generalizability, outcome differences in SPORT's surgical center sites, patient preferences, patient expectations, level of education, and effects of watching an evidence-based video. Ten years after its inception, SPORT has made strides in standardization and optimization of treatment for spinal pathologies. SPORT has provided clinicians with insight about outcomes of surgical and nonoperative treatment of IDH. Results showed significantly greater improvements in patients treated surgically. Level of Evidence: 3.

Partial Lateral Meniscectomy Affects Knee Stability Even in Anterior Cruciate Ligament-Intact Knees.

BACKGROUND: The effects of a partial lateral meniscectomy on knee kinematics and forces in the lateral meniscus are critical to understand. The purpose of this study was to quantify the effects of varying sizes of partial lateral meniscectomies of the posterior horn and a total lateral meniscectomy on knee kinematics and resultant forces in the lateral meniscus. METHODS: Using a robotic testing system, loads (134-N anterior tibial load + 200-N axial compression, 5-Nm internal tibial torque + 5-Nm valgus torque, and 5-Nm external tibial torque + 5-Nm valgus torque) were applied to 10 fresh-frozen cadaveric knees. The resulting joint motion and resultant forces in the lateral meniscus were determined for 4 knee states: intact, one-third and two-thirds partial lateral meniscectomies of the posterior horn, and total lateral meniscectomy. RESULTS: A decrease in lateral translation of the tibia (up to 166.7%) was observed after one-third partial lateral meniscectomies of the posterior horn compared with the intact knee, in response to an anterior load at all knee flexion angles tested (p < 0.05). One-third partial lateral meniscectomies of the posterior horn decreased the resultant forces in the lateral meniscus compared with the intact knee at all knee flexion angles tested in response to an anterior load (p < 0.05) and to an internal tibial torque (p < 0.05). The results of two-thirds partial lateral meniscectomies of the posterior horn were similar to those of one-third partial meniscectomies (p > 0.05). Total lateral meniscectomies further decreased the lateral translation of the tibia (up to 316.6%) compared with the intact knee in response to an anterior load (p < 0.05). CONCLUSIONS: The changes in joint motion and meniscal forces observed in this study after even small partial lateral meniscectomies may predispose knees to further injury. CLINICAL RELEVANCE: Surgeons should always consider repairing and minimizing the resection of even small lateral meniscal tears to prevent the potential deleterious effects of partial meniscectomy reported in this cadaveric study.

Obesity Is Associated with Significant Morbidity after Multiligament Knee Surgery.

The objective was to report the effect of obesity, utilizing a body mass index (BMI) threshold of 35 kg/m2, on outcomes and complications of multiple ligament knee injury (MLKI). It was hypothesized that obese patients would have longer intraoperative times and hospital length of stay, greater estimated blood loss, and higher rates of wound infection requiring irrigation and debridement (I&D) and revision ligament surgery. A retrospective review was performed on 143 individuals who underwent surgery for an MLKI between 2011 and 2018 at a single academic center. Patients were included if there was a plan for potential surgical repair/reconstruction of two or more ligaments. Patients with prior surgery to the affected knee or intra-articular fracture requiring reduction and fixation were excluded. Comparisons between obese and nonobese patients were made using two-sample t-test and either chi-square or Fisher's exact test for continuous and categorical variables, respectively. Significance was set at p < 0.05. Of 108 patients meeting inclusion criteria, 83 had BMI < 35 kg/m2 and 25 had BMI ≥ 35 kg/m2. Obese patients sustained higher rates of MLKI due to ultralow velocity mechanisms (28.0 vs. 1.2%; p = 0.0001) and higher rates of concomitant lateral meniscus injury (48.0 vs. 25.3%; p = 0.04). Among patients undergoing single-staged surgery, obese patients had significantly longer duration of surgery (219.8 vs. 178.6 minutes; p = 0.02) and more wound infections requiring I&D (20.0 vs. 4.8%; p = 0.03). In contrast, nonobese patients had higher rates of arthrofibrosis requiring manipulation under anesthesia and/or arthrolysis (25.3 vs. 0%; p = 0.003). Obese patients undergoing surgery of an MLKI have longer operative times, greater rates of wound infection requiring I&D, and lower rates of arthrofibrosis. Surgeons may consider these results when counseling patients on their postoperative course and risk for complications. Future research might focus on strategies to reduce complication rates in obese patients with MLKI. This is a Level III, retrospective comparative study.

Systematic Review of Outcomes Following 10-year Mark of Spine Patient Outcomes Research Trial (SPORT) for Spinal Stenosis.

STUDY DESIGN: We performed a comprehensive search of Pubmed, MEDLINE, and EMBASE for all English-language studies of all levels of evidence pertaining to SPORT, in accordance with Preferred Reported Items for Systematic Reviews and Meta-analayses (PRISMA) guidelines. OBJECTIVE: We aim to summarize the 10-year clinical outcomes of SPORT and its numerous follow-up studies for spinal stenosis. SUMMARY OF BACKGROUND DATA: The Spine Patient Outcomes Research Trial (SPORT) was a landmark randomized control trial including approximately 2,500 patients at 13 clinics across the country. SPORT compared surgical and nonoperative management of the three most common spinal pathologies. METHODS: Keywords utilized in the literature search included: SPORT, spine patient outcomes research trial, spinal stenosis, and surgical outcomes. RESULTS: Surgical intervention showed significantly greater improvement in pain and physical function scales from 6 weeks through 4 years. However, between 4 and 8 years, the difference between the two groups diminished, and the benefits in both groups stabilized. Secondary factors investigated showed that smoking was a confounding variable for treatment benefits and a positive sedimentation sign correlated with a greater surgical treatment effect. Obese patients were found to have higher rates of infection and reoperation and less improvement from baseline function. Risk factors for reoperation included duration of pretreatment symptoms for longer than 12 months, increased age, multiple levels of stenosis, predominant back pain, no physical therapy, greater leg pain, the use of antidepressants and no neurogenic claudication upon enrollment. CONCLUSION: Ten years after its inception, SPORT has made strides in standardization and optimization of treatment for spinal pathologies. SPORT has provided clinicians with insight about outcomes of surgical and nonoperative treatment of spinal stenosis. Results showed significantly greater improvement through 4 year follow up in those patients that received surgical treatment, however the difference between the surgical and nonsurgical groups diminished at 8 year follow up. LEVEL OF EVIDENCE: 3.

Rotatory Knee Laxity Exists on a Continuum in Anterior Cruciate Ligament Injury.

BACKGROUND: The purpose of this investigation was to compare the magnitude of rotatory knee laxity in patients with a partial anterior cruciate ligament (ACL) tear, those with a complete ACL tear, and those who had undergone a failed ACL reconstruction. It was hypothesized that rotatory knee laxity would increase with increasing injury grade, with knees with partial ACL tears demonstrating the lowest rotatory laxity and knees that had undergone failed ACL reconstruction demonstrating the highest rotatory laxity. METHODS: A prospective multicenter study cohort of 354 patients who had undergone ACL reconstruction between 2012 and 2018 was examined. All patients had both injured and contralateral healthy knees evaluated using standardized, preoperative quantitative pivot shift testing, determined by a validated, image-based tablet software application and a surface-mounted accelerometer. Quantitative pivot shift was compared with the contralateral healthy knee in 20 patients with partial ACL tears, 257 patients with complete ACL tears, and 27 patients who had undergone a failed ACL reconstruction. Comparisons were made using 1-way analysis of variance (ANOVA) with post hoc 2-sample t tests with Bonferroni correction. Significance was set at p < 0.05. RESULTS: There were stepwise increases in side-to-side differences in quantitative pivot shift in terms of lateral knee compartment translation for patients with partial ACL tears (mean [and standard deviation], 1.4 ± 1.5 mm), those with complete ACL tears (2.5 ± 2.1 mm), and those who had undergone failed ACL reconstruction (3.3 ± 1.9 mm) (p = 0.01) and increases in terms of lateral compartment acceleration for patients with partial ACL tears (0.7 ± 1.4 m/s), those with complete ACL tears (2.3 ± 3.1 m/s), and those who had undergone failed ACL reconstruction (2.4 ± 5.5 m/s) (p = 0.01). A significant difference in lateral knee compartment translation was found when comparing patients with partial ACL tears and those with complete ACL tears (1.2 ± 2.1 mm [95% confidence interval (CI), 0.2 to 2.1 mm]; p = 0.02) and patients with partial ACL tears and those who had undergone failed ACL reconstruction (1.9 ± 1.7 mm [95% CI, 0.8 to 2.9 mm]; p = 0.001), but not when comparing patients with complete ACL tears and those who had undergone failed ACL reconstruction (0.8 ± 2.1 [95% CI, -0.1 to 1.6 mm]; p = 0.09). Increased lateral compartment acceleration was found when comparing patients with partial ACL tears and those with complete ACL tears (1.5 ± 3.0 m/s [95% CI, 0.8 to 2.3 m/s]; p = 0.0002), but not when comparing patients with complete ACL tears and those who had undergone failed ACL reconstruction (0.1 ± 3.4 m/s [95% CI, -2.2 to 2.4 m/s]; p = 0.93) or patients with partial ACL tears and those who had undergone failed ACL reconstruction (1.7 ± 4.2 m/s [95% CI, -0.7 to 4.0 m/s]; p = 0.16). An increasing lateral compartment translation of the contralateral, ACL-healthy knee was found in patients with partial ACL tears (0.8 mm), those with complete ACL tears (1.2 mm), and those who had undergone failed ACL reconstruction (1.7 mm) (p < 0.05). CONCLUSIONS: A progressive increase in rotatory knee laxity, defined by side-to-side differences in quantitative pivot shift, was observed in patients with partial ACL tears, those with complete ACL tears, and those who had undergone failed ACL reconstruction. These results may be helpful when assessing outcomes and considering indications for the management of high-grade rotatory knee laxity. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Lateral Meniscal Allograft Transplantation With Bone Block and Suture-Only Techniques Partially Restores Knee Kinematics and Forces.

BACKGROUND: The ability of lateral meniscal allograft transplantation (MAT) to improve knee stability and the meniscal load-bearing function in patients after meniscectomy is critical for surgical success. PURPOSE: To compare the effects of 2 lateral MAT fixation techniques-bone block and suture only-on knee kinematics and forces. STUDY DESIGN: Controlled laboratory study. METHODS: With a robotic testing system, loads were applied during flexion on 10 fresh-frozen cadaveric knees: 134-N anterior tibial load + 200-N axial compression, 5-N·m internal tibial + 5-N·m valgus torques, and 5-N·m external tibial + 5-N·m valgus torques. Kinematic data were recorded for 4 knee states: intact, total lateral meniscectomy, lateral MAT bone block, and lateral MAT suture-only fixation. In situ force in the anterior cruciate ligament and resultant forces in the lateral meniscus and in the meniscal allograft were quantified via the principle of superposition. A repeated measures analysis of variance was used to analyze variations in kinematics and forces at 0°, 30°, 60°, and 90° of knee flexion. Significance was set at P < .05. RESULTS: When anterior loads were applied, a decrease in medial translation of the tibia that was increased after total lateral meniscectomy was observed at 30°, 60°, and 90° of knee flexion for both the lateral MAT bone block (54.2%, 48.0%, and 50.0%) and the MAT suture-only (50.0%, 40.0%, and 34.6%) fixation techniques (P < .05). Yet, most of the increases in knee kinematics after lateral meniscectomy were not significantly reduced by either lateral MAT technique (P > .05 for each MAT technique vs the total lateral meniscectomy state). Resultant forces in the meniscal allograft were 50% to 60% of the resultant forces in the intact lateral meniscus in response to all loading conditions at all flexion angles (P < .05). Overall, no significant differences between lateral MAT techniques were observed regarding kinematics and forces (P > .05). CONCLUSION: Lateral MAT partially restored medial translation of the tibia, and the resultant forces in the meniscal allograft were only 50% to 60% of the intact lateral meniscus forces in the cadaver model. In the majority of testing conditions, no significant changes of the in situ force in the anterior cruciate ligament were observed. Surgeons should consider the potential benefits of lateral MAT when deciding the appropriate treatment for symptomatic patients after lateral meniscectomies. Both lateral MAT techniques functioned similarly. CLINICAL RELEVANCE: The load-bearing function of the meniscal allograft observed in this study may be beneficial in ameliorating the short- and long-term disability associated with lateral meniscal deficiency.

Labral Repair Versus Biceps Tenodesis for Primary Surgical Management of Type II Superior Labrum Anterior to Posterior Tears: A Systematic Review.

PURPOSE: To examine the outcomes of SLAP repair versus biceps tenodesis (BT) for the index treatment of isolated type II SLAP tears. METHODS: A search of PubMed, MEDLINE, and EMBASE was performed in April 2018 for English-language studies that presented outcomes data on patients with isolated type II SLAP tears treated with either SLAP repair or BT at the primary surgical time point. RESULTS: Twenty-three studies (i.e., 2 randomized control trials, 7 retrospective cohort, 3 prospective cohort, 4 case-control, and 7 case series) were included. Isolated type II SLAP tears were treated via SLAP repair in 781 patients with a mean age of 35 years (range, 22-58 years) and a mean postoperative follow-up of 35 months (range, 3-63 months). BT was performed in 100 patients with a mean age of 44 years (range, 18-64 years) and a mean postoperative follow-up of 32 months (range, 24-75 months). Similar postoperative scores were noted in both the SLAP repair and BT groups for American Shoulder and Elbow Surgeons, Constant, University of California, Los Angeles, and visual analog scale pain scores. The rate of return to sports was 20% to 95% for SLAP repair and 73% to 100% for BT. Reoperation rates for SLAP repair and BT were 2.9% to 40% and 0% to 15.3%, respectively. CONCLUSIONS: This study suggests that SLAP repair and BT are both acceptable as index treatment for isolated type II SLAP tears. SLAP repair remains the most commonly performed index procedure; however, BT appears equally efficacious and may represent an attractive alternative. LEVEL OF EVIDENCE: Level IV, systematic review of Level I through IV studies.

Long-Term Survival Analysis and Outcomes of Meniscal Allograft Transplantation With Minimum 10-Year Follow-Up: A Systematic Review.

PURPOSE: To investigate the long-term survivorship rates and functional outcomes of meniscal allograft transplantation (MAT) in patients with minimum 10-year postoperative follow-up. METHODS: Two reviewers independently searched EMBASE, MEDLINE, and PubMed from database inception for literature related to MAT according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Data are reported in a narrative summary fashion with descriptive statistics. RESULTS: Eleven studies with a total of 658 patients and 688 MATs were included. Mean age of patients was 33.1 years (range 14-66), of whom 63% were male. Mean survivorship rates were 73.5% at 10-year and 60.3% at 15-year follow-up, with 2 studies reporting 19- and 24-year survivorship of 50% and 15.1%, respectively. Pre- and postoperative Lysholm scores ranged from 36 to 60.5 and 61 to 75, respectively. Pre- and postoperative Tegner scores ranged from 1 to 3 and 2.5 to 4.6, respectively. Postoperative Knee injury and Osteoarthritis Outcome Score subset scores were as follows: Pain: 61.6 to 76.3; Symptoms: 57.9 to 61.8; Function in Daily Living: 68.5 to 79.9; Sport and Recreation: 33.9 to 49.3; Quality of Life: 37.3 to 45.9. Postoperative International Knee Documentation Committee scores ranged from 46 to 77. Regarding surgical technique, 194 MAT bone-fixation technique (53.8%) and 165 MAT suture-only fixation techniques (46.2%) were reported. The most common type of allograft used was cryopreserved (54.5% of the allografts). The most frequent concomitant procedures performed with MAT were to address chondral (20.8% of the cases) and ligament injuries (12.4% of the cases), and realignment procedures (9.4% of the cases). The most common complications observed that were not directly related to concomitant procedures were meniscal allograft partial tears (11.1%), arthrofibrosis (3.6%), and infection (2.0%). Several criteria were used among studies to define failure of MAT, the most common parameters being removal of meniscal allograft (8/11 studies) and conversion to total knee arthroplasty (7/11 studies). CONCLUSIONS: MAT can yield good long-term survivorship rates, with 73.5% and 60.3% of allografts remaining functional after 10 and 15 years, respectively. Functional outcomes 10 years after MAT were fair and improved compared with preoperative scores. LEVEL OF EVIDENCE: Level IV, systematic review of Level III and IV studies.

Comparative Efficacy and Safety of Nonsurgical Treatment Options for Enthesopathy of the Extensor Carpi Radialis Brevis: A Systematic Review and Meta-analysis of Randomized Placebo-Controlled Trials.

BACKGROUND: Numerous treatment options have been proposed for enthesopathy of the extensor carpi radialis brevis (eECRB). PURPOSE: To (1) compare the efficacy and safety of nonsurgical treatment options for eECRB described in randomized placebo-controlled trials at short-term, midterm, and long-term follow-up and (2) evaluate outcomes in patients receiving placebo. STUDY DESIGN: Systematic review and meta-analysis. METHODS: Following PRISMA guidelines, 4 electronic databases were searched for randomized placebo-controlled trials for eECRB. Studies reporting visual analog scale (VAS) for pain scores and/or grip strength were included. Random- or fixed-effects meta-analysis was employed to compare treatments with at least 2 eligible studies using the standardized mean difference and odds ratio. The study protocol was registered at PROSPERO (ID: CRD42018075009). RESULTS: Thirty-six randomized placebo-controlled trials, evaluating 11 different treatment modalities, with a total of 2746 patients were included. At short-term follow-up, only local corticosteroid injection improved pain; however, it was associated with pain worse than placebo at long-term follow-up. At midterm follow-up, laser therapy and local botulinum toxin injection improved pain. At long-term follow-up, extracorporeal shock wave therapy provided pain relief. With regard to grip strength, only laser therapy showed better outcomes in comparison with placebo. While there was no difference among various treatments in the odds ratio of an adverse event, they all increased adverse events compared with placebo. In placebo-receiving patients, a sharp increase in the percentage of patients reporting mild pain or less was observed from 2% at short-term follow-up to 92% at midterm follow-up. CONCLUSION: Most patients experienced pain resolution after receiving placebo within 4 weeks of follow-up. At best, all treatments provided only small pain relief while increasing the odds of adverse events. Therefore, if clinicians are inclined to provide a treatment for particular patients, they may consider a pain relief regimen for the first 4 weeks of symptom duration. Patient-specific factors should be considered when deciding on treatment or watchful waiting.

Static Lateral Tibial Plateau Subluxation Predicts High-Grade Rotatory Knee Laxity in Anterior Cruciate Ligament-Deficient Knees.

BACKGROUND: In anterior cruciate ligament-deficient (ACL-D) knees, injury pattern and bony morphologic features have been shown to influence both static anterior tibial subluxation relative to the femur and dynamic rotatory knee laxity. Therefore, the relationship between static anterior tibial subluxation and dynamic rotatory knee laxity was investigated. PURPOSE: To determine whether static tibial subluxation as measured on magnetic resonance imaging (MRI) is associated with the grade of rotatory knee laxity in ACL-D knees. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Two-hundred fifty-eight knees underwent preoperative, image-guided assessment of lateral knee compartment translation during quantitative pivot shift (QPS). Subluxations of the medial and lateral tibial plateaus were measured on preoperative MRI in a subset of primary ACL-D knees meeting criteria for high-grade (QPS > 5.2 mm) and low-grade (QPS < 2.4 mm) rotatory laxity. Tibial subluxations on MRI were compared between patients with high- and low-grade rotatory laxity through use of pairwise t test and were analyzed via univariate and multivariate logistic regression. Significance was set at P < .05. RESULTS: On MRI, greater anterior subluxation of the lateral tibial plateau was observed in patients with high-grade compared with low-grade rotatory knee laxity (4.5 mm vs 2.3 mm; P < .05). No similar relationship was observed for the medial tibial plateau (-0.9 mm vs -0.4 mm; P > .05). Univariate logistic regression demonstrated that static subluxation of the lateral tibial plateau was associated with high-grade rotatory knee laxity (odds ratio [OR], 1.2; P < .05). An optimal cutoff of 2.95 mm of static lateral tibial subluxation was associated with high-grade rotatory knee laxity (sensitivity, 75%; specificity, 63%). Lateral meniscal injury was the first variable entered into a multivariate regression analysis and proved to be most associated with high-grade rotatory knee laxity (OR, 6.8; P < .05). When lateral meniscal injury was excluded from multivariate regression analysis, static anterior subluxation of the lateral tibial plateau alone was associated with high-grade rotatory knee laxity (OR, 1.2; P < .05). CONCLUSION: Data from this MRI study of two distinct rotatory knee laxity groups showed that static anterior subluxation of the lateral tibial plateau of 2.95 mm or greater was associated with high-grade rotatory knee laxity, and each millimeter increase of lateral tibial plateau subluxation was associated with a 1.2-fold odds of high-grade rotatory knee laxity. Anterior subluxation of the lateral tibial plateau on MRI was not independently associated with high-grade rotatory knee laxity in the presence of concomitant lateral meniscal injury. Static measurements made preoperatively may aid in predicting high-grade rotatory knee laxity and refining the indications for individualized knee surgery.

Intercondylar Notch Measurement During Arthroscopy and on Preoperative Magnetic Resonance Imaging.

Small intercondylar notch size is associated with increased risk of anterior cruciate ligament (ACL) injuries and increased difficulty of ACL reconstruction. When encountering a small notch during surgery, some surgeons may resort to a notchplasty, which has been shown to have associated morbidity. The ability to predict notch size on preoperative imaging could allow the orthopaedic surgeon to anticipate surgical difficulty such as an oversized graft and graft impingement and possibly avoid a notchplasty. Many methods have been proposed for measuring intercondylar notch size, but they do not correlate with intraoperative measurements or they utilize computed tomography scanning, which is not readily obtained before ACL reconstruction. The purpose of this study was to develop a method of notch measurement on preoperative radiography and magnetic resonance imaging that match intraoperative arthroscopic measurements. The method presented here can be used to identify narrow intercondylar notches, prepare for potential intraoperative challenges, and formulate surgical plans such as for graft choice in individualized ACL reconstruction.