Editorial Commentary: Suture-Button Fixation May Have Advantages Over Screw Fixation for Glenoid Bone Grafting Procedures for Shoulder Instability.

Orthopaedic suture buttons have been increasingly used in a variety of procedures, such as syndesmosis stabilization, coracoclavicular ligament repair, anterior cruciate ligament graft fixation, and Lisfranc injury treatment. In many instances, suture-button fixation constructs have shown equivalent, if not superior, outcomes to screw fixation. More recently, suture buttons have been suggested for osseous fixation of the coracoid during the Latarjet procedure, as well as other anterior (or posterior) bone block reconstruction of the glenoid using distal tibial allograft, tricortical iliac crest, or distal clavicle in cases of complex shoulder instability. Suture buttons offer several unique advantages, including the ability to tension and retension graft fixation, smaller driller paths with bone preservation, less osteolysis, lower risk of hardware removal, and greater ease of hardware revision and/or secondary surgery. However, certain disadvantages also exist, such as higher implant costs, less time-zero implant rigidity, technical difficulty, and, potentially, less mediolateral stability of the bone graft. Time will tell if these suture-button constructs will supplant traditional screw fixation for the Latarjet procedure in terms of clinical and cost-effectiveness.

Editorial Commentary: Lower Trapezius Transfer May Be Indicated for Surgical Management of Massive Irreparable Rotator Cuff Tears in Younger, Non-Arthritic Patients.

Although shoulder rotator cuff repair fixation constructs and suture anchor design have evolved, repair of massive or functionally irreparable tears historically has relied on tendon mobilization and compression, optimizing footprint biology, and attempting a tension-free repair. However, despite these efforts, rates of failure of complete healing may be high, ranging from 20% to 94%. This has led to a search for alternative approaches, including bridging grafts, subacromial balloons, superior capsular reconstructions, biologic tuberoplasties, bursal acromial grafts, and, ultimately, renewed interest in tendon transfers. The latissimus dorsi transfer was traditionally a preferred tendon-transfer technique for posterosuperior massive cuff tears, but inconsistent outcomes have resulted in declining popularity. Recently, the lower trapezius transfer (LTT) has gained acceptance for the treatment of posterosuperior tears, particularly with external rotation weakness and lag signs. The LTT is biomechanically superior to the latissimus dorsi transfer, offering a more native vector of pull and in-phase activation. LTT could be indicated for younger patients with massive cuff tears. However, LTT is relatively contraindicated in patients with cuff tear arthropathy; combined loss of elevation and external rotation; irreparable subscapularis tear; teres minor involvement; and/or those of advanced age or unable to comply with rigid rehabilitation guidelines.

Editorial Commentary: Meniscal Allograft Transplantation Is Effective for Adolescents With Meniscal Insufficiency, Although Outcomes May Decline Over Time.

Over the last several years, there has been a shift from arthroscopic partial meniscectomy to meniscal repair, especially in the younger patient. In case of a necessary partial meniscectomy, some patients have unremittent symptoms of pain and effusion corresponding to the postmeniscectomy syndrome. In these patients without large coronal malalignment, meniscal allograft transplantation is a valuable option to restore contact pressures, promote a chondroprotective microenvironment, and potentially delay secondary surgical interventions symptoms. In the adolescent population, meniscal allograft transplantation has been shown to effectively improve patient-reported outcomes with a low conversion to arthroplasty. However, these treatments are far from ideal, and prevention is certainly better than the cure: timely diagnosis of meniscus injuries, appropriate treatment with meniscus repair rather than partial meniscectomy, even in the complex tear patterns, and consideration of corrective osteotomy for milder cases of malalignment.

Early Anterior Cruciate Ligament Treatment Might Be Crucial for Acute Combined Anterior Cruciate Ligament and Medial Collateral Ligament Injuries: A Systematic Review of the Various Treatment Strategies.

PURPOSE: To assess the outcomes of acute, combined, complete anterior cruciate ligament (ACL) and medial collateral ligament (MCL) injuries in the literature. METHODS: A literature search using PubMed, Embase, Scopus, and Cochrane Reviews was performed following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. The inclusion criteria were studies reporting outcomes of complete ACL-MCL injuries at a minimum of 12 months' follow-up. Data were presented as ranges. RESULTS: Twenty-seven studies with 821 patients were included (mean age, 29 years; 61% male patients; mean follow-up period, 27 months). There were 4 randomized trials, 10 Level III studies, and 13 Level IV studies. Nine different strategies were noted, of which nonoperative MCL treatment with acute ACL reconstruction and acute MCL repair with acute ACL reconstruction were most commonly performed. Nonoperative MCL-ACL treatment and acute MCL repair with nonoperative ACL treatment led to low rates of valgus stability at 30° of flexion (27%-68% and 36%-77%, respectively) compared with acute ACL reconstruction with either nonoperative MCL treatment (80%-100%), acute MCL repair (65%-100%), or acute MCL reconstruction (81%-100%). Lysholm scores were not different between the strategies. CONCLUSIONS: Outcomes in this systematic review suggest that ACL stabilization in the acute setting might result in the lowest rates of residual valgus laxity, whereas there is no clear difference between the different MCL treatments along with acute ACL reconstruction. Nonoperative MCL treatment with either nonoperative or delayed ACL reconstruction, as well as acute MCL repair with either nonoperative or delayed ACL reconstruction, leads to higher rates of valgus laxity. LEVEL OF EVIDENCE: Level IV, systematic review of Level I to IV studies.

Low Recurrence of Instability and Satisfying Patient-Reported Outcomes Following Various Surgical Treatments of Reverse Hill-Sachs Lesions in the Setting of Posterior Instability: A Systematic Review.

PURPOSE: To systematically review the literature and report the outcomes of various surgical treatments for reverse Hill-Sachs lesions (RHSL) in the setting of posterior shoulder instability. METHODS: Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. All studies assessing outcomes of surgical treatment of RHSL from inception to January 2023 were identified in PubMed, Embase, and Cochrane Library. Inclusion criteria consisted of studies reporting outcomes, minimum mean 1-year follow-up, and minimum Level IV evidence. Outcomes were assessed using Forest plots with random effects models using R software. RESULTS: A total of 29 studies consisting of 291 patients were included with a mean age of 42 years (range 16-88 years), 87% male gender, and mean follow-up of 4.5 years. The mean size of impacted or affected cartilage was 35%, and time from injury to surgery was mean 15 weeks. Nearly all studies were Level IV evidence, and quality of studies was low. Random effect models were performed, and data are presented as range. A low incidence of instability was noted for all surgical techniques with good patient-reported outcome measures. Most studies reported outcomes of the modified McLaughlin procedure (13 studies, 126 patients) with overall Constant-Murley Score of 65 to 92. Trends were seen towards better Constant-Murley Score and external rotation with a shorter delay between injury, and when arthroscopic and joint preserving treatments were performed. CONCLUSIONS: This systematic review showed low rates of instability recurrence, reproducible range of motion, and favorable patient-reported outcome measures were reported following all treatments for RHSLs with posterior instability. There was a significant association between better outcomes and a shorter delay between injury and surgery. The level of evidence is limited, given the small and retrospective studies which can be explained by the rarity of these injuries. LEVEL OF EVIDENCE: Level IV; systematic review of Level III and IV studies.

Bioactive and Bioinductive Implants Are Increasingly Used in Orthopaedic Sports Medicine but Adequately Controlled Studies Are Needed: A Scoping Review.

PURPOSE: To describe the currently available literature reporting clinical outcomes for bioactive and bioinductive implants in sports medicine. METHODS: In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic search of 4 databases was completed to identify eligible studies. Inclusion criteria were studies using bioactive or bioinductive implants in human clinical studies for sports medicine procedures. Data were extracted and reported in narrative form, along with study characteristics. RESULTS: In total, 145 studies were included involving 6,043 patients. The majority of included studies were level IV evidence (65.5%), and only 36 included a control group (24.8%). Bioactive materials are defined as any materials that stimulate an advantageous response from the body upon implantation, whereas bioinductive materials provide a favorable environment for a biological response initiated by the host. Bioactivity can speed healing and improve clinical outcome by improving vascularization, osteointegration, osteoinduction, tendon healing, and soft-tissue regeneration or inducing immunosuppression or preventing infection. The most common implants reported were for knee (67.6%, primarily cartilage [most commonly osteochondral defects], anterior cruciate ligament, and meniscus), shoulder (16.6%, primarily rotator cuff), or ankle (11.7%, primarily Achilles repair). The most common type of implant was synthetic (44.1%), followed by autograft (30.3%), xenograft (16.6%), and allograft (9.0%). In total, 69% of implants were standalone treatments and 31% were augmentation. CONCLUSIONS: The existing bioactive and bioinductive implant literature in sports medicine is largely composed of small, low-level-of-evidence studies lacking a control group. CLINICAL RELEVANCE: Before bioactive implants can be adapted as a new standard of care, larger, comparative clinical outcome studies with long-term follow-up are essential.

Humeral Head Reconstruction of Reverse Hill-Sachs Lesions.

Compared with anterior instability, posterior shoulder dislocations are a rare entity and are often missed at presentation. A concomitant anteromedial impression fracture of the humeral head, or a reverse Hill-Sachs lesion, is commonly present with these dislocations and is more pronounced with a longer timeline to reduction. Treatment of these defects ranges from nonsurgical treatment to soft-tissue procedures, bony reconstruction, and arthroplasty. Management may be dictated by various factors, such as patient demands, defect size and location, concomitant injuries, and underlying etiology. Small reverse Hill-Sachs defects without engagement can generally be treated nonsurgically or with benign neglect, whereas larger defects (>20%) often require surgery. The most reported surgical techniques are the (arthroscopic) McLaughlin and modified McLaughlin procedure, disimpaction and bone grafting, or reconstruction of the defect with autograft or with fresh (or fresh-frozen) osteochondral allograft. Finally, arthroplasty is generally required for large defects, where more than 45% to 50% of the articular cartilage is involved. Overall, reported outcomes generally reflect patient satisfaction for most patients, with a low incidence of secondary instability or posttraumatic arthritis, although better results are achieved when recognizing and treating these injuries in the more acute setting.

Anxiety and depression prior to total knee arthroplasty are associated with worse pain and subjective function: A prospective comparative study.

PURPOSE: The aim of this study was to investigate the influence of preoperative anxiety and depression on subjective function, pain and revision rates following total knee arthroplasty (TKA). METHODS: A prospective comparative study was conducted, including 349 patients undergoing TKA surgery between January 2019 and April 2021. Patients completed the Hospital Anxiety and Depression Scale (HADS) questionnaire preoperatively, and a set of Patient-Reported Outcome Measures (PROMs) preoperatively and at 6, 12 and 24 months postoperatively. Patients were categorized into anxiety and depression groups based on HADS scores. PROMs included the Knee injury and Osteoarthritis Outcome Score-Physical Function Shortform (KOOS-PS), Oxford Knee Score (OKS) and NRS-Pain. Differences in PROM scores between the anxiety/depression group and, respectively, nonanxiety/nondepression group were assessed, as well as differences in minimal clinical important difference (MCID) and attainment of Patient Acceptable Symptom State (PASS). Lastly, revision rates were compared. RESULTS: Anxiety and depression groups exhibited inferior subjective function preoperatively and postoperatively compared to nonanxiety and nondepression groups (all p < 0.05), experienced more pain preoperatively (p < 0.001) and also postoperatively for depression patients (all p < 0.05). Significantly fewer patients with anxiety and depression reached the PASS for KOOS-PS, OKS and NRS-Pain (all p < 0.05). There were no differences in the proportion of patients reaching the MCID for all PROMs (all p > 0.060), and revision rates did not differ between groups (both p > 0.96). CONCLUSION: Preoperative anxiety and depression negatively influence subjective function and pain preoperatively and up to 2-year follow-up in patients undergoing TKA. Revision rates did not differ between groups, and there were no relevant differences in clinical improvement of subjective function and pain. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Anterior cruciate ligament primary repair revision rates are increased in skeletally mature patients under the age of 21 compared to reconstruction, while adults (>21 years) show no significant difference: A systematic review and meta-analysis.

PURPOSE: To evaluate the impact of age as a risk factor on the revision rates of anterior cruciate ligament (ACL) primary repair (ACLPR), dynamic intraligamentary stabilization (DIS) and bridge-enhanced ACL restoration (BEAR) compared to ACL reconstruction (ACLR). METHODS: A systematic literature search was performed for comparative studies comparing outcomes for ACLPR, DIS or BEAR to ACLR. A random-effects meta-analysis was performed to assess nondifferentiated and age-differentiated (skeletally mature patients ≤21 and >21 years) ACL revision and reoperation risk, as well as results for subjective outcomes. Methodological study quality was assessed using the Risk of Bias Tool 2.0c and Methodological Index for Nonrandomized Studies tools. RESULTS: A total of 12 studies (n = 1277) were included. ACLR demonstrated a lower nonage-stratified revision risk at 2 years versus ACLPR, DIS and BEAR, but a similar revision risk at 5 years when compared to DIS. However, an age-stratified analysis demonstrated a significantly increased ACLPR revision risk as compared to ACLR in skeletally mature patients ≤21 years of age (risk ratios [RR], 6.33; 95% confidence interval [CI], 1.18-33.87, p = 0.03), while adults (>21 years) showed no significant difference between groups (RR, 1.48; 95% CI, 0.25-8.91, n.s.). Furthermore, DIS reoperation rates were significantly higher than respective ACLR rates (RR, 2.22; 95% CI, 1.35-3.65, p = 0.002), whereas BEAR (RR, 1.07; 95% CI, 0.41-2.75, n.s.) and ACLPR (RR, 0.81; 95% CI, 0.21-3.09, n.s.) showed no differences. IKDC scores were equivalent for all techniques. However, ACLPR exhibited significantly better FJS (mean difference, 11.93; 95% CI, 6.36-17.51, p < 0.0001) and Knee injury and Osteoarthritis Outcome Score Symptoms (mean difference, 3.01; 95% CI, 0.42-5.60, p = 0.02), along with a lower Tegner activity reduction. CONCLUSIONS: ACLPR in skeletally mature patients ≤21 years of age is associated with up to a six-fold risk increase for ACL revision surgery compared to ACLR; however, adults (>21 years) present no significant difference. Based on the current data, age emerges as a crucial risk factor and should be considered when deciding on the appropriate treatment option in proximal ACL tears. LEVEL OF EVIDENCE: Level III.

The phenotypic diversity of anteromedial osteoarthritis before and after treatment with medial unicompartmental knee arthroplasty: A radiographic analysis of 1000 knees.

PURPOSE: This study aimed to assess phenotypic variation in the coronal plane of knees with anteromedial osteoarthritis using the functional knee phenotype classification, before and after treatment with medial unicompartmental knee arthroplasty (UKA). METHODS: The study comprised 1000 knees of 835 patients (45% females, 55% males, 90% Caucasian) who underwent medial UKA for anteromedial osteoarthritis. Pre and postoperative alignment was evaluated through the hip-knee-ankle angle (HKA), femoral mechanical angle (FMA), and tibial mechanical angle (TMA). Knees were classified according to the functional knee phenotype system which combines limb phenotype (HKA), and femoral and tibial knee phenotypes (FMA and TMA, respectively). Restoration of prearthritic coronal alignment following medial UKA was evaluated by phenotype. RESULTS: Preoperatively, 76 distinct and 25 relevant (prevalence ≥1%) functional knee phenotypes were identified, of which VARHKA 6°VARFMA 3°NEUTMA 0° was the most common (9.4% of knees). The most prevalent limb phenotype, VARHKA 6°, comprised 15 distinct knee phenotypes (FMA and TMA combinations). Postoperatively, 58 distinct and 17 relevant functional knee phenotypes were observed, of which VARHKA 3°NEUFMA 0°NEUTMA 0° had the highest prevalence at 18.3%. Knees with combined tibial and femoral deformities were associated with a lower probability of restoration of prearthritic coronal alignment following medial UKA, compared to knees without extra-articular deformity, or knees with an isolated tibial or femoral deformity. CONCLUSION: Phenotype analysis using the functional knee phenotype system demonstrated a wide diversity of coronal alignment phenotypes among knees with anteromedial osteoarthritis in a predominantly Caucasian population. Following medial UKA, a reduction from 25 preoperative to 17 postoperative relevant phenotypes was observed. Consideration of phenotypic variation can be of importance when aiming to restore prearthritic coronal alignment during medial UKA. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Role of Preoperative Intra-Articular Corticosteroid Injections on Periprosthetic Joint Infection in Total Hip Arthroplasty and Its Association With Preoperative Timing: A Single-Center Series of 5,909 Hips.

BACKGROUND: Preoperative intra-articular corticosteroid injections to the hip joint increase the risk of periprosthetic joint infection (PJI) during primary total hip arthroplasty (THA). This study aimed to determine the relationship between preoperative timing of intra-articular corticosteroid injections and PJI risk following THA using data from a single-center hospital. METHODS: This single-center, retrospective cohort study included patients who underwent a THA between 2014 and 2020. Medical records were checked for intra-articular corticosteroid injections and PJI within 1 year of surgery. Patients were categorized into groups based on whether they received "no injection" or "injection 0 to 3 months," "3 to 6 months," and "> 6 months prior to THA." Hazard ratios (HRs) for these groups were calculated using multivariate Cox regression analysis, correcting for potential confounders, and presented with 95% confidence intervals [95% CIs]. RESULTS: In total, 4,507 patients (5,909 THAs) were identified. A total of 1,581 patients (27%) received an injection prior to THA. Without considering the timing factor, no increased risk for PJI following an intra-articular injection was noted (P = .19). Comparing the specified groups using multivariate analysis, corticosteroid injection within 3 months of THA showed an increased risk of PJI (HR 2.63, 95% CI 1.18 to 5.87, P = .018), but this effect was not observed for the "injection 3 to 6 months" group (HR 1.51, 95% CI 0.74 to 3.08, P = .264). CONCLUSIONS: Corticosteroid injections administered up to 3 months prior to THA increased the risk of PJI within 1 year after THA, with an HR of 2.63; however, injections between 3 and 6 months before surgery did not have a significantly higher infection rate.

Magnitude of Change in Leg Length and Clinical Impact Following Medial Unicompartmental Knee Arthroplasty.

BACKGROUND: Change in leg length and leg-length discrepancy (LLD) are common concerns among patients undergoing medial unicompartmental knee arthroplasty (UKA). This study aimed to quantify the magnitude of leg-length change, prevalence of postoperative LLD, and their clinical implications following medial UKA. METHODS: Leg length and mechanical hip-knee-ankle angle (mHKA) were retrospectively measured in 332 patients following unilateral robotic-arm assisted medial UKA for medial compartment osteoarthritis, using calibrated long-leg radiographs. The Knee Injury and Osteoarthritis Otcome Score for Joint Replacement and patient satisfaction were analyzed to assess impact of leg-length change and LLD on outcomes. RESULTS: Following medial UKA, median leg-length change was 2.0 mm (interquartile range, -1.0 to 5.0 mm; P < .001) with a mean correction in mHKA of 4.4° ± 2.7 (P < .001). A total of 158 patients (48%) had a leg-length increase by 0 to 5 mm, 64 (19%) by 6 to 10 mm, and 11 (3%) by >10 mm. Leg-length change was positively correlated with mHKA correction (R = 0.44, P < .001). Postoperatively, moderate (5 to 10 mm) and substantial LLD (≥10 mm) were present in 49% and 17% of patients, respectively. Four-year Knee Injury and Osteoarthritis Outcome Score for Joint Replacement were comparable between patients with and without substantial postoperative LLD (P = .976). Proportions of satisfied patients were similar between groups (P = .687). CONCLUSION: Following medial UKA, the majority of patients had a moderate increase in leg length, the magnitude of which was positively correlated to the correction in mechanical alignment. Postoperative substantial LLD was not uncommon (17% prevalence); however, it had no significant impact on patient-reported outcomes or satisfaction at 4 years follow-up.

Editorial Commentary: What to Reinforce When You Have a Small Anterior Cruciate Ligament Graft? Focus on the Anterolateral Side!

Many surgeons performing anterior cruciate ligament (ACL) reconstruction have encountered the problem of harvesting small hamstring grafts. For this situation, several options are available such as harvesting contralateral hamstring tendons, reinforce the ACL graft with allografts, take a bone-patellar tendon-bone or quadriceps graft or add an anterolateral ligament reconstruction or lateral extra-articular tenodesis. Recent studies have shown that the presence of a lateral extra-articular procedure might be more important than the thickness of an isolated ACL graft, which is reassuring news. Current evidence suggests that both anterolateral ligament reconstruction and modified Lemaire tenodesis are similar biomechanically and clinically and could solve the problem of small-diameter hamstring ACL autografts.

Treating Combined Anterior Cruciate Ligament and Medial Collateral Ligament Injuries Operatively in the Acute Setting Is Potentially Advantageous.

Combined injury of the anterior cruciate ligament (ACL) and medial collateral ligament (MCL) remains among the most common knee injury patterns in orthopaedics. Optimal treatment of grade III MCL injuries is still debated, especially when combined with ACL injury. Most patients with these severe injuries are treated conservatively for at least 6 weeks to allow for MCL healing, followed by delayed ACL reconstruction. Although acute treatment of the MCL was common in the 1970s, postoperative stiffness was frequently reported. Moreover, studies of such treatment failed to show clinical benefits of surgical over conservative treatment, and the MCL exhibited intrinsic healing capacity, leading to the consensus that all MCL injuries are treated conservatively. The current delayed treatment algorithm for ACL-MCL injuries has several disadvantages. First, MCL healing may be incomplete, resulting in residual valgus laxity that places the ACL graft at greater risk of failure. Second, delayed treatment lengthens the overall rehabilitation period, thereby prolonging the presence of atrophy and delaying return to preinjury activity levels. Third, the initial healing period leaves the knee unstable for longer and risks further intra-articular damage. Acute simultaneous surgical treatment of both ligaments has the potential to avoid these shortcomings. This article will review the evolution of treatment of ACL-MCL injuries and explain how it shifted toward the current treatment algorithm. We will (1) discuss why the consensus shifted, (2) discuss the shortcomings of the current treatment plan, (3) discuss the potential advantages of acute simultaneous treatment, and (4) present an overview of the available literature.

Successful same-day discharge in 88% of patients after unicompartmental knee arthroplasty: a systematic review and meta-analysis.

PURPOSE: The purpose of this study was to evaluate the effectiveness of day-case unicompartmental knee arthroplasty (UKA) by assessment of successful same-day discharge (SDD), readmission, complication and reoperation rates in the recent literature. METHODS: For this systematic review and meta-analysis, PubMed, Embase and Cochrane Library were comprehensively searched to identify all eligible studies reporting outcomes of day-case UKA. Studies with intended same-day home discharge after UKA were included. A meta-analysis of proportions, using a random-effects model, was performed to estimate overall rates of successful SDD and adverse events. Subgroup analyses were performed for studies including selected patients (i.e., patients had to meet certain patient-specific criteria to be eligible for day-case UKA) and unselected patients (i.e., no additional criteria for day-case UKA), as well as for clinical and registry-based studies. Additional outcomes included reasons for the failure of SDD and patient satisfaction. RESULTS: A total of 29 studies and 9694 patients were included with a mean age of 66 ± 9 years and mean follow-up of 59 days (mean range 30-270 days). Based on 24 studies (2733 patients), the overall successful SDD rate was 88% (95% confidence interval [CI] 80-92). These rates were 91% (95% CI 84-95) across studies with selected patients and 76% (95% CI 55-89) across studies with unselected patients. Overall readmission, complication and reoperation rates were 3% (95% CI 1.9-4.4), 4% (95% CI 2.8-5.2) and 1% (95% CI 0.8-1.3), respectively. Inability to mobilize, nausea and uncontrolled pain were frequently reported reasons for failed SDD. The overall patient satisfaction rate was 94%. CONCLUSION: This systematic review with meta-analysis found an overall successful SDD rate of 88% after UKA in a heterogeneous cohort of selected and unselected patients. Readmission, complication and reoperation rates suggest UKA can be performed safely and effectively as a same-day discharge procedure. LEVEL OF EVIDENCE: Level IV, systematic review of level III and IV studies.

Restoration or relative overcorrection of pre-arthritic coronal alignment leads to improved results following medial unicompartmental knee arthroplasty.

PURPOSE: A pre-arthritic alignment strategy for medial unicompartmental knee arthroplasty (UKA) aims to restore a patient's native lower limb alignment which may translate into improved outcomes. This study aimed to assess whether patients with pre-arthritically aligned knees versus patients with non-pre-arthritically aligned knees demonstrated improved mid-term outcomes and survivorship following medial UKA. The hypothesis was that pre-arthritic alignment in medial UKA would lead to better postoperative outcomes. METHODS: A retrospective study of 537 robotic-assisted fixed-bearing medial UKA was conducted. During this procedure, the surgical goal was to restore pre-arthritic alignment guided by re-tensioning of the medial collateral ligament (MCL). For study purposes, coronal alignment was retrospectively evaluated using the mechanical hip-knee-ankle angle (mHKA). Pre-arthritic alignment was estimated through the arithmetic hip-knee-ankle (aHKA) algorithm. Knees were grouped according to the difference between postoperative mHKA and estimated pre-arthritic alignment (i.e., mHKA - aHKA) as Group 1 (pre-arthritically aligned: mHKA restored within 2.0° of the aHKA), Group 2 (mHKA > 2.0° overcorrected relative to the aHKA), or Group 3 (mHKA > 2.0° undercorrected relative to the aHKA). Outcomes included the Knee Injury and Osteoarthritic Outcome Score for Joint Replacement (KOOS, JR), Kujala, proportions of knees achieving the patient acceptable symptom state (PASS) for these scores, and survivorship. PASS thresholds for KOOS, JR and Kujala were determined using a receiver operating characteristic curve method. RESULTS: A total of 369 knees were categorized as Group 1, 107 as Group 2, and 61 as Group 3. At 4.4 ± 1.6 years follow-up, mean KOOS, JR was comparable among groups, while Kujala was significantly worse in Group 3. The proportion of knees achieving the PASS for Kujala (76.5 points) was lower in Group 3 (n = 32; 59%) compared to Group 1 (n = 260; 74%) (p = 0.02). 5-year survivorship was higher in Group 1 and Group 2 (99% and 100%, respectively) compared to Group 3 (91%) (p = 0.04). CONCLUSION: Pre-arthritically aligned knees and knees with relative overcorrection from their pre-arthritic alignment following medial UKA demonstrated improved mid-term outcomes and survivorship compared to knees with relative under correction from their pre-arthritic alignment. These results encourage restoring or relatively overcorrecting pre-arthritic alignment to optimize outcomes following medial UKA, and caution against under correction from the pre-arthritic alignment. LEVEL OF EVIDENCE: IV, case series.

Preoperative Pain Catastrophizing Prior to Total Knee Arthroplasty is Associated With Worse Preoperative Symptoms and More Clinical Improvement: A Prospective Comparative Study.

BACKGROUND: Total knee arthroplasty (TKA) is a reliable procedure for end-stage osteoarthritis with excellent long-term survivorship, but approximately 15% of patients are not satisfied. Pain catastrophizing (PC) has been proposed as a potential cause but current evidence is limited to smaller studies with short-term follow-up. Our goal was to assess outcomes following TKA in a large cohort with and without PC. METHODS: A prospective comparative study was performed with patients undergoing unilateral primary TKA between 2019 and 2021 with 2-year follow-up. All patients completed a PC Scale questionnaire preoperatively and a score of minimum 30 was considered PC. Outcomes consisted of Knee injury and Osteoarthritis Outcome Score-Physical Function Shortform (KOOS-PS), Oxford Knee Score (OKS), numeric rating scale Pain, and aseptic revisions. Ultimately, 301 patients were included (mean age 69 years [range, 30-92 years], with 60.8% women). Forty four patients (14.6%) had PC. RESULTS: Preoperatively, PC patients had inferior KOOS-PS, inferior OKS, and more pain than non-PC patients (all P < .001). PC patients had more improvement from preoperatively to 6 months postoperatively for KOOS-PS, OKS, and pain (all P < .05) and to 12 months for KOOS-PS and OKS (both P < .005). Similarly, PC patients had more improvement from preoperative to 24 months for OKS (P = .003). At 24 months, however, PC patients reported more pain than non-PC patients. There was no difference in revision rates (P = .192). CONCLUSION: Patients who had PC reported worse function and pain preoperatively but had more improvement to 6 months and 12 months postoperatively. At 24 months, similar subjective function was noted, although PC patients reported more pain.

Repair versus reconstruction for proximal anterior cruciate ligament tears: a study protocol for a prospective multicenter randomized controlled trial.

BACKGROUND: For active patients with a tear of the anterior cruciate ligament (ACL) who would like to return to active level of sports, the current surgical gold standard is reconstruction of the ACL. Recently, there has been renewed interest in repairing the ACL in selected patients with a proximally torn ligament. Repair of the ligament has (potential) advantages over reconstruction of the ligament such as decreased surgical morbidity, faster return of range of motion, and potentially decreased awareness of the knee. Studies comparing both treatments in a prospective randomized method are currently lacking. METHODS: This study is a multicenter prospective block randomized controlled trial. A total of 74 patients with acute proximal isolated ACL tears will be assigned in a 1:1 allocation ratio to either (I) ACL repair using cortical button fixation and additional suture augmentation or (II) ACL reconstruction using an all-inside autologous hamstring graft technique. The primary objective is to assess if ACL repair is non-inferior to ACL reconstruction regarding the subjective International Knee Documentation Committee (IKDC) score at two-years postoperatively. The secondary objectives are to assess if ACL repair is non-inferior with regards to (I) other patient-reported outcomes measures (i.e. Knee Injury and Osteoarthritis Outcome Score, Lysholm score, Forgotten Joint Score, patient satisfaction and pain), (II) objective outcome measures (i.e. failure of repair or graft defined as rerupture or symptomatic instability, reoperation, contralateral injury, and stability using the objective IKDC score and Rollimeter/KT-2000), (III) return to sports assessed by Tegner activity score and the ACL-Return to Sports Index at two-year follow-up, and (IV) long-term osteoarthritis at 10-year follow-up. DISCUSSION: Over the last decade there has been a resurgence of interest in repair of proximally torn ACLs. Several cohort studies have shown encouraging short-term and mid-term results using these techniques, but prospective randomized studies are lacking. Therefore, this randomized controlled trial has been designed to assess whether ACL repair is at least equivalent to the current gold standard of ACL reconstruction in both subjective and objective outcome scores. TRIAL REGISTRATION: Registered at Netherlands Trial Register ( NL9072 ) on 25th of November 2020.

Role of Age on Success of Arthroscopic Primary Repair of Proximal Anterior Cruciate Ligament Tears.

PURPOSE: To assess failure rates and patient-reported outcomes measures following arthroscopic primary anterior cruciate ligament (ACL) repair of proximal tears in different age groups. METHODS: Between 2008 and 2017, the first 113 consecutive patients treated with repair were retrospectively reviewed at minimum of 2 years. Patients were stratified into 3 age groups: ≤21, 22-35, and >35 years. Primary outcomes were ipsilateral reinjury or reoperation, and contralateral injury rates, and secondary outcomes consisted of Lysholm, modified Cincinnati, Single Assessment Numeric Evaluation, International Knee Documentation Committee subjective, pain, and satisfaction scores. Group differences were compared using χ2 tests and Mann-Whitney U tests. RESULTS: Follow-up was obtained in 113 patients (100%). Median age was 35 years (interquartile range [IQR] 23-43) and median follow-up was 2.2 years (IQR 2.0-2.8). Overall, ACL reinjury occurred in 13 patients (11.5%), reoperation in 7 patients (6.2%), complications in 2 patients (1.8%) and contralateral ACL injury in 4 patients (3.5%). Overall, median Lysholm was 95 (IQR 89-100) and International Knee Documentation Committee subjective 92 (IQR 84-99). Treatment failure was significantly greater in the youngest age group (37.0%) as compared with the middle and older groups (4.2% and 3.2%, both P < .005). No significant differences were seen in reoperation, complication, or contralateral injury rates between groups (all P > .2), nor in patient-reported outcomes measures between the groups (all P > .1). CONCLUSIONS: The failure rate of primary repair of proximal ACL tears is high in patients aged 21 or younger (37.0%), and this should be taken into account when discussing repair in this patient group. In patients older than 21, repair may be an excellent treatment with low failure (3.5%) and complication rates (1.2%) and good subjective scores. LEVEL OF EVIDENCE: Level III, retrospective comparative therapeutic trial.

Distal remnant length can be measured reliably and predicts primary repair of proximal anterior cruciate ligament tears.

PURPOSE: To assess the reliability and predictive value of quantifying anterior cruciate ligament (ACL) tear location on magnetic resonance imaging (MRI) and assess the predictive value of tear location on the eligibility for arthroscopic primary repair of proximal ACL tears. METHODS: In this case-control study, all adult patients undergoing acute ACL surgery between 2008 and 2020 were retrospectively reviewed. All patients were treated with the treatment algorithm of undergoing primary repair when proximal tears with sufficient tissue quality were present intraoperatively, and otherwise underwent single-bundle ACL reconstruction. Sagittal MRI images were reviewed to measure proximal and distal remnant lengths along the anterior aspect of the torn ligament, and tear location was calculated as distal remnant divided by total remnant length. Interobserver and intraobserver reliability for remnant measurements were calculated. Then, receiver operating curve analysis (ROC) was performed to calculate the optimal cut-off for the possibility of primary repair with the different measurements. RESULTS: Two hundred and forty-eight patients were included, of which 151 underwent repair (61%). Inter- and intraobserver reliability ranged between 0.92 and 0.96 [95% confidence interval (CI) 0.55-0.98] and 0.91-0.97 (95% CI 0.78-0.98, respectively). All patients with a tear location of ≥ 80% on MRI could undergo repair, whereas all patients with tear location of < 60% required reconstruction. The positive predictive value of a proximal quarter tear (≥ 75%) on primary repair was 94%. Older age was correlated with more proximal tear location (p < 0.001), but there was no correlation between tear location and gender, BMI, or timing of surgery (all n.s). CONCLUSION: This study showed that tear location could reliably be quantified on MRI by assessing distal and proximal remnant lengths. Tear location in the proximal quarter of the ACL was found to have a positive predictive value for repairability of 94%. These findings may assist orthopaedic surgeons in evaluating which patients are eligible for primary ACL repair preoperatively. LEVEL OF EVIDENCE: III.