Editorial Commentary: A Gap-Based Subclassification of Ramp Lesions Has the Potential to Enhance Treatment Precision and Patient Outcomes in Anterior Cruciate Ligament-Deficient Knees Subtitle: Customizing Solutions for Anterior Cruciate Ligament-Deficient Knees.

Our evolving understanding of ramp lesions has significantly affected the field of anterior cruciate ligament injury and meniscal repair. Although these lesions have been linked consistently to increased anterior and rotational instability in anterior cruciate ligament-deficient knees, there remains a contentious debate regarding their optimal treatment. The current literature is divided, as some advocate for surgical repair of only arthroscopically unstable lesions. Others point to a substantial risk of complications, noting a 28.6% incidence in untreated stable lesions, and thus advocate for surgical repair of all lesions. Through the use of magnetic resonance imaging scans of flexed knees, a novel subclassification of ramp lesions based on gap distance at the tear site shows a correlation with posterior capsular displacement, anterior laxity, lesion size, and joint effusion. This nuanced classification offers new insights and promises to refine treatment decisions, potentially minimizing unnecessary surgeries and improving patient outcomes.

Meniscal Radial Tears Repaired with All-Inside and Inside-Out Techniques Result in Improved Clinical Outcome Scores; However, More Complications are Reported After Inside-Out Repair: A Systematic Review.

PURPOSE: To compare patient-reported outcomes (PROs), failure, and healing rates following all-inside (AI) repair versus inside-out (IO) repair for the treatment of meniscal radial tears. METHODS: A literature search was performed according to the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using the Scopus, PubMed, and Embase computerized databases. Level of evidence I through IV human clinical studies evaluating PROs and/or the incidence of failure and healing following AI versus IO repairs for meniscal radial tears were included. Clinical failure was defined by the presence of joint-line tenderness, a positive McMurray test, and mechanical symptoms such as locking, catching, or giving way. Study quality was assessed using the Methodological Index for Non-Randomized Studies (MINORS) criteria and Modified Coleman Methodology Score (MCMS). RESULTS: Ten studies published from 2008 to 2023 comprising 205 patients were identified including 142 patients who underwent AI repair and 63 patients who underwent IO repair for radial meniscus tears. Postoperative Lysholm and Tegner scores ranged from 90.8 to 95.6 and 5.7 to 8.2, respectively, in the AI repair group, compared to 86.9 to 94.2 and 6 to 7.5, respectively, in the IO repair group, and all patients exceeded published values for MCID for the Lysholm score. Clinical failure ranged from 0% to 40% in the AI group and 0% to 62.5% in the IO group. Healing assessments on second-look arthroscopy revealed failure rates ranging from 0% to 13.3% in the AI group and 0% to 39% in the IO group. Complete and partial healing ranged from 28.6% to 92.3% in the AI group and from 25% to 70% in the IO group. Chondral damage on second-look arthroscopy ranged from 0% to 95% in the IO group and 0% to 57.7% in the AI group. Postoperative complications ranged from 0%-2% within the AI group, while no complications were reported in the IO group. No implant-related complications were reported in any study group. CONCLUSION: Both all-inside and inside-out repairs for meniscal radial tears demonstrated improved PROs; however, current literature suggests that the IO technique may have higher failure rates both clinically and on second-look arthroscopy.

Increased Alpha Angles and Younger Age Increase the Risk of Contralateral Femoral Acetabular Impingement Syndrome Symptom Development and Surgical Intervention: A Systematic Review.

PURPOSE: To identify the preoperative risk factors associated with contralateral symptom development and surgical intervention for patients presenting with unilateral femoral acetabular impingement (FAI) syndrome. METHODS: A literature search was performed using PubMed and Scopus computerized databases according to the 2020 Preferred Reporting Items for Systematic Meta-Analyses guidelines. Studies evaluating preoperative risk factors associated with the contralateral progression of FAI were included. Quality assessment was completed using the Methodological Index for Non-Randomized Studies criteria. RESULTS: A total of 5 studies (n = 1,011 patients; mean age, 29.9 years) published from 2013 to 2022 met the inclusion/exclusion criteria. Mean follow-up ranged from 12 to 132 months. The overall rate of contralateral progression of symptomatic FAI ranged from 32.4% to 81%. Increased alpha angle was frequently reported factor associated with contralateral symptom progression, followed by decreased total arc of rotation, decreased internal rotation, reduced neck-shaft angle, and head-neck offset. The incidence rate of progression to contralateral surgery ranged from 15.7% to 24% of patients. Younger age was frequently reported factor associated with contralateral surgical intervention, followed by male sex, increased level of activity, and increased alpha angle. CONCLUSIONS: Increased alpha angle and younger age were commonly reported risk factors associated with an increased risk of symptom development and surgical progression of contralateral FAI, respectively. The overall rate of contralateral progression of symptomatic FAI and the rate of progression to surgical intervention ranged up to 81% and 24%, respectively. This information may help both patients and surgeons to establish expectations regarding development of contralateral hip symptoms and possible need for surgery. LEVEL OF EVIDENCE: Level III; systematic review of Level II-III studies.

All-Inside and Inside-Out Repair Techniques for Bucket-Handle Meniscus Tears Both Result in Improved Patient Outcomes and a Broad Range of Failure Rates: A Systematic Review.

PURPOSE: To compare patient-reported outcomes, failure rates, risk factors for failure, and complications in patients with bucket-handle meniscus tears (BHMTs) undergoing repair with inside-out (IO) versus all-inside (AI) techniques. METHODS: A literature search was performed using the PubMed, Embase, and Scopus databases from database inception to August 2023 according to the 2020 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. The inclusion criteria consisted of Level I to IV clinical studies published in the past 10 years with greater than 2 years of follow-up that evaluated patient-reported outcome scores and/or the incidence of failure after IO or AI repairs for BHMTs. Clinical studies not reporting outcomes or failure rates, older studies using outdated implants, animal studies, reviews, letters to the editor, case reports, cadaveric studies, and articles not written in the English language or with English-language translation were excluded. Study quality was assessed using the Methodological Index for Non-randomized Studies (MINORS) criteria. Outcomes were reported as ranges and qualitatively compared. RESULTS: A total of 16 studies published from 2013 to 2023, consisting of 1,062 patients with BHMTs, were identified. Thirteen studies (14 cohorts, 649 patients) reported on AI repair (mean age range, 23.7-32 years) and 7 studies (7 cohorts, 413 patients) reported on IO repair (mean age range, 16.7-34.6 years). Both groups had improved postoperative Lysholm and Tegner scores. Decreased range of motion was the most commonly reported complication in the AI group (range, 2.6%-4%), whereas adhesions for arthrofibrosis were the most commonly reported complication in the IO group (n = 12; range, 6%-7.9%). The overall reported failure rate ranged from 6.9% to 20.5% within the AI group and from 0% to 20% within the IO group. CONCLUSIONS: AI and IO repair techniques for BHMTs both result in improved Lysholm and Tegner scores. However, broad ranges of failure are reported in the literature, with overall failure rates ranging from 6.9% to 20.5% after AI repair and from 0% to 20% after IO repair. Younger age and isolated medial BHMT repair are the most frequently reported risk factors for the AI technique, whereas postoperative stiffness is the most frequently reported complication after both repair techniques. LEVEL OF EVIDENCE: Level IV, systematic review of Level I to IV studies.

Adults Have a Higher Incidence of Discoid Lateral Meniscus Tears Than Children-Adults Tend to Present With Complex Tears, While Horizontal Tear Patterns Are Frequently Encountered in Children: A Systematic Review.

PURPOSE: To systematically review the available literature on patients with discoid lateral meniscus (DLM) with the goal of elucidating the rates and types of meniscal tears, clinical symptoms, treatment strategies, and postoperative clinical and radiographic outcomes in adult patients compared with a pediatric population. METHODS: A literature search was performed using the PubMed, Embase, and Scopus databases from database inception to October 2023 according to the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Level of evidence I through IV human clinical studies evaluating rate and type of meniscal tears, clinical symptoms, patient-reported outcome measures, and postoperative radiographical assessments in patients with DLM were included. Comparisons were made by age younger and older than 16 years. Study quality was assessed using the Methodological Index for Non-Randomized Studies criteria. RESULTS: Thirteen studies comprising 1,772 adult patients (>16 years old) with DLM (n = 1,856 knees) and 8 studies conducted in 304 pediatric patients (≤16 years old, n = 353 knees) were included. The reported mean age ranged from 22.4 to 45 years (mean follow-up, 24-157.5 months) in the adult group and from 5 to 12.9 years (mean follow-up, 37-234 months) in the pediatric DLM group. Among studies that reported on tear patterns, the majority of adult (n = 553; 96.5%) and pediatric (n = 163; 71.8%) patients had tears of the DLM. Complete DLM was the predominant type of DLM in both study groups (range in adults, 49.6% to 88%; range in pediatric patients, 19%-100%) with complex (46.1%; range, 5.3%-100%) and horizontal tears (18.2%; range, 20%-37.5%) being the most frequently described tear patterns in the adult and pediatric DLM groups, respectively. Pain was the predominant reported symptom in both study groups (range in adults, 12.1%-99.3%; range in pediatric patients, 32.4%-100%). Partial meniscectomy was the most frequently reported treatment option conducted in 334 adult knees (39.5%; range, 24.2%-100%) and 66 pediatric knees (63.5%; range, 15%-100%). Overall, improved postoperative clinical outcomes were reported in both study groups; however, radiographic progression of degenerative changes after subtotal meniscectomy was noted. CONCLUSIONS: More adult patients with DLM present with tears in the literature compared with the pediatric population. Complex and horizontal tear patterns are the most frequently reported tears in adult and pediatric patients, respectively. Pain was the most relevant symptom in both study groups. There was generally significant improvement in postoperative clinical outcome scores; partial meniscectomy, however, remains the most frequently reported treatment option and is associated with fewer degenerative changes than in subtotal meniscectomy. LEVEL OF EVIDENCE: Level IV, systematic review of Level I to IV studies.

Blood Flow Restriction Enhances Recovery After Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

PURPOSE: To conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) evaluating neuromuscular and clinical outcomes of blood flow restriction (BFR) training after anterior cruciate ligament reconstruction (ACLR) compared to non-BFR rehabilitation protocols. METHODS: A systematic review was performed in accordance with the 2020 Preferred Reporting Items for Systematic Reviews and Meta Analyses guidelines by querying PubMed, MEDLINE, Scopus, the Cochrane Database for Systematic Review, and the Cochrane Central Register for Controlled Trials databases from inception through December 2023 to identify Level I-II RCTs evaluating outcomes of BFR training after ACLR compared to non-BFR rehabilitation. A meta-analysis was performed using random-effects models with standardized mean difference (SMD) for pain, muscle strength, and muscle volume, while mean difference (MD) was calculated for patient-reported outcome measures. RESULTS: Eight RCTs, consisting of 245 patients, met inclusion criteria, with 115 patients undergoing non-BFR rehabilitation versus 130 patients undergoing BFR after ACLR. Mean patient age was 27.2 ± 6.7 years, with the majority of patients being male (63.3%, n=138/218). The length of the BFR rehabilitation protocol was most commonly between 8-12 weeks (range, 14 days - 16 weeks). The majority of studies set the limb/arterial occlusion pressure in the BFR group at 80%. When compared to non-BFR rehabilitation, BFR resulted in significant improvement in isokinetic muscle strength (SMD: 0.77, p=0.02, I2: 58%), IKDC score (MD: 10.97, p=<.00001, I2: 77%), and pain (SMD: 1.52, p=.04, I2: 87%), but not quadriceps muscle volume (SMD: 0.28, p=0.43, I2: 76%). CONCLUSION: The use of BFR following ACLR led to improvements in pain, IKDC score and isokinetic muscle strength, with variable outcomes based on quadriceps strength, volume and thickness when compared to non-BFR rehabilitation.

The Large Language Model ChatGPT-4 Demonstrates Excellent Triage Capabilities and Diagnostic Performance for Patients Presenting with Various Causes of Knee Pain.

PURPOSE: To provide a proof-of-concept analysis of the appropriateness and performance of ChatGPT-4 to triage, synthesize differential diagnoses, and generate treatment plans concerning common presentations of knee pain. METHODS: Twenty knee complaints warranting triage and expanded scenarios were input into ChatGPT-4, with memory cleared prior to each new input to mitigate bias. For the 10 triage complaints, ChatGPT-4 was asked to generate a differential diagnosis which was graded for accuracy and suitability in comparison to a differential created by two orthopaedic sports medicine physicians. For the 10 clinical scenarios, ChatGPT-4 was prompted to provide treatment guidance for the patient, which was again graded. To test the higher-order capabilities of ChatGPT-4, further inquiry into these specific management recommendations was performed and graded. RESULTS: All ChatGPT-4 diagnoses were deemed appropriate within the spectrum of potential pathologies on a differential. The top diagnosis on the differential was identical between surgeons and ChatGPT-4 for 70% of scenarios, and the top diagnosis provided by the surgeon appeared as either the first or second diagnosis in 90% of scenarios. Overall, 16/30 (53.3%) of diagnoses in the differential were identical. When provided with 10 expanded vignettes with a single diagnosis, the accuracy of ChatGPT-4 increased to 100%, with the suitability of management graded as appropriate in 90% of cases. Specific information pertaining to conservative management, surgical approaches, and related treatments was appropriate and accurate in 100% of cases. CONCLUSION: ChatGPT-4 provided clinically reasonable diagnoses to triage patient complaints of knee pain due to various underlying conditions that was generally consistent with differentials provided by sports medicine physicians. Diagnostic performance was enhanced when providing additional information, allowing ChatGPT-4 to reach high predictive accuracy for recommendations concerning management and treatment options. However, ChatGPT-4 may demonstrate clinically important error rates for diagnosis depending on prompting strategy and information provided; therefore, further are necessary to prior to implementation into clinical workflows.

Lower Range of Recurrent Instability Rates Following Bankart Repair and Remplissage Compared to Isolated Bankart Repair in Patients With "Nonengaging/On-Track" Hill-Sachs Lesions and <20% Glenoid Bone Loss.

PURPOSE: To compare recurrent instability and return-to-sport rates along with external rotation differences between on-track (nonengaging) Hill-Sachs lesion patients undergoing either an isolated Bankart repair (IBR) or a Bankart repair augmented with a remplissage procedure (B+R). METHODS: A search was conducted using 3 databases (PubMed, EMBASE, CINAHL) in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Only clinical comparative (level of evidence I-III) studies were considered for inclusion. Quality assessment was performed using the Methodological Index for Non-Randomized Studies criteria. RESULTS: Six level of evidence III studies, totaling 537 patients (202 B+R and 335 IBR) were included for analysis. All patients had <20% glenoid bone loss and a nonengaging, on-track Hill-Sachs lesion. At a median final follow-up of 34.7 months, recurrent dislocation rates ranged from 0% to 7.7% and 3.5% to 30% in the B+R and IBR groups, respectively. Moreover, subjective instability and revision surgery rates presented lower ranges in the B+R upon comparison with the IBR cohort (0%-32% vs 5%-71.4% and 0%-5% vs 0%-35%, respectively). Furthermore, return to preinjury level of sports ranged from 64% to 100% in the remplissage-augmented group and 50% to 90% in the IBR cohort. Postoperative external rotation at side varied from 50° to 63° in the B+R and 55° to 63° in the IBR arm. Additional subgroup analysis revealed recurrent dislocation rates in athletes and patients with near-track Hill-Sachs lesions undergoing remplissage augmentation to be 0% to 5% and 2% to 47% while ranging from 8.8% to 30% and 9% to 66% for IBR patients, respectively. CONCLUSIONS: Upon qualitative analysis, ranges of recurrent instability measures, including recurrent dislocation rates, are higher in patients undergoing IBR in comparison to B+R. Activity level influences outcomes as athletes were found to have a higher range of recurrent dislocation rates in the IBR group. The addition of remplissage showed a higher range of return-to-sport rates with comparable postoperative external rotation between groups. LEVEL OF EVIDENCE: Level III, systematic review of Level III studies.

Neither All-Inside, nor Inside-Out, nor Outside-In Repair Demonstrates Superior Biomechanical Properties for Vertical Meniscal Tears: A Systematic Review of Human Cadaveric Studies.

PURPOSE: To systematically review the literature regarding the biomechanical properties of different repair techniques and fixation methods for vertically oriented meniscal tears. METHODS: Human cadaveric studies evaluating the biomechanical properties of different repair techniques for vertically oriented meniscal tears were identified using the PubMed, EMBASE, and Cumulative Index to Nursing & Allied Health databases. Primary outcomes included load to failure, displacement, stiffness, peak contact pressure, and contact area of repaired menisci. Repair techniques from included studies were reclassified into a total of 19 distinct all-inside (AI), inside-out (IO), or outside-in (OI) techniques. RESULTS: Sixteen studies were included (420 total menisci). Contact pressure and area were restored to intact-state values across all 5 compressive load studies at low knee flexion angles but not at greater knee flexion angles (i.e., >60°). There were no significant differences in contact pressure or area between AI, IO, and OI techniques across all studies. Some studies demonstrated statistically significant advantages in tensile properties with IO techniques when compared with AI techniques, whereas others found AI techniques to be superior. No studies directly compared tensile properties of OI techniques with those of AI or IO techniques. Vertical mattress suture configurations resulted in significantly greater load to failure and decreased displacement compared with horizontal mattress configurations in 67% of studies comparing the 2 techniques. There was no difference in the rate of tissue failure in AI (66.97%), IO (60.38%), or OI (66.67%, χ2 = 0.83, P = .66) techniques. CONCLUSIONS: Contact mechanics are reliably restored after repair of vertical meniscal tears at low flexion angles but inconsistently restored at greater flexion angles, regardless of technique. Vertical mattress configurations outperformed horizontal mattress configurations under tensile load. There are conflicting data regarding the comparison of tensile properties between AI and IO techniques. Ultimately, neither AI, IO, nor OI repair demonstrated superior biomechanical properties in the present literature. CLINICAL RELEVANCE: Several repair techniques demonstrate favorable biomechanical properties for vertical meniscal tears under tensile and compressive loads. Neither AI, IO, nor OI repair techniques demonstrate superior biomechanical properties at this time.

Reported Anterior Cruciate Ligament Injury Incidence in Adolescent Athletes Is Greatest in Female Soccer Players and Athletes Participating in Club Sports: A Systematic Review and Meta-analysis.

PURPOSE: To identify the risk of anterior cruciate ligament (ACL) injury in adolescent athletes based on sex, sport, and sport affiliation. METHODS: A literature search was performed using 3 online databases (PubMed, Cochrane Library, and EMBASE) from database inception to November 2023 per the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Included studies consisted of Level I or II studies reporting on ACL injury exposures in time (hours) or injuries per 1,000 athlete-exposures (AEs) (1 game or practice) in adolescent athletes. Exclusion criteria consisted of non-English studies, case reports, animal/cadaveric studies, and review articles. Methodological quality and bias assessment of the included studies was assessed using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. ACL injuries were analyzed and pooled to calculate incidence rates (IRs), per-season risk, and relative risk (RR) based on sex, sport, and sport affiliation (club sport participation vs school sport participation). RESULTS: A total of 1,389 ACL injuries over 19,134,167 AEs were identified (IR, 0.075; 95% confidence interval [CI], 0.071-0.079). Of these, 670 ACL injuries were reported in female athletes over 7,549,892 AEs (IR, 0.089; 95% CI, 0.087-0.091) with 719 in males over 11,584,275 AEs (IR, 0.062; 95% CI, 0.058-0.067). The greatest RR for ACL injury in females was in soccer (RR, 3.12; 95% CI, 2.58-3.77) for AEs. The greatest per-season risk of ACL injuries reported in female athletes occurred in soccer (1.08%), basketball (1.03%), and gymnastics (1.01%). The greatest per-season risk of ACL injuries reported in male athletes occurred in football (0.82%), lacrosse (0.64%), and soccer (0.35%). Club sport participation, in both AEs (RR, 3.94; 95% CI, 3.19-4.87) and hours of exposure (RR, 1.57; 95% CI, 1.07-2.28), demonstrated an increased risk of ACL injury. CONCLUSIONS: The risk of ACL injuries was 1.56-fold greater in adolescent female athletes compared with male athletes. The highest-risk sport for females was soccer. Participation in club sports possessed higher rates of injury compared with school sports. LEVEL OF EVIDENCE: Level II; meta-analysis of Level I and II studies.

Capsular Management at the Time of Hip Arthroscopy for Femoroacetabular Impingement Syndrome Varies With Geography and Surgeon Subspecialty Training: A Cross-Sectional, Multinational Surgeon Survey.

PURPOSE: To perform a multinational survey and identify patterns in capsular management at the time of hip arthroscopy. METHODS: An anonymous, nonvalidated survey was distributed by the American Orthopaedic Society for Sports Medicine; Arthroscopy Association of North America; European Society of Sports Traumatology, Knee Surgery & Arthroscopy; International Society for Hip Arthroscopy; and Turkish Society of Sports Traumatology, Arthroscopy, and Knee Surgery. The questions were broken down into 6 categories: demographic characteristics, capsulotomy preference, traction stitches, capsular closure, postoperative rehabilitation, and postoperative complications. RESULTS: The survey was completed by 157 surgeons. Surgeons who performed half or full T-type capsulotomies had 2.4 higher odds of using traction sutures for managing both the peripheral and central compartments during hip arthroscopy for femoroacetabular impingement (P = .024). Surgeons who believed that there was sufficient literature regarding the importance of hip capsular closure had 1.9 higher odds of routinely performing complete closure of the capsule (P = .044). Additionally, surgeons who practiced in the United States had 8.1 higher odds of routinely closing the capsule relative to international surgeons (P < .001). Moreover, surgeons who received hip arthroscopy training in residency or fellowship had 2.4 higher odds of closing the capsule completely compared with surgeons who did not have exposure to hip arthroscopy during their training (P = .009). CONCLUSIONS: Geographic and surgeon-related variables correlate with capsular management preferences during hip arthroscopy. Surgeons who perform half or full T-capsulotomies more often use traction stitches for managing both the peripheral and central compartments. Surgeons performing routine capsular closure are more likely to believe that sufficient evidence is available to support the practice, with surgeons in the United States being more likely to perform routine capsular closure in comparison to their international colleagues. CLINICAL RELEVANCE: As the field of hip preservation continues to evolve, capsular management will likely continue to play an important role in access, instrumentation, and postoperative outcomes.

Preoperative Depression Negatively Impacts Pain and Functionality Outcomes After Anterior Cruciate Ligament Reconstruction: A Systematic Review.

PURPOSE: To systematically investigate the influence of preoperative depression diagnosis and symptom severity on outcomes after anterior cruciate ligament reconstruction (ACLR). METHODS: A literature search was performed using the PubMed, Scopus, and Embase databases according to the 2020 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. Studies evaluating the impact of depression on clinical outcomes after ACLR were included. Clinical outcomes, changes in depression, and complications were aggregated. RESULTS: Nine studies comprising 308,531 patients (mean age, 28.1 years; age range, 14-50 years) were included. The depression incidence ranged from 3.8% to 42%. Seven studies showed postoperative improvement in depression scores, with 5 reporting statistical significance. Assessment of depression exhibited substantial variability, with Patient-Reported Outcomes Measurement Information System (PROMIS) scores being the most common method. Patients with depression, despite showing greater improvements in scores, experienced significantly higher PROMIS Pain Interference scores preoperatively (range, 59.1-65.7 vs 56.8-59.2) and postoperatively (range, 46.3-52.3 vs 46.3-47.4) than patients without depression. They also showed significantly lower preoperative (range, 33-38.1 vs 39.7-41.5) and postoperative (range, 51.6-56.7 vs 56.7-57.6) PROMIS Physical Function scores, regardless of greater score improvement. Patients affected by depression had significantly higher rates of minimal clinically important difference achievement for the PROMIS Physical Function score (71%-100% vs 80%) and similar rates for the PROMIS Pain Interference score (71%-81% vs 68%) compared with patients without depression in 3 studies. Depression was associated with reduced adherence to rehabilitation protocols and increased postoperative complications, including infection, graft failure, arthrofibrosis, and readmission. CONCLUSIONS: ACLR yields favorable outcomes for patients with and without preoperative depression. Individuals with preoperative depression may report inferior outcomes in terms of pain and functionality; nevertheless, despite these challenges, they exhibit significant improvements across all outcome measures after surgery, including reductions in depression levels. LEVEL OF EVIDENCE: Level IV, systematic review of Level II to IV studies.

Isolated Primary Latarjet Procedures for Anterior Shoulder Instability Results in High Rates of Graft Resorption and Glenohumeral Degenerative Changes With Low Rates of Failure at a Minimum 2-Year Follow-Up: A Systematic Review.

PURPOSE: To evaluate the incidence of postoperative complications after an isolated primary Latarjet procedure for anterior shoulder instability at a minimum 2-year follow-up. METHODS: A systematic review was performed in accordance with 2020 PRISMA guidelines. EMBASE, Scopus, and PubMed databases were queried from database inception through September 2022. The literature search was limited to human clinical studies reporting on postoperative complications and adverse events after a primary Latarjet procedure with a minimum 2-year follow-up. Risk of bias was measured using the Newcastle-Ottawa Scale. RESULTS: Twenty-two studies, consisting of 1,797 patients (n = 1,816 shoulders), with a mean age of 24 years were identified. The overall postoperative complication rate ranged from 0% to 25.7%, with the most common complication being persistent shoulder pain (range: 0%-25.7%). Radiological changes included graft resorption (range: 7.5%-100%) and glenohumeral degenerative changes (range: 0%-52.5%). Recurrent instability following surgery was documented in 0% to 35% of shoulders, while the incidence of bone block fractures ranged from 0% to 6% of cases. Postoperative nonunion, infection, and hematomas had a reported incidence rate ranging from 0% to 16.7%, 0% to 2.6%, and 0% to 4.4%, respectively. Overall, 0% to 7.5% of surgeries were reported failures, and 0% to 11.1% of shoulders required reoperation, with a revision rate ranging from 0% to 7.7%. CONCLUSIONS: The incidence of complications following the primary Latarjet procedure for shoulder instability was variable, ranging from 0% to 25.7%. High rates of graft resorption, degenerative changes, and nonunion were present while failure and revision rates remained low at a minimum 2-year follow-up. LEVEL OF EVIDENCE: Level III, systematic review of Level I-III studies.

Platelet-Rich Plasma, Bone Marrow Aspirate Concentrate, and Hyaluronic Acid Injections Outperform Corticosteroids in Pain and Function Scores at a Minimum of 6 Months as Intra-Articular Injections for Knee Osteoarthritis: A Systematic Review and Network Meta-analysis.

PURPOSE: To compare the efficacy of common intra-articular injections used in the treatment of knee osteoarthritis, including corticosteroid (CS), hyaluronic acid (HA), platelet-rich plasma (PRP), and bone marrow aspirate concentrate (BMAC), with a minimum follow-up of 6-months. METHODS: A literature search was conducted using the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines in August 2022 in the following databases: PubMed/MEDLINE, Scopus, Cochrane Database of Controlled Trials, and the Cochrane Database of Systematic Reviews. Level I to II randomized clinical trials with a minimum follow-up of 6 months that investigated the treatments of interest were included. Patient-reported outcome scores for pain and function at baseline and at latest follow-up were extracted, and the change in scores was converted to uniform 0 to 100 scales. Arm-based Bayesian network meta-analysis using a random-effects model was created to compare the treatment arms in pain and function. RESULTS: Forty-eight studies comprising a total of 9,338 knees were included. The most studied intra-articular injection was HA (40.9%), followed by placebo (26.2%), PRP (21.5%), CS (8.8%), and then BMAC (2.5%). HA and PRP both led to a significant improvement in pain compared with placebo. HA, PRP, and BMAC all led to a significant improvement in function scores when compared with placebo. Surface under the cumulative ranking curves (SUCRAs) of the interventions revealed that PRP, BMAC, and HA were the treatments with the highest likelihood of improvement in both pain and function, with overall SUCRA scores of 91.54, 76.46, and 53.12, respectively. The overall SUCRA scores for CS and placebo were 15.18 and 13.70, respectively. CONCLUSIONS: At a minimum 6-month follow-up, PRP demonstrated significantly improved pain and function for patients with knee osteoarthritis compared with placebo. Additionally, PRP exhibited the highest SUCRA values for these outcomes when compared with BMAC, HA, and CS. LEVEL OF EVIDENCE: Level II, meta-analysis of Level I to II studies.

From Platelet-Rich Plasma to Mesenchymal Stem Cells: Cartilage, Tendon, and Bone Regeneration With Orthobiologics.

The use of orthobiologics such as platelet-rich plasma, bone marrow aspirate, and stem cells has been proposed as a biologic augmentation for treatment of various conditions of cartilage, tendon, and bone. Although the published evidence is not conclusive, the safety of these treatments and benefits in improving the biologic condition of treated tissues have been confirmed. Osteoarthritis, rotator cuff injuries, and osteonecrosis of the femoral head are three common musculoskeletal conditions associated with the use of orthobiologics in patients with cartilage, tendon, and bone injuries. When reviewing the use of platelet-rich plasma, bone marrow aspirate, and mesenchymal stem cells in patients with these conditions, there is evidence of high safety and positive, but variable, efficacy. Recent studies have shown promising results and have paved the way for research being conducted at many specialized centers around the world.

Meniscus Extrusion, Radial Tears, and Root Tears.

Management of meniscal radial and root tears and extrusion is complex and has changed significantly over recent years. It is important to provide a comprehensive overview of the management of radial and root tears and meniscal extrusion and be aware of the currently available evidence on repair techniques, rehabilitation, and outcomes following radial and root repairs.

Meniscal extrusion consensus statement: A collaborative survey within the Meniscus International Network (MenIN) Study Group.

PURPOSE: The purpose of the present study was to perform a survey administered to members of the Meniscus International Network (MenIN) Study Group, seeking to delineate the most contentious aspects of meniscal extrusion classification and provide a foundation for new, more comprehensive definitions and treatments for these pathologies. METHODS: MenIN Study Group is a group of international experts treating and performing research on meniscus pathology and treatment. All MenIN Study Group members were asked to complete a survey aimed at establishing criteria for the optimal classification system for meniscal extrusion. Data obtained from the completed questionnaires were transferred into a spreadsheet and then analysed. All responses are presented as counts, percentages or means. RESULTS: Forty-seven (85.5%) MenIN Study Group members completed the survey and were included in this analysis. Key aspects recommended for inclusion in a comprehensive classification system for meniscal extrusion included laterality (93.6%), anatomical location (76.6%), patient age (76.6%), body mass index (BMI) (68.1%) and aetiology (68.1%). For classifying meniscal extrusion, 53.2% considered the distance in millimetres from the tibial plateau's outer margin as the most reliable measurement technique on imaging. Preferences for imaging modalities varied, with 44.7% favouring weight-bearing magnetic resonance imaging (MRI) and 36.2% opting for weight-bearing ultrasound due to its greater availability. Respondents advocated for a classification system addressing stability or progression of meniscal extrusion (66%), reducibility (53.2%), potential progression of knee osteoarthritis (OA) (83%), influencing treatment approaches (83%), a gradation system (83%), consideration of dynamic factors (66%), association with clinical outcomes and prognosis (76.6%) and investigation around centralization procedures (57.4%). CONCLUSIONS: In conclusion, the findings of this survey shed light on the global perspectives regarding meniscal extrusion classification. It was generally felt that a new classification of extrusion measured on MRI scans at the mid-tibial plateau should be developed, which considers factors such as laterality, anatomical location, age, BMI and aetiology. Additionally, the results support the integration of dynamic factors and clinical outcomes in MRI-based classifications to inform treatment approaches. LEVEL OF EVIDENCE: Level IV.

Meniscal ramp lesion classification systems: A systematic review.

PURPOSE: To describe the proposed classification systems for meniscal ramp lesions (RLs) in the literature and evaluate their accuracy and reliability. METHODS: A systematic search was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-analyses guidelines utilising PubMed, Embase and Cochrane Library databases. Level I-IV studies referencing RLs along with either an arthroscopic- or magnetic resonance imaging (MRI)-based classification system used to describe RL subtypes were included. RESULTS: In total, 21 clinical studies were included. Twenty-seven (79%) of the included studies were published in 2020 or later. There were four main classification systems proposed within the literature (two arthroscopic-, two MRI-based), describing tear patterns, mediolateral extent, associated ligament disruption and stability of the lesion. The first classification was proposed in 2015 by Thaunat et al. and is referenced in 22 (64.7%) of the included studies. The application of the Thaunat et al. criteria to MRI showed variable sensitivity (31.70%-93.8%) and interobserver agreement (k = 0.55-0.80). The Greif et al. modification to the Thaunat et al. system was referenced in 32.4% of the included studies and had a substantial interobserver agreement (k = 0.8). Stability to probing and specific tear location were each used to classify RLs in 28.6% and 23.8% of the included clinical studies, respectively. CONCLUSION: Although there has been a recent increase in the recognition and treatment of meniscal RLs, there is limited consistency in descriptive classifications used for this pathology. Current RL classification systems based on preoperative MRI have variable reliability, and arthroscopic examination remains the gold standard for diagnosis and classification. LEVEL OF EVIDENCE: Level IV.

No significant difference in thick versus thin osteochondral flap trochleoplasty in the treatment of trochlear dysplasia: A systematic review.

PURPOSE: Trochleoplasty has become increasingly utilised to address patellar instability in the setting of severe trochlear dysplasia. There remains a paucity of literature on the outcomes of 'thick'- versus 'thin'-osteochondral flap trochleoplasty. The purpose of this study is to compare clinical and radiographic outcomes between patients with patellar instability with symptomatic trochlear dysplasia treated using a 'thick' versus 'thin' osteochondral flap trochleoplasty. METHODS: A systematic review and meta-analysis were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using a PRISMA checklist. Quality assessment of final articles was conducted by two blinded reviewers. Articles were separated based on the use of a 'thick' versus 'thin' flap trochleoplasty. Data collection consisted of recording the following variables: patient demographics, indications for trochleoplasty, mean follow-up time, additional procedures performed during trochleoplasty, patient-reported outcome measures (PROMs), radiographic outcomes (tibial tubercle-trochlear groove [TT-TG] distance, Caton-Deschamps Index [CDI] and sulcus angle [SA]) and the incidence of any postoperative complications and patellar redislocation rates. RESULTS: A total of 24 studies, consisting of 927 patients, were identified as meeting inclusion criteria. A total of five papers described a 'thick' flap technique, while 19 papers described the use of a 'thin' flap technique. No significant difference in the mean improvement of Kujala scores was appreciated when comparing 'thick' versus 'thin' techniques (p > 0.05). Improvements in mean radiographic outcomes based on TT-TG, CDI and SA were observed in both 'thick' and 'thin' flap trochleoplasty groups. The overall redislocation rate was 0.35%. CONCLUSION: No significant difference in Kujala scores was observed in patients undergoing trochleoplasty utilising 'thick' versus 'thin' technique, while improvements in mean TT-TG, CDI and SA were noted in both technique groups, with an overall redislocation rate of 0.35%. LEVEL OF EVIDENCE: Level IV.

Correlation between articular cartilage status on outcomes and survivorship following meniscal allograft transplantation: A systematic review.

PURPOSE: To conduct a systematic review evaluating potential correlations between preoperative articular cartilage integrity on outcomes and survivorship in patients undergoing meniscal allograft transplantation (MAT). METHODS: A literature search was performed by querying SCOPUS, PubMed, Medline, and the Cochrane Central Register for Controlled Trials from database inception through May 2023 according to the 2020 PRISMA statement. Inclusion criteria were limited to studies reporting on outcomes and survivorship following MAT based on preoperative cartilage status. RESULTS: Sixteen studies, consisting of 1723 patients (n = 1758 total menisci), were identified in six level III and 10 level IV evidence studies. There was high heterogeneity in cartilage grading scales, reporting of concomitant cartilage procedures, and indications for MAT based on osteoarthritis. Patients with lower limb malalignment were either excluded or corrected with an osteotomy. MAT failure rate was reported in nine studies, with four studies reporting a greater rate of failure in knees with higher degrees of cartilage damage. Eight studies reported on clinical outcomes based on cartilage grade, with two studies reporting significant differences in clinical outcomes based on cartilage grade. Of the five studies reporting management of full-thickness chondral defects with cartilage surgery, three studies reported no significant difference in survivorship based on preoperative cartilage grade, while one study reported lower survivorship and one study reported unclear results. No studies found significant differences in survivorship and outcomes between medial and lateral MAT. CONCLUSIONS: Conflicting results and high variability in reporting of concomitant cartilage repair and indications for MAT exist in studies evaluating the efficacy of MAT based on articular cartilage status. The degree of preoperative chondral damage did not have a strong relationship with clinical outcomes following MAT. Higher degrees of cartilage damage were associated with higher MAT failure rates, with possible improvement in survivorship when treated with an appropriate cartilage procedure. LEVEL OF EVIDENCE: Level IV.